Pennsylvania Neurological Society E-Newsletter

Transcription

1 Pennsylvania Neurological Society E-Newsletter Summer 2010 INSIDE THIS ISSUE LETTER FROM THE PRESIDENT...1 CAUTION WITH CURBSIDE CONSULT....2 SEIZURES AND COMMERCIAL DRIVERS RESIDENT S CORNER...4 UPCOMING EVENTS S AVE T HE D ATE! O CTOBER 1, 2010 A NNUAL C ONFERENCE A BINGTON, PA CALL FOR ABSTRACTS! R ESIDENT AND F ELLOW R ESEARCH D AY AT PNS A NNUAL C ONFERENCE NOW ACCEPTING ABSTRACTS CASH PRIZES!! F OR MORE DETAILS CONTACT: STACEYLYNNCLARDY@ YAHOO. COM PNS WEBSITE: C ENTRAL MEDICAL ARTS BLDG R.D. 7, O LD R OUTE 30 G REENSBURG, PA TEL: (724) FAX: (724) @pns.aan.com Welcome to the Pennsylvania Neurological Society (PNS). As the new president, my goal is to continue to progress this organization from its infancy to early adolescence, in order to provide value for all neurologists in Pennsylvania. Dr. Brad Klein, our past president, and I have been working behind the scenes to establish a venue for our fall meeting in Philadelphia. We are delighted to report that the meeting will be held conjointly with Abington Memorial Hospital on Friday, October 1, One of our Board Members, Dr. Qaisar Shah, is moderating the Second Annual Pursuit of Neurovascular Excellence 2010 at The Abington Hospital Frobese Conference Center in Abington, PA. The esteemed guest presenters are some of the most notable individuals in the field of stroke and stroke treatment, and we are most fortunate that a busy clinical interventional neurologist, Dr. Shah, has created a program of excellence that all clinical neurologists throughout the state can profit from, and take home new and exciting knowledge. We are planning to have an advocacy meeting in the afternoon after the conference to bring everyone up to date on national affairs and the efforts of The Pennsylvania Neurological Society on behalf of Pennsylvania s neurologists and our members. The meeting will also host a student poster section with invitation extended to all residency programs in the state. We will have monetary prizes for the top three presentations. I continue to work with Dr. Michael Mazowiecki exploring the Electronic Medical Records issues. I believe that a significant number of Pennsylvania s 750 neurologists remain frozen in a decision to get a system that is reasonably priced, and meets the clinical and other economic needs of busy clinicians. We are all trying to delay the inevitable! I realize that academic centers are well-established with these systems, but many private practitioners are looking for guidance. Dr. Mazowiecki and I have looked at nearly 10 systems so far and will continue to work on this over the next months before the fall meeting. The NeuroAlliance, under the care of Dr. Anthony May, is slowly proceeding to try to engage all of the individual advocacy neurological societies throughout the state. The PNS leadership believes that our total state-wide alliance has much to offer as a voice for all patients with neurological illnesses. State-supported programs, budget cuts, and shrinking reimbursements both federal and state as well as insurance company / economic contraction, are driving neurologists from the state and harming those we serve in Pennsylvania. The PNS must create a joint task-force to deal with these issues. The PNS is reaching out to all neurologists in Pennsylvania to join our membership. The nominal costs ($100 per year; $150 for 2 years) will keep the momentum going forward for continued growth of services and advocacy for all of our state neurologists. Many state societies across the country are now well organized and continue to grow in this manner, and our efforts continue to reach out to all of you. Please join immediately ( while the opportunity is fresh in your mind. Also, I hope you will plan to come to Philadelphia on Friday, October 1, 2010 at Abington Memorial Hospital for this great educational opportunity. Louis W. Catalano, MD, FAAN President, Pennsylvania Neurological Society Page 1

2 Curbside consults: accompany courtesy with caution Steven Mandel, MD, James R. Kahn, Esq. and Gregory D. Hanscom, Esq. Physicians are often requested to provide informal consultations with fellow doctors or lay persons. These discussions -- sometimes known as curbside consults -- may be approached reluctantly by the solicited physician. That is properly so as they can occasionally expose the doctor to a malpractice claim. Indeed, the courts, in limited situations, have allowed claims against a physician who provided just informal advice. For this reason, when providing curbside consults, a doctor must temper her courtesy with caution. There are four situations which could be considered a curbside consult or something close to it: (1) another physician or nurse seeks advice concerning the treatment of a patient not under the care of the physician who is being questioned; (2) there is a general conversation between physicians about interesting cases, either in an informal or formal setting; (3) a doctor screens radiological or other studies or conducts physicals for an employer or other third party but is not serving a patient directly; and (4) a lay friend or acquaintance seeks informal advice from a doctor. Unfortunately, the law is unsettled whether such informal, indirect or limited discussions could expose a physician to malpractice liability. The longstanding touchstone of malpractice liability is that a physician owes a duty to her patient; if there is no physician-patient relationship, there can be no liability. But this doctrine has been eroding in decisions from courts in Pennsylvania as well as other states. Some courts have concluded that some of the curbside consult situations involved enough of a contact to create a physician-patient relationship. As might be expected, a situation involving a formal screening for an employer is more likely to result in the finding of a relationship than a simple telephone call. But allegations have been attempted against doctors in all of these situations. However, there are some simple steps that can be taken to reduce a physician s risk from these encounters. If another physician or nurse seeks advice informally, try to frame all responses in general or abstract terms, suggesting several potential treatment options and their risks and benefits, emphasizing that such a conversation does give rise to a formal consulting relationship nor is the physician advocating a particular course of action. Avoid evaluating tests results or providing a specific diagnosis. Attempt to keep all consultations regarding a specific patient to a minimum. Also, create a special office folder with notes about such informal consults. Naturally, a doctor would not be writing up a consult note for a hospital or office chart when it is not the doctor s patient who is discussed. But very often the doctor soliciting the advice will have made a note, and that will be the only written recording. However, the doctor consulted can protect himself by making his own note, kept in a special miscellaneous file that does not imply a doctorpatient relationship, but which does allow the consulted doctor to make a written record that emphasizes the informal, non-specific and non-conclusory nature of the advice. If a patient s treating physician pushes for more specific guidance suggest that a more comprehensive evaluation may be appropriate. This will ensure that any specific treatment recommendations are based on a full understanding of the particular patient s medical history and is not the result of either second-hand or incomplete information. In the realm of the employer screening and other formal situations, it is more difficult to avoid a claim that there was a misdiagnosis or failure to diagnose. Here the physician should protect himself, at least from a monetary standpoint, by obtaining a contractual indemnity or agreement to provide insurance from the company employing the physician to screen. Further, it could be helpful to create a document for each employee to sign which explains the limited nature of the screening, the fact that there is no doctor-patient relationship and that the screening is not meant to diagnose conditions for the employee. Where advice is sought by a lay person, the physician responding must emphasize that it would be best for the inquirer to consult her own physician or set up a formal appointment with the doctor if appropriate. Do not discuss matters outside one s field of expertise and never prescribe medications informally. Make sure that any comments are explicitly framed as informal, general, and not conclusory, at best only suggestions for the person to take to a doctor who is actually serving as the person s physician, which the responder is not. Try to make clear that the person should not be relying on the responder s advice and that the responder is not the inquirer s doctor -- both of which are requirements for legal liability. Also, contemplate later making a note for that miscellaneous file. These informal situations are difficult to avoid. But if handled properly, if courtesy is accompanied by caution, they are far less likely to lead to later legal difficulties. Seizure disorders and commercial motor vehicle operators Natalie P. Hartenbaum, MD, MPH, FACOEM Most neurologists in Pennsylvania are aware that in general an individual may not drive for 6 months after a seizure and that seizure is one of the medical conditions that health care providers are required to report to the State Department of Page 2

3 Motor Vehicles(1). What many do not realize is that there are very specific regulation and guidance for those drivers who operate commercial motor vehicles, including trucks and buses. The Federal Motor Carrier Safety Administration (FMCSA) is responsible for administering medical standards for commercial motor vehicle (CMV) operators operating in interstate commerce. There are 13 medical standards and all but the ones for vision, hearing, seizures and the use of insulin leave some discretion to the commercial driver medical examiners. Exemptions have been issued by the FMCSA to some drivers who do not meet the vision or insulin standard but to date, there have been none granted for seizures or hearing. The medical standard (2) which addresses seizures in CMV operators states that an individual is qualified to operate a CMV in interstate commerce if they have; no established medical history or clinical diagnosis of epilepsy; or any other condition which is likely to cause the loss of consciousness, or any loss of ability to control a commercial motor vehicle. The Advisory Criteria, guidance to examiners, which accompanies this medical standard state that the following drivers cannot be qualified; (1) a driver who has a medical history of epilepsy; (2) a driver who has a current clinical diagnosis of epilepsy; or (3) a driver who is taking antiseizure medication. The Advisory Criteria also explains that drivers with a history of epilepsy/seizures cannot be qualified until they are off antiseizure medication and seizure-free for 10 years. If the individual has only a single unprovoked seizure, the seizure-free, off medication waiting period is five years. The determination of whether a driver who has had a sudden episode of a nonepileptic seizure or loss of consciousness of unknown cause which did not require antiseizure medication can be made by the medical examiner in consultation with the treating physician. A 6- month waiting period prior to commercial driving is recommended. The FMCSA is currently in the process of reviewing most of the medical standards. The process includes the extensive, evidence based review of the literature by a Medical Expert Panel (MEP) with recommendations presented to the Medical Review Board (MRB) and the FMCSA. The MRB, which is advisory to the FMCSA, makes their recommendation based on the expert panel and an understanding of the other issues which affect commercial driver medical certification. Based on input from the MEP, the MRB and other information, the FMCSSA would then issue updated medical standards and/or guidance. While a Medical Expert Panel on Seizures Disorders and Commercial Motor Vehicle Driver Safety (3) recommended permitting some drivers on anti- seizure medications to operate CMV, the MRB did not believe the evidence was sufficient to ensure safety to overturn the current guidance (4). The FMCSA has not, to date, issued new guidance. Pennsylvania has adopted the Federal Medical Standards as the physical qualification for PA intrastate commercial drivers (5). Those driver with a medical condition which would have been disqualifying under Federal Medical Standards when the state adopted those criteria effective September 23, 1995 (6) may be able to be medically qualified under specific conditions to operate in solely in intrastate commerce (this is determined by where the driver is operating but what he is transporting and whether that property is moved interstate). School bus drivers, operating only as school bus drivers, not also providing charter bus services using the school buses, are covered under slightly different medical requirements. For those PA school bus drivers with seizures, the if the driver (7); Has no established medical history or clinical diagnosis of seizure disorders or another condition likely to cause loss or impairment of consciousness or loss of ability to drive a school bus safely. (i) A waiver may be granted to these persons provided: (A)There has been no more than a single, nonrecurring episode of altered consciousness or loss of bodily control, occurring at least 2 years preceding application, which did not require treatment. (B) A seizure disorder has been diagnosed, but the person has been episode-free for at least 5 years preceding application and has not required treatment for at least 5 years preceding application. It is important to understand your patients work tasks and whether they are required to meet any medical standards prior to issuing a return to work note. Some employers will accept a note from a treating provider, assuming the provider is aware of any relevant medical standard, potentially placing both the provider and the employer at risk of liability. Some employers will have an occupational health professional evaluate the individual and it is very frustrating to both the patient/employee and the examining physician when the examiner is trying to explain that although the treating provider may have released him to return to work, he may not be permitted to do so. References PA Code Chapter 83.Physical And Mental Criteria, Including Vision Standards Relating To The Licensing Of Drivers. ml. Accessed December 1, Medical Advisory Criteria for Evaluation Under 49CFRPart Accessed December 1, Page 3

4 3. Engel J, et. al. Expert Panel Recommendations. Seizure Disorders and Commercial Motor Vehicle Driver Safety. October regulations/topics/mep/report/seizure-disorders-mep- Recommendations-v2-prot.pdf. 4. Meeting Summary from the Medical Review Board meeting. January 28, _2008MRB_Meet_Revised pdf. Accessed December 1, PA Code Intrastate Motor Carrier Safety Requirements; Physical Qualifications of Drivers. ml. Accessed December 1, PA Code Drivers regularly employed as of September 23, ml Accessed December 1, PA Code Physical examination. Accessed December 1, Resident s Corner Case Provided by: Prabhu Emmady, MD PGY3 Resident, Faculty Mentor: Jayant N. Acharya, MD, DM, Professor of Neurology Director, Comprehensive Epilepsy Program Department of Neurology Penn State University-Hershey Medical Center A 57-year-old lady with medically refractory epilepsy on multiple antiepileptic medications including ethosuximide, primidone, valproate, levetiracetam and vagus nerve stimulation presented to the Emergency Department with an episode of unresponsiveness. At the time of initial assessment, she appeared to be alert but did not maintain eye contact, answered questions in monosyllables and obeyed simple commands intermittently and inconsistently. She had some eye fluttering and lip movements. An EEG was requested immediately and is given below: What is the diagnosis? 1) Non-convulsive status epilepticus 2) Bi-PLEDs 3) Triphasic waves 4) EKG artifact Page 4

5 Answer: (1) This record shows rhythmic, bisynchronous spike and wave complexes consistent with status epilepticus. illustrative case history manifesting as delirium. Australasian Journal on Ageing, Vol: 28 No 3 September 2009, Hospital Course: The patient received 2 mg lorazepam intravenously and there was significant EEG improvement with reappearance of background activity. She also improved clinically and became fully responsive. Apart from lorazepam, she was given a partial bolus of intravenous valproic acid as her level was low. She was placed on continuous EEG monitoring with video. Her overnight EEG showed interictal generalized spikes and several electrographic seizures lasting seconds without clinical changes. Her mental status examination including level of alertness, attention, language, and recent and remote memory remained normal. Discussion: Non-convulsive status epilepticus (NCSE) is a complex clinical entity of great diagnostic and therapeutic challenge in modern day neurology. The clinical features in this disorder may be very subtle and hard to differentiate from normal behavior. NCSE is easily overlooked when the clinical suspicion is not high enough. Clinically, the signs may vary from minimal lethargy or mild change in the patient s behavior and psychological performance to severe clouding of consciousness and confusion. As the change in mental status may be very subtle, EEG is the only way to diagnose or rule out NCSE. Convulsive status epilepticus is a neurological emergency and failure to treat it promptly and appropriately may result in significant mortality and morbidity. Cerebral metabolic decompensation likely occurs after approximately 30 min of uncontrolled convulsive activity and the window for treatment is therefore limited. However, no data exist as to precisely when these changes occur and it is not clear if this applies to NCSE as well. A high index of suspicion for possible NCSE must be present when evaluating every epileptic patient. Continuous EEG monitoring is helpful in identifying additional seizures and, in our patient, intermittent electrographic seizures were noted after initial resolution of her NCSE. Teaching Point: Patients suspected of NSCE must have an EEG immediately and must be monitored with continuous EEG monitoring even after resolution of NCSE to pick up subclinical electrographic seizures. Appropriate and timely treatment can decrease the morbidity, mortality and risk of recurrent NCSE. Additional Reading: 1) Status epilepticus, Anesthesia, 2001, , M. G. Chapman, M. Smith and N. P. Hirsch 2) Review of non-convulsive status epilepticus and an Page 5

6 Pennsylvania Neurological Society Board of Directors President Louis Catalano Jr., MD, FAAN Vice-President Stephen Ross, MD Secretary-Treasurer Nabila Dahodwala, MD Members-At-Large Michael Mazowecki, MD Elliot Schulman, MD Qaiser Shah, MD Michael Sperling, MD Charles S. Yanofsky, MD Chair, Resident and Fellow Section Stacey Clardy, MD, PhD E VENTS October 1, 2010 October 1, th Annual PA Neurological Society Conference in collaboration with the Second Annual Pursuit of Neurovascular Excellence at The Abington Hospital Frobese Conference Center For Information: Call: KEsmond@amh.org Resident and Fellow Research Day (at the Annual PNS Conference) For Information and submission: staceylynnclardy@yahoo.com Immediate Past President Brad Klein, MD, MBA Medicare Advisory Committee Paul McCabe, MD Newsletter Editors Nabila Dahodwala, MD Stacey Clardy, MD, PhD PNS news wanted! Your colleagues would like to know what you re up to. If you would like to contribute an article to this newsletter, please contact us at @pns.aan.com. Page 6