Cocaine – Hydros – Weed – “The Three Amigos” in the Workplace

Workplace drug tests recently have shown a decrease in cocaine positives during the first half of 2007. The positive tests for cocaine dropped 16% as the overall rate was 0.58 percent. This rate is the lowest since tracking the information back in 1997 by one lab. The lowest rate of decline was in the Midwest while the highest rate of decline was in the New England areas. The total tests counted for this tracking included about four and one-half million urine drug tests, which all included testing for cocaine and other drugs of abuse. Some believe the shortage of cocaine and higher costs are driving the decline, while European cocaine abuse is becoming increasingly popular, adding to world-wide demand. As a Medical Review Officer for Work-Place Drug Testing, cocaine remains popular.

In another report on drugs of abuse, marijuana recently was highlighted. It is apparent that reefing the great weed is about 5 times more harmful than one cigarette. The apparent problem is a greater intensity of airway obstruction. This effect may be caused by an increased “holding” of the smoke which is a longer time of interaction with the lung tissue. Another concept is that the smoke is literally hotter, creating a deeper thermal injury to the lung tissue itself. Interestingly, when compared to regular smokers, the marijuana smokers had less emphysema changes.

DAWN, or the Drug Abuse Warning Network, continues to focus on hydrocodone. This narcotic goes with the brand names of Norco, Lortab, Vicodin – but is generic in many prescriptions. Sales of hydrocodone and oxycodone have dramatically increased over the past years. The Pharma industry spends over 3 times as much on advertising as it did a decade ago. has written on this plague and the advertising push to addiction by the Pharma industry in past postings.

Despite the pressure to put these dangerous and addictive drugs on a higher schedule of restriction of prescribing, Schedule II, the FDA and DEA has been lobbied heavily to not do so.

With all the Pharma advertising, a push toward better pain management, and the abuse of narcotics, hydrocodone based drugs and combo drugs ranked number 2 in 2006 just behind the cholesterol lowering brand name, Lipitor. From 2001 to 2006, hydrocodone prescriptions rose by 2/3rds.

Hydrocodone is the number one drug in its category to arrive at the Emergency Department. It is also the number one drug of its category reported to the National Forensic Lab Info System. says, “Ban hydrocodone or elevate the Schedule.” It is a considerable concern of abuse in junior high kids, high school kids, and patients.”    Should it be banned?

adapted:  acoem/castMD



And the money makes the politics “responsive!”



TIME: JAN 1, 2007 THROUGH JUNE 30, 2007

TYPES OF BUSINESS                                    DOLLARS         PARTY

LAW FIRM-LAWYERS                             27.8 MILLION 78 % TO DEMS

SECURITIES-INVST                                   18 MILLION 56 % TO DEMS

RETIRED                                                     16.5 MILLION 51 % TO DEMS

REALESTATE                                             11.7 MILLION 50 % TO DEMS

BUSINESS                                                     8.2 MILLION 75 % TO DEMS

BUSINESS SERVICE                                      6 MILLION 63 % TO DEMS

FINANCE                                                       5.9 MILLION 46 % TO DEMS

MOVIE-TV                                                    4.6 MILLION 82 % TO DEMS

HEALTH PROF                                             4.4 MILLION 53 % TO DEMS

EDUCATION                                                  4.1 MILLION 75 % TO DEMS


It is amazing that the discrepancy of donation dollars regarding the legal industry is so extraordinarily excessive compared to many other business sectors. No wonder tort reform is impossible in many areas of the country. This non-action on tort reform effects all businesses, not just medicine. Now you know. The money follows the “silent bias of the quid pro quo.”

(The data is from the Center for Responsive Politics)


Some insurers and their plans still make it difficult for patients to see the doctor of their choice.  The “Any Willing Provider Law” in Idaho mandates that all insurance companies open their doors to any provider, granted the provider apply and follow the terms of the contractual agreement.  It still seems some insurances companies restrict access to doctors and hospitals and make it difficult to get through that open door. 

In the emergency rooms of America, EMTALA took care of that.  It’s definition now is the “layperson’s view of the emergency.”

One case in Idaho went to the Supreme Court already, where the Supremes overruled the lower court, and award costs and a new appeal to a group of cardiologists. 

Isn’t it time all companies and groups representing themselves as gatekeepers to care – that insure patients in Idaho – obey the law?   Patients need to be pro-active knowing their rights.


AWP laws come in a variety of forms but the most common type prohibits managed care networks from excluding physicians, pharmacists, hospitals, and other health care providers who are willing to accept the network’s terms and conditions from participation. As the term implies, AWP laws require managed care network sponsors to include any provider who agrees to abide by the terms of their contract and accept their payment schedule.

AWP laws adopted around the country differ considerably. Some permit managed care plan subscribers freedom of choice to select any provider in general, and others have choice with respect to pharmacies or even narrow categories of specialists such as chiropractors, optometrists, or psychiatrists. Some AWP laws apply to institutional providers such as hospitals and still others require network sponsors to merely notify subscribers of plan practices.

As best as we can determine at least 17 states have passed some form of AWP law. But, the governors of Maine, Massachusetts, and Vermont vetoed their respect AWP legislation. The laws in nine states apply only to pharmacies and pharmacists. Among these is the Massachusetts proposal which the governor vetoed. The Massachusetts legislature voted to override the veto.

California has an open-panel requirement with respect to health maintenance organizations (HMOs). Minnesota adopted a law that requires managed care plans to expand network providers
and Virginia has an open-panel requirement for preferred provider organizations (PPOs) networks that permit chiropractors, optometrists, podiatrists, and psychologists to join if they agree to terms and conditions.

Idaho (1994)

Idaho enacted an AWP law and grievance procedure. The law includes provisions that specify that (1) any provider who is qualified and willing to meet plan terms and conditions must be allowed to participate as a network provider; (2) termination or nonrenewal of a provider may occur only after written notice of intended breach of contract, and (3) all insurers must have a grievance procedure in place that includes arbitration or other reasonable due process features (HB 886). (Adapted from: olr@po. state. ct. us)

Is your doctor getting old? Ask the mature doctor if:

Does the doctor know that doctors and nurses wrote on the same non-electronic paper?

Does your doctor know that intravenous solutions came in glass, as well as “shots” – bottles like milk?

Does your doctor know that bedpans were steel and cold?

Does your doctor know that the coroner and funeral director and the ambulance driver were all the same guy?

Does your doctor know that appendix can come out without a catscan?

Does your doctor know that defibrillators were once very big devices and heavy?

Does your doctor reminisce when nurses got up to let the doctor sit down?

Does your doctor remember the times of routine housecalls?

Does your doctor know the Rat Pak is not a surgical dressing?

Does your doctor know the ER was not manned 24/7?

Does your doctor know that a wet xray reading was actually wet?

Does your doctor know listening to patients is a good thing?

adapted with additional content from EPM and


Diarrhea is certainly a “not so talked about” medical condition. But today, at least one kind of diarrhea is becoming quite a medical problem. It is the Clostridium Difficile colitis (colon infection and inflammation).

Physicians, nurses, clinics and hospitals as well as Public Health agencies are seeing a rise in the incidence of this C. Difficile associated diarrhea. This change in the demographics of this disease is toward a younger and healthier group of patients, and not the classic patients.

The typical patients for this “C. Diff.” diarrhea have been the elderly, those with recent antibiotic usage, and those on certain higher risk medications such as clindamycin, cephalosporins, and quinolones. Recent hospitalization and the use of gastric acid blockers, now advertised daily on television and print media are also higher risk factors.

The use of gastric acid blockers has been studied and continues to be. This arena of high use of these acid pH changing medicines in the gut may be contributing to the growth of the C. Diff. more quickly in the gut, than without the acid blocker.

The toxin in itself from the bacteria, can cause worsening symptoms such as toxic mega colon, severe sepsis, perforation of the gut, a need for colectomy (removal of the colon), and even death.

The diarrhea is many times unrelenting. It continues to be watery, sometimes mucous-like, and eventually bloody. But many patients wait to see if the diarrhea will clear. Dehydration and weight loss can be associated with such diarrhea also.

There are both blood tests for the disease and stool tests specific to the disease.

If you are on antibiotics, and develop diarrhea over 24 hours you must call your health care provider or doctor. The best treatment is to stop the antibiotic immediately with your doctor’s order if possible.

Many times two different OTHER antibiotics are used to treat the C. Diff. infection of the colon. One antibiotic for the C. Diff. is only about 80% effective now, while the backup drug is only about 90% effective. But now, resistance is starting to mount to these treatments, leaving patients in severe distress with life-threatening diarrhea and infection.

New studies are being done now using probiotics. Specifically Sacharomyces boulardii and other lactobacilli have been studied. Many are recommending the use of probiotics with the initiation of antibiotics and other antimicrobials.

There are many reasons patients get diarrhea.  But you can eliminate some high risk yourself.  So, do not use antibiotics without a reason. Do not borrow or loan antibiotics. Always talk with your doctor if you develop diarrhea while on antibiotics. When in doubt, call.

CastMD says, “You do NOT want to develop this toxic type of diarrhea.”



A month or so ago the Feds released their workplace data regarding use of drugs while on duty in various jobs and employments. These are the newest data compared to previous studies in mid-nineties.

Industries that continue to have high rates of on the job drug use and use of drugs are those industries in general that continue to have high job turnover rates.

Illicit drug usage among the 18-64 year olds working full-time was the highest in food service and accommodation industry, construction work, entertainment and arts, information services, and management support companies.

The highest rate was 16.9 percent of the food and accommodation employees used illicit drugs in the last month, in the survey.

Construction workers and miners had the highest heavy use alcohol rates at 17.8 percent. Even CEO’s rate was at 8 percent for heavy alcohol usage.

Marijuana continues to lead the pack on illicit drug use for these surveys.

Over 12 percent of the illicit drug users had three or more employers in the past year! Current drug users had twice the rate of missing one or more days in the last month.

Increased rates of illicit drug use were seen in men and lesser paid jobs.

About half of the full-time workers report that their company does pre-placement drug testing. Protective services had the highest rate (76%) of this type of testing, while legal occupations had the lowest (14%) reported in the study.

Only one-third of the workers reported random drug testing policies by their employers.

ONLY one-third of the workers reported they would be less likely to work for companies with random testing programs in place.


Over the many years as an Emergency Physician working with trauma and teaching, many patients have presented by ambulance and private car with water diving injuries.

This summer there have been injuries related to diving into the lakes and rivers.


Years ago, not sure if it still is going, was a program I believe by the Neurosurgeons College called “Feet First.” This program tried to educate parents and kids on the value of not diving into water in the lakes and rivers.

A few years ago, going up the Spokane River, I heard a boat literally rip its outdrive off by a “deadhead.” Imagine if that boat would have let the occupants dive in that area “to cool off” only hitting the submerged log.


When a person dives into the water, all the force is decelerated, into the skull onto the brain. But more importantly, the cervical spine “the neck” gets flexed or extended quite rapidly and dramatically. Then as the flexion or extension is exaggerated, the force (weight) of the body from the height of the dive is literally driven into the spinal vertebrae.  This force is so great it can fracture (break) the neck, rupture the ligaments that hold them in place, and dramatically injure – even push bone fragments into the spinal cord itself.  Thus, paraplegia or quadriplegia ensues….never to walk or move again!

Facial injuries of jaw fractures, nasal fractures, lost teeth, eye injures and even skull fractures, as well as lacerations of all of the above-do occur.  Head injury is commom.

Risk of drowning is high when these injuries occur.  Risk of additional injury is high as “helpers” try to get the victim out of the water…in a “layperson” way…without EMS techniques or even lifeguard techniques.

These are  just plain sad cases.  So preventable.  So life options limiting.  So challenging for the victim, their family, their friends, and their doctors.  Can you imagine how hard it is to hear, “Your child is paralyzed.”

 So castMD says:




er.jpgAn Idaho case in Boise is coming down the legal pipeline. This case is significant as the plaintiff is support by the Center of Individual Rights group.

According to my understanding these are the general issues.

The baby was presented to the ER for evaluation and treatment.  The baby was ill. The baby was five-weeks old. The mother consented to evaluation on this sick infant. The mother agreed to labs and iv fluids.  ivbaghanging.jpg

The rub came when the baby required a spinal tap and iv antibiotics for evaluation and treatment, immediate or early, to limit the diagnostic possibilities and to provide early treatment for a potential devastating and possible deadly meningitis.

The mother evidently refused.

The Emergency Physician evidently requested protective custody for this infant to proceed. The hospital, the police, the courts agreed with the Emergency Physician and allowed the doctor to proceed.

Now about 5 years later, an entire community to protect this baby is being sued, as the baby and the mother’s rights were violated.

The defense of the doctor, hospital, and police state that the temporary custody allowed the proper diagnosis and treatment of this infant. Infants are tough diagnositc dilemmas naturally.

Courts have upheld even traditional medicine over holistic and alternative methods in cases of seriously or potentially seriously ill or injured children. Of course, that is with needed medical support clinically.

This case will be watched closely by all Emergency Physicians, Emergency Rooms, Law Enforcement Officers, and Courts.  If plaintiffs win this case, a significant shockwave will start a sunami of “hands-off” litigation and will create a mountain of defensive medicine procedures, especially in documentation of refusal of treatment and the risks involved. 

Who has the right to refuse treatment of an infant and who has the right to treat that infant? Should the law allow medical morbidity and mortality even in the face of “lay person” judgement?


(castMD commentary with EM News review contribution)


Recently, during a Fourth of July parade, many bikers, cyclists, gymnasts, cheerleaders, rollerskaters, Shriners’ clowns, speed-skaters, and even horseriders were watched with such intensity…and were applauded for their acts, high flying or racing speed. BUT……..Why not wear a helmet?

Some states have passed and then repealed helmet laws. There has been some emphasis on kids with bicycles to wear helmets, and some push to wear helmets during down-hill skiing. BUT…..Why not wear the helmet always?

Is it a personal right NOT to wear a helmet? Is it a business right then for taxpayers, insurers, employers, disability companies and worker comp programs to refuse coverage retrospectively for such injuries and morbidity when someone does NOT wear a helmet? What about a seat-belt? What about smoking, drinking, obesity, and lack of exercise? Sounds far fetched?

Well, back to the parade…..

The Emergency Departments see generally over 2 million head trauma victims annually in the United States.  It is the leading cause of death in persons under 25 years old, with over 50,000 persons dying yearly from head injury.

Head injury crosses all boundaries of socio-economics, ethnicity, financial burden, and coverage.  Just ask the attorney that fell from the bus he was watching a parade from…a little too much partying possibly…Ask his wife who was unrecognized by this smart man after hitting his head.  Life as it was…over…New rules, new learning, new start – ALL difficult to say the least.  Career, family, dreams, and hopes all snuffed due to the head injury.

Some patients have intra-cranial bleeding from their head injury, which is about 5-10%.   This means there is bleeding either in the brain itself, or around the brain under the skull.  Each of the types of bleeding is extremely serious.  Some do not need surgery, while other types of head injury with bleeding inside the skull require immediate life-saving procedures and surgeries. 

High risk groups for “closed” (no external injury) head injury that need a CT scan, which now is the standard, are kids under 6 months, elderly, persistent vomiting, neurological or mental changes, alcohol abuse or overuse, prolonged loss of consciousness and those on blood thinners.  The medical legal world has driven the doctors to scan more often defensively, even with minor head injury.  This has been pushed by successful litigation for what appears minor, only later to be a significant injury.

Even the NFL has now taken up the banner.  It is evident now that boxers and football players with repeated or recurrent head injuries have shown brain disability later in life.  Most of the athletic associations understand now that head injury, even minor, is not to be taken lightly.   Even many of the “rough and tough” rodeo cowboys now wear helmets with the rodeo association.  The bronco-busters are leading the pro charge.

So what’s up with the ultimate boxing and cage fighting until loss of consciousness?  Should insurers, payors, and hospitals be forced to insure these programs and their victims? 

Long term complications of concussion, (which ranges from a confusion with loss of consciousness to complete coma)  are many.  Memory difficulties exist, and may stay persistent.  Dizziness, a general feeling of weakness or lack of energy may continue for months to years.  Headache is common, as well as a problem of focusing on projects or things that require intense thought.  Amnesia, or ability to remember is certainly a problem many victims of head injury encounter.  This retrograde (backwards) memory loss can be devastating.  Thus the attorney’s wife….sobbing….and wondering….

Generally there are three classes of initial head injury in evaluation and prognosis.  They are:  mild, moderate, and severe.  This category is really of doctor’s category based on an initial scoring designed by Glascow.

castMD in a previous post discussed more about head injury.  Please see the following link if you wish to read more about concussion and sports

But head injury is a very serious matter…So teach your kids to wear their helmets by wearing yours.  Consider the no helmet-no activity rule for this. 

As for what the future will bring for insurance coverage for dangerous behavior regarding helmets is still up in the air…..but many insurance companies require a rider or no insurance coverage for trampolines now…..too many broken necks and spinal cord injuries!

I remember the little boy as he was lying there.  Absolutely beautiful 4 year old.  Unconscious.  Comatose.  Scheduled for long-term care preparation and surgeries.  No sign of external injury.  “Just a closed head injury…..”