Are you monitoring a pregnant patient who had gastric banding or stapling?

There’s a code for that, as of Oct. 1.

Have you seen female genital cutting or mutilation in your practice?

There is a code for that.

Has your patient’s obesity made it difficult to obtain a diagnostic image?

You get the picture.

The new International Diagnostic Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) adds specific codes for these and other disorders.

Cancer codes clinch the case

Specific codes now describe findings that indicate a cancer diagnosis and support appropriate treatment.

Estrogen receptor status

V86.0 Estrogen receptor positive

V86.1 Estrogen receptor negative

The 2007 ICD-9-CM adds a new category: estrogen receptor status. This bit of diagnostic information is an important indicator of the type of treatment to which breast cancer will be responsive. For instance, an estrogen-receptor–positive (ER+) finding means estrogen is causing the tumor to grow. This information in conjunction with a primary diagnosis of malignant neoplasm of the breast (ICD-9-CM codes 174.0–174.9) instantly gives the payer a snapshot of the patient’s condition and supports hormone suppression treatment.

Elevated tumor markers

795.81 Elevated carcinoembryonic antigen [CEA]

795.82 Elevated cancer antigen 125 [CA 125]

795.89 Other abnormal tumor markers

Previously, an elevated CA-125 tumor marker was reported using the unspecified code 790.99 (other nonspecific findings in blood), but with the addition of a new code subcategory, 795.8x, to report elevated tumor-associated and specific antigens, this will no longer be a problem.

Abnormal cervical cytology

795.06 Papanicolaou smear of cervix with cytologic evidence of malignancy

The inclusion term “cytologic evidence of carcinoma” was deleted from code 795.04 (Papanicolaou smear of cervix and cervical HPV). A new code reports this finding, and this new code is now an “excludes” diagnosis under code 233.1 (carcinoma in situ of cervix uteri). Furthermore, code 233.1 has a new inclusion definition: cervical intraepithelial glandular neoplasia.

OB complications

649.xx Other conditions or status of the mother, complicating pregnancy, childbirth, or the puerperium

Preexisting conditions are covered in the new category.

Bariatric surgery and pregnancy

649.2X Bariatric surgery status complicating pregnancy, childbirth, or the puerperium

Until now, if you were monitoring a pregnant woman more closely because of her previous bariatric surgery, your only option was code 648.93 (other current conditions, classifiable elsewhere). The new code is for any intervention required during the pregnancy, if the mother has had obesity surgery such as gastric banding or gastric stapling.

A 5th digit must be appended: 0, unspecified episode of care; 1, delivered with or without mention of antepartum condition; 2, delivered with postpartum condition; 3, antepartum condition or complication; 4, postpartum complication.

Smoking, obesity, epilepsy, and more

649.0 [0–4] Tobacco use disorder

You must clearly indicate that the patient’s current smoking is complicating the management of her pregnancy.

649.1 [0–4] Obesity

A secondary code for type of obesity is required; for instance, 278.01 (morbid obesity).

649.3 [0–4] Coagulation defects

A second code from the 286 category (coagulation defects) must be added to identify the exact condition. If a coagulation defect causes antepartum hemorrhage, the correct code is 641.3x. A coagulation defect that appears only in the postpartum period is coded 666.3x.

649.4 [0–4] Epilepsy

A secondary code identifies the type of epilepsy (345.00–345.91). However, if the patient has eclampsia, use the code 642.6 (eclampsia with convulsions).

649.5 [0, 1, 3] Spotting

This code will be used predominately in early pregnancy when spotting is the chief complaint and there is no evidence of miscarriage. Note that the allowable 5th digits for this code exclude 2 and 4, because spotting is not considered a complication in the postpartum period. If the patient is bleeding heavily, other existing codes would be selected, such as 640.0x (threatened abortion) or 641.1x (hemorrhage from placenta previa).

649.6 [0–4] Uterine size-date discrepancy

This condition, which was formerly included under 646.8x (other specified complications of pregnancy), is used most often when an ultrasound is performed to date the pregnancy, especially when the last monthly period is unknown.

666.1x Other immediate postpartum hemorrhage

This code is revised, and now specifies uterine atony with hemorrhage. Uterine atony without hemorrhage is coded 669.8x.

More specific “other” codes

Several “other”-type codes for gynecologic conditions got more specific. For example, 2 new, more specific, 5-digit codes replace code 616.8 (other specified inflammatory diseases of cervix, vagina, and vulva).

 

616.81 Mucositis (ulcerative) of the cervix, vagina, and vulva

Requires an additional E code to identify the adverse affects of therapy that caused the mucositis, such as antineoplastic or immunosuppressive drugs or radiation therapy.

616.89 Other inflammatory disease of the cervix, vagina, and vulva

Identifies conditions such as a caruncle of the vagina or labium or ulcer of the vagina.

616.84 Cervical stump prolapse

Previously was reported with the code 618.39 (other specified genital prolapse).

629.29 Other types of female genital mutilation

This code includes female genital cutting or mutilation Type IV status, the collective term for other types of mutilation that can include such things as pricking the clitoris with needles, burning or scarring the genitals, and ripping or tearing the vagina.

Code 629.8 (other specified disorders of female genital organs) was deleted and replaced by these 2 new 5-digit codes:

629.81 Habitual aborter without current pregnancy

629.89 Other unspecified disorders of female genital organs

Index changes to ICD-9-CM are also important to note. This year the reference for vaginal intraepithelial neoplasia (VIN I and VIN II) was changed from code 624.8 (other specified noninflammatory disorders of vulva and perineum) to:

624.0 Dystrophy of vulva

New category: Pain control

338 Pain, not elsewhere classified

338.18 Other acute postoperative pain

338.28 Other chronic postoperative pain

338.3 Neoplasm-related pain (acute) (chronic)

Diagnostic coding just got easier if your practice includes insertion of an On-Q device for postoperative pain. A whole new category of codes groups pain into acute and chronic classifications and includes codes for both types of postoperative pain. These new codes would not be used to report generalized pain (780.96) or localized pain by site (eg, pelvic pain, 625.9), or pain disorders attributed to psychological factors. Listed above are some of the new codes in this category that may be of particular interest to ObGyns.

Imaging

Breast calcifications

793.81 Microcalcifications seen on a mammogram

793.89 Other abnormal findings on radiological examination of breast

ICD-9-CM now differentiates microcalcifications. The less-specific code is for findings documented as simply mammographic calcification or mammographic calculus.

Inconclusive imaging due to obesity

793.91 Image test inconclusive due to excess body fat

You must add a second code indicating the patient’s body mass index (BMI).

Other imaging abnormalities

793.99 Other nonspecific abnormal findings on radiological and other examination of body structure

This code could be reported for such things as an abnormal placental finding on ultrasound or an abnormal finding in the skin or subcutaneous tissue, where a more definitive diagnosis is not available.

Urinary symptoms

Additions to your diagnostic arsenal:

788.64 Urinary hesitancy

788.65 Straining on urination

Hyperglycemia

A new inclusion term is added

790.29 Other abnormal glucose

The existing code now includes a diagnosis of hyperglycemia not elsewhere specified.

V-codes for men

V26.34 Testing of male for genetic disease carrier status

V26.35 Encounter for testing of male partner of habitual aborter

V26.39 Other genetic testing of male

Use these new codes to identify the male as the reason for doing the testing—something that has been lacking for years.

Are you monitoring a pregnant patient who had gastric banding or stapling?

There’s a code for that, as of Oct. 1.

Have you seen female genital cutting or mutilation in your practice?

There is a code for that.

Has your patient’s obesity made it difficult to obtain a diagnostic image?

You get the picture.

The new International Diagnostic Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) adds specific codes for these and other disorders.

Cancer codes clinch the case

Specific codes now describe findings that indicate a cancer diagnosis and support appropriate treatment.

Estrogen receptor status

V86.0 Estrogen receptor positive

V86.1 Estrogen receptor negative

The 2007 ICD-9-CM adds a new category: estrogen receptor status. This bit of diagnostic information is an important indicator of the type of treatment to which breast cancer will be responsive. For instance, an estrogen-receptor–positive (ER+) finding means estrogen is causing the tumor to grow. This information in conjunction with a primary diagnosis of malignant neoplasm of the breast (ICD-9-CM codes 174.0–174.9) instantly gives the payer a snapshot of the patient’s condition and supports hormone suppression treatment.

Elevated tumor markers

795.81 Elevated carcinoembryonic antigen [CEA]

795.82 Elevated cancer antigen 125 [CA 125]

795.89 Other abnormal tumor markers

Previously, an elevated CA-125 tumor marker was reported using the unspecified code 790.99 (other nonspecific findings in blood), but with the addition of a new code subcategory, 795.8x, to report elevated tumor-associated and specific antigens, this will no longer be a problem.

Abnormal cervical cytology

795.06 Papanicolaou smear of cervix with cytologic evidence of malignancy

The inclusion term “cytologic evidence of carcinoma” was deleted from code 795.04 (Papanicolaou smear of cervix and cervical HPV). A new code reports this finding, and this new code is now an “excludes” diagnosis under code 233.1 (carcinoma in situ of cervix uteri). Furthermore, code 233.1 has a new inclusion definition: cervical intraepithelial glandular neoplasia.

OB complications

649.xx Other conditions or status of the mother, complicating pregnancy, childbirth, or the puerperium

Preexisting conditions are covered in the new category.

Bariatric surgery and pregnancy

649.2X Bariatric surgery status complicating pregnancy, childbirth, or the puerperium

Until now, if you were monitoring a pregnant woman more closely because of her previous bariatric surgery, your only option was code 648.93 (other current conditions, classifiable elsewhere). The new code is for any intervention required during the pregnancy, if the mother has had obesity surgery such as gastric banding or gastric stapling.

A 5th digit must be appended: 0, unspecified episode of care; 1, delivered with or without mention of antepartum condition; 2, delivered with postpartum condition; 3, antepartum condition or complication; 4, postpartum complication.

Smoking, obesity, epilepsy, and more

649.0 [0–4] Tobacco use disorder

You must clearly indicate that the patient’s current smoking is complicating the management of her pregnancy.

649.1 [0–4] Obesity

A secondary code for type of obesity is required; for instance, 278.01 (morbid obesity).

649.3 [0–4] Coagulation defects

A second code from the 286 category (coagulation defects) must be added to identify the exact condition. If a coagulation defect causes antepartum hemorrhage, the correct code is 641.3x. A coagulation defect that appears only in the postpartum period is coded 666.3x.

649.4 [0–4] Epilepsy

A secondary code identifies the type of epilepsy (345.00–345.91). However, if the patient has eclampsia, use the code 642.6 (eclampsia with convulsions).

649.5 [0, 1, 3] Spotting

This code will be used predominately in early pregnancy when spotting is the chief complaint and there is no evidence of miscarriage. Note that the allowable 5th digits for this code exclude 2 and 4, because spotting is not considered a complication in the postpartum period. If the patient is bleeding heavily, other existing codes would be selected, such as 640.0x (threatened abortion) or 641.1x (hemorrhage from placenta previa).

649.6 [0–4] Uterine size-date discrepancy

This condition, which was formerly included under 646.8x (other specified complications of pregnancy), is used most often when an ultrasound is performed to date the pregnancy, especially when the last monthly period is unknown.

666.1x Other immediate postpartum hemorrhage

This code is revised, and now specifies uterine atony with hemorrhage. Uterine atony without hemorrhage is coded 669.8x.

More specific “other” codes

Several “other”-type codes for gynecologic conditions got more specific. For example, 2 new, more specific, 5-digit codes replace code 616.8 (other specified inflammatory diseases of cervix, vagina, and vulva).

 

616.81 Mucositis (ulcerative) of the cervix, vagina, and vulva

Requires an additional E code to identify the adverse affects of therapy that caused the mucositis, such as antineoplastic or immunosuppressive drugs or radiation therapy.

616.89 Other inflammatory disease of the cervix, vagina, and vulva

Identifies conditions such as a caruncle of the vagina or labium or ulcer of the vagina.

616.84 Cervical stump prolapse

Previously was reported with the code 618.39 (other specified genital prolapse).

629.29 Other types of female genital mutilation

This code includes female genital cutting or mutilation Type IV status, the collective term for other types of mutilation that can include such things as pricking the clitoris with needles, burning or scarring the genitals, and ripping or tearing the vagina.

Code 629.8 (other specified disorders of female genital organs) was deleted and replaced by these 2 new 5-digit codes:

629.81 Habitual aborter without current pregnancy

629.89 Other unspecified disorders of female genital organs

Index changes to ICD-9-CM are also important to note. This year the reference for vaginal intraepithelial neoplasia (VIN I and VIN II) was changed from code 624.8 (other specified noninflammatory disorders of vulva and perineum) to:

624.0 Dystrophy of vulva

New category: Pain control

338 Pain, not elsewhere classified

338.18 Other acute postoperative pain

338.28 Other chronic postoperative pain

338.3 Neoplasm-related pain (acute) (chronic)

Diagnostic coding just got easier if your practice includes insertion of an On-Q device for postoperative pain. A whole new category of codes groups pain into acute and chronic classifications and includes codes for both types of postoperative pain. These new codes would not be used to report generalized pain (780.96) or localized pain by site (eg, pelvic pain, 625.9), or pain disorders attributed to psychological factors. Listed above are some of the new codes in this category that may be of particular interest to ObGyns.

Imaging

Breast calcifications

793.81 Microcalcifications seen on a mammogram

793.89 Other abnormal findings on radiological examination of breast

ICD-9-CM now differentiates microcalcifications. The less-specific code is for findings documented as simply mammographic calcification or mammographic calculus.

Inconclusive imaging due to obesity

793.91 Image test inconclusive due to excess body fat

You must add a second code indicating the patient’s body mass index (BMI).

Other imaging abnormalities

793.99 Other nonspecific abnormal findings on radiological and other examination of body structure

This code could be reported for such things as an abnormal placental finding on ultrasound or an abnormal finding in the skin or subcutaneous tissue, where a more definitive diagnosis is not available.

Urinary symptoms

Additions to your diagnostic arsenal:

788.64 Urinary hesitancy

788.65 Straining on urination

Hyperglycemia

A new inclusion term is added

790.29 Other abnormal glucose

The existing code now includes a diagnosis of hyperglycemia not elsewhere specified.

V-codes for men

V26.34 Testing of male for genetic disease carrier status

V26.35 Encounter for testing of male partner of habitual aborter

V26.39 Other genetic testing of male

Use these new codes to identify the male as the reason for doing the testing—something that has been lacking for years.

Are you monitoring a pregnant patient who had gastric banding or stapling?

There’s a code for that, as of Oct. 1.

Have you seen female genital cutting or mutilation in your practice?

There is a code for that.

Has your patient’s obesity made it difficult to obtain a diagnostic image?

You get the picture.

The new International Diagnostic Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) adds specific codes for these and other disorders.

Cancer codes clinch the case

Specific codes now describe findings that indicate a cancer diagnosis and support appropriate treatment.

Estrogen receptor status

V86.0 Estrogen receptor positive

V86.1 Estrogen receptor negative

The 2007 ICD-9-CM adds a new category: estrogen receptor status. This bit of diagnostic information is an important indicator of the type of treatment to which breast cancer will be responsive. For instance, an estrogen-receptor–positive (ER+) finding means estrogen is causing the tumor to grow. This information in conjunction with a primary diagnosis of malignant neoplasm of the breast (ICD-9-CM codes 174.0–174.9) instantly gives the payer a snapshot of the patient’s condition and supports hormone suppression treatment.

Elevated tumor markers

795.81 Elevated carcinoembryonic antigen [CEA]

795.82 Elevated cancer antigen 125 [CA 125]

795.89 Other abnormal tumor markers

Previously, an elevated CA-125 tumor marker was reported using the unspecified code 790.99 (other nonspecific findings in blood), but with the addition of a new code subcategory, 795.8x, to report elevated tumor-associated and specific antigens, this will no longer be a problem.

Abnormal cervical cytology

795.06 Papanicolaou smear of cervix with cytologic evidence of malignancy

The inclusion term “cytologic evidence of carcinoma” was deleted from code 795.04 (Papanicolaou smear of cervix and cervical HPV). A new code reports this finding, and this new code is now an “excludes” diagnosis under code 233.1 (carcinoma in situ of cervix uteri). Furthermore, code 233.1 has a new inclusion definition: cervical intraepithelial glandular neoplasia.

OB complications

649.xx Other conditions or status of the mother, complicating pregnancy, childbirth, or the puerperium

Preexisting conditions are covered in the new category.

Bariatric surgery and pregnancy

649.2X Bariatric surgery status complicating pregnancy, childbirth, or the puerperium

Until now, if you were monitoring a pregnant woman more closely because of her previous bariatric surgery, your only option was code 648.93 (other current conditions, classifiable elsewhere). The new code is for any intervention required during the pregnancy, if the mother has had obesity surgery such as gastric banding or gastric stapling.

A 5th digit must be appended: 0, unspecified episode of care; 1, delivered with or without mention of antepartum condition; 2, delivered with postpartum condition; 3, antepartum condition or complication; 4, postpartum complication.

Smoking, obesity, epilepsy, and more

649.0 [0–4] Tobacco use disorder

You must clearly indicate that the patient’s current smoking is complicating the management of her pregnancy.

649.1 [0–4] Obesity

A secondary code for type of obesity is required; for instance, 278.01 (morbid obesity).

649.3 [0–4] Coagulation defects

A second code from the 286 category (coagulation defects) must be added to identify the exact condition. If a coagulation defect causes antepartum hemorrhage, the correct code is 641.3x. A coagulation defect that appears only in the postpartum period is coded 666.3x.

649.4 [0–4] Epilepsy

A secondary code identifies the type of epilepsy (345.00–345.91). However, if the patient has eclampsia, use the code 642.6 (eclampsia with convulsions).

649.5 [0, 1, 3] Spotting

This code will be used predominately in early pregnancy when spotting is the chief complaint and there is no evidence of miscarriage. Note that the allowable 5th digits for this code exclude 2 and 4, because spotting is not considered a complication in the postpartum period. If the patient is bleeding heavily, other existing codes would be selected, such as 640.0x (threatened abortion) or 641.1x (hemorrhage from placenta previa).

649.6 [0–4] Uterine size-date discrepancy

This condition, which was formerly included under 646.8x (other specified complications of pregnancy), is used most often when an ultrasound is performed to date the pregnancy, especially when the last monthly period is unknown.

666.1x Other immediate postpartum hemorrhage

This code is revised, and now specifies uterine atony with hemorrhage. Uterine atony without hemorrhage is coded 669.8x.

More specific “other” codes

Several “other”-type codes for gynecologic conditions got more specific. For example, 2 new, more specific, 5-digit codes replace code 616.8 (other specified inflammatory diseases of cervix, vagina, and vulva).

 

616.81 Mucositis (ulcerative) of the cervix, vagina, and vulva

Requires an additional E code to identify the adverse affects of therapy that caused the mucositis, such as antineoplastic or immunosuppressive drugs or radiation therapy.

616.89 Other inflammatory disease of the cervix, vagina, and vulva

Identifies conditions such as a caruncle of the vagina or labium or ulcer of the vagina.

616.84 Cervical stump prolapse

Previously was reported with the code 618.39 (other specified genital prolapse).

629.29 Other types of female genital mutilation

This code includes female genital cutting or mutilation Type IV status, the collective term for other types of mutilation that can include such things as pricking the clitoris with needles, burning or scarring the genitals, and ripping or tearing the vagina.

Code 629.8 (other specified disorders of female genital organs) was deleted and replaced by these 2 new 5-digit codes:

629.81 Habitual aborter without current pregnancy

629.89 Other unspecified disorders of female genital organs

Index changes to ICD-9-CM are also important to note. This year the reference for vaginal intraepithelial neoplasia (VIN I and VIN II) was changed from code 624.8 (other specified noninflammatory disorders of vulva and perineum) to:

624.0 Dystrophy of vulva

New category: Pain control

338 Pain, not elsewhere classified

338.18 Other acute postoperative pain

338.28 Other chronic postoperative pain

338.3 Neoplasm-related pain (acute) (chronic)

Diagnostic coding just got easier if your practice includes insertion of an On-Q device for postoperative pain. A whole new category of codes groups pain into acute and chronic classifications and includes codes for both types of postoperative pain. These new codes would not be used to report generalized pain (780.96) or localized pain by site (eg, pelvic pain, 625.9), or pain disorders attributed to psychological factors. Listed above are some of the new codes in this category that may be of particular interest to ObGyns.

Imaging

Breast calcifications

793.81 Microcalcifications seen on a mammogram

793.89 Other abnormal findings on radiological examination of breast

ICD-9-CM now differentiates microcalcifications. The less-specific code is for findings documented as simply mammographic calcification or mammographic calculus.

Inconclusive imaging due to obesity

793.91 Image test inconclusive due to excess body fat

You must add a second code indicating the patient’s body mass index (BMI).

Other imaging abnormalities

793.99 Other nonspecific abnormal findings on radiological and other examination of body structure

This code could be reported for such things as an abnormal placental finding on ultrasound or an abnormal finding in the skin or subcutaneous tissue, where a more definitive diagnosis is not available.

Urinary symptoms

Additions to your diagnostic arsenal:

788.64 Urinary hesitancy

788.65 Straining on urination

Hyperglycemia

A new inclusion term is added

790.29 Other abnormal glucose

The existing code now includes a diagnosis of hyperglycemia not elsewhere specified.

V-codes for men

V26.34 Testing of male for genetic disease carrier status

V26.35 Encounter for testing of male partner of habitual aborter

V26.39 Other genetic testing of male

Use these new codes to identify the male as the reason for doing the testing—something that has been lacking for years.

Did benzodiazepines prescribed to patient
with addiction cause delirium?

Maricopa County (AZ) Superior Court

A 40-year-old woman addicted to diazepam sought treatment from a psychiatric nurse who performed a psychological evaluation. The patient claimed that the nurse negligently prescribed benzodiazepines and other medications for anxiety, panic attacks, and depression.

The patient claimed that the prescriptions caused a drug-induced delirium, during which she put a nonlethal amount of the medication on her two minor daughters’ ice cream, then attempted suicide by overdosing with her prescriptions. The patient and her daughters survived.

The patient was charged with two counts of attempted murder and was incarcerated for 18 months while awaiting trail. She was acquitted of the charges but lost custody of her daughters.

The psychiatric nurse argued that the medication prescribed was appropriate and the patient was not in a drug-induced delirium when she tried to kill herself and her daughters. The defense alleged that other factors caused the patient to attempt suicide/homicide, including a pending divorce and financial problems.

• A defense verdict was returned
  

Woman claims she was prescribed narcotics
despite alprazolam addiction

Multnomah County (OR) Superior Court

The patient, age 57, began seeing a psychiatrist in March 1993 for anxiety and panic attacks. She had kicked a 10-year alprazolam addiction and had been drug-free for more than 6 months when she first visited the psychiatrist.

The patient claimed that over the next 11 years she developed an intimate friendship with the psychiatrist. The patient visited the psychiatrist’s office almost weekly—sometimes twice a week—and incurred almost $100,000 in fees. The patient says that the psychiatrist prescribed her narcotics, then sought the drugs from her for his personal use, and was negligent in his treatment.

• A $593,000 verdict was returned, which included $200,000 in punitive damages
  

Box 1

Dr. Grant’s observations

Should benzodiazepines or other addictive substances be prescribed to a patient with a history of substance abuse? Little evidence guides clinicians,^1,2 and limited research has examined whether former substance abusers are more likely than other patients to abuse benzodiazepines or if these medications increase the risk of substance abuse relapse.²

A psychiatrist can prescribe medication whenever a medical basis exists. In the first case a patient with anxiety and panic attacks was given benzodiazepines, an appropriate treatment for anxiety disorder.³ But what if the patient has a history of substance abuse? When is prescribing these medications negligent?

The fiduciary relationship between psychiatrist and patient states that the therapist is the patient’s ally and should always act in the patient’s best interest. With limited data, clinicians have no clear rule for a standard of care.

On one hand, benzodiazepine misuse is a problem and these medications must be prescribed cautiously. In 2004 roughly 300,000 Americans reported using prescription sedatives for nonmedical purposes.⁴ Many addiction specialists believe benzodiazepines are contraindicated for patients with current alcohol or drug abuse problems and for those in recovery. In this scenario, the clinician could choose an appropriate alternative to a benzodiazepine such as an antidepressant, buspirone, beta blocker, or anticonvulsant. Explain to the patient that these medications’ clinical effect is slower than that of benzodiazepines. Also consider psychotherapy to address anxiety.

On the other hand, benzodiazepines might be underused because of fear of addiction.⁵ Clinicians must consider whether their prescribing practices are designed to protect themselves or are in the patients’ best interests (Box 1). Of course, when treating a patient with a benzodiazepine addiction, the risk-benefit analysis shifts and abuse concerns may be more appropriate.

In the first case, the patient attempted suicide by overdosing on the prescribed medication. This fact might support the patient’s argument that she was not an appropriate candidate for benzodiazepines and the psychiatric nurse could be held liable—even though in this case she was not. One court found that a psychiatrist writing prescriptions for large amounts of controlled substances to someone addicted to drugs could be held liable for the patient’s suicide.⁶

 

In the second case, a psychiatrist prescribed narcotics to a patient with a history of addiction. The code of medical ethics is clear: A psychiatrist who regularly practices outside his or her area of professional competence should be considered as having acted in an unethical manner.⁷ So if you wish to prescribe narcotics, you must follow internal medicine’s ethical standards (Box 2).

Responsibility of care

Although the nurse in the first case could be liable for her actions, the psychiatrist who supervised the nurse might also be partially responsible. The law assumes that those who work under a physician’s supervision act as his or her agents. Nurses working for a physician are the physician’s agents, and the physician is responsible for a nurse’s acts. This legal principle is respondeat superior, or “let the master reply.”

Generally, the physician’s lack of knowledge about what the nurse prescribes is not a defense for a malpractice claim. In fact, the law requires that the physician know whether his or her agents meet the profession’s standard of care. In cases where a nurse prescribes an inappropriate medication, the psychiatrist can be charged with negligent supervision—that is, failing to provide to the nurse proper guidance and instruction.

Ethical conduct

Relationships with patients. The second case raises several egregious issues in patient care. Although intimate relationships with patients are prohibited, the fact that these cases still come before licensing boards and courts suggests that physicians are not getting the message. Although the report of this case is vague about what “intimate” means, several points are raised:

• Sexual relationships with current or former patients are not allowed.⁷ A patient is vulnerable, and the power differential makes it difficult for the patient to resist the therapist’s requests.
  
• Nonsexual, intimate relationships likely would be seen as a boundary violation, akin to a sexual relationship. In the case presented, the boundary violation is obvious even though the relationship may not have been sexual.
  

Box 2

Inappropriate prescribing. There is no justification for a physician seeking drugs from a patient for personal use, as was reported in the second case. Interestingly, one study found that 17.6% of physicians had used opioids in the past year in an unsupervised fashion.¹⁰

Medical ethics prohibit this behavior and state that psychiatrists should not:⁷

• use the unique position afforded by the psychotherapeutic situation to influence the patient in any way that is not directly relevant to treatment goals
  
• exploit information furnished by patients.
  

In this case, the psychiatrist could face federal and state criminal charges because of his use of a patient’s narcotics and inappropriate prescribing.

State medical boards have varying procedures in place to handle a physician’s substance abuse.

These programs’ goal is to assist recovery, eliminate risk to the public, and allow the physician to return to work. Clinicians should be aware of such programs in their jurisdictions.

Drug brand names

• Alprazolam • Xanax
  
• Buspirone • BuSpar
  
• Diazepam • Valium
  

Did benzodiazepines prescribed to patient
with addiction cause delirium?

Maricopa County (AZ) Superior Court

A 40-year-old woman addicted to diazepam sought treatment from a psychiatric nurse who performed a psychological evaluation. The patient claimed that the nurse negligently prescribed benzodiazepines and other medications for anxiety, panic attacks, and depression.

The patient claimed that the prescriptions caused a drug-induced delirium, during which she put a nonlethal amount of the medication on her two minor daughters’ ice cream, then attempted suicide by overdosing with her prescriptions. The patient and her daughters survived.

The patient was charged with two counts of attempted murder and was incarcerated for 18 months while awaiting trail. She was acquitted of the charges but lost custody of her daughters.

The psychiatric nurse argued that the medication prescribed was appropriate and the patient was not in a drug-induced delirium when she tried to kill herself and her daughters. The defense alleged that other factors caused the patient to attempt suicide/homicide, including a pending divorce and financial problems.

• A defense verdict was returned
  

Woman claims she was prescribed narcotics
despite alprazolam addiction

Multnomah County (OR) Superior Court

The patient, age 57, began seeing a psychiatrist in March 1993 for anxiety and panic attacks. She had kicked a 10-year alprazolam addiction and had been drug-free for more than 6 months when she first visited the psychiatrist.

The patient claimed that over the next 11 years she developed an intimate friendship with the psychiatrist. The patient visited the psychiatrist’s office almost weekly—sometimes twice a week—and incurred almost $100,000 in fees. The patient says that the psychiatrist prescribed her narcotics, then sought the drugs from her for his personal use, and was negligent in his treatment.

• A $593,000 verdict was returned, which included $200,000 in punitive damages
  

Box 1

Dr. Grant’s observations

Should benzodiazepines or other addictive substances be prescribed to a patient with a history of substance abuse? Little evidence guides clinicians,^1,2 and limited research has examined whether former substance abusers are more likely than other patients to abuse benzodiazepines or if these medications increase the risk of substance abuse relapse.²

A psychiatrist can prescribe medication whenever a medical basis exists. In the first case a patient with anxiety and panic attacks was given benzodiazepines, an appropriate treatment for anxiety disorder.³ But what if the patient has a history of substance abuse? When is prescribing these medications negligent?

The fiduciary relationship between psychiatrist and patient states that the therapist is the patient’s ally and should always act in the patient’s best interest. With limited data, clinicians have no clear rule for a standard of care.

On one hand, benzodiazepine misuse is a problem and these medications must be prescribed cautiously. In 2004 roughly 300,000 Americans reported using prescription sedatives for nonmedical purposes.⁴ Many addiction specialists believe benzodiazepines are contraindicated for patients with current alcohol or drug abuse problems and for those in recovery. In this scenario, the clinician could choose an appropriate alternative to a benzodiazepine such as an antidepressant, buspirone, beta blocker, or anticonvulsant. Explain to the patient that these medications’ clinical effect is slower than that of benzodiazepines. Also consider psychotherapy to address anxiety.

On the other hand, benzodiazepines might be underused because of fear of addiction.⁵ Clinicians must consider whether their prescribing practices are designed to protect themselves or are in the patients’ best interests (Box 1). Of course, when treating a patient with a benzodiazepine addiction, the risk-benefit analysis shifts and abuse concerns may be more appropriate.

In the first case, the patient attempted suicide by overdosing on the prescribed medication. This fact might support the patient’s argument that she was not an appropriate candidate for benzodiazepines and the psychiatric nurse could be held liable—even though in this case she was not. One court found that a psychiatrist writing prescriptions for large amounts of controlled substances to someone addicted to drugs could be held liable for the patient’s suicide.⁶

 

In the second case, a psychiatrist prescribed narcotics to a patient with a history of addiction. The code of medical ethics is clear: A psychiatrist who regularly practices outside his or her area of professional competence should be considered as having acted in an unethical manner.⁷ So if you wish to prescribe narcotics, you must follow internal medicine’s ethical standards (Box 2).

Responsibility of care

Although the nurse in the first case could be liable for her actions, the psychiatrist who supervised the nurse might also be partially responsible. The law assumes that those who work under a physician’s supervision act as his or her agents. Nurses working for a physician are the physician’s agents, and the physician is responsible for a nurse’s acts. This legal principle is respondeat superior, or “let the master reply.”

Generally, the physician’s lack of knowledge about what the nurse prescribes is not a defense for a malpractice claim. In fact, the law requires that the physician know whether his or her agents meet the profession’s standard of care. In cases where a nurse prescribes an inappropriate medication, the psychiatrist can be charged with negligent supervision—that is, failing to provide to the nurse proper guidance and instruction.

Ethical conduct

Relationships with patients. The second case raises several egregious issues in patient care. Although intimate relationships with patients are prohibited, the fact that these cases still come before licensing boards and courts suggests that physicians are not getting the message. Although the report of this case is vague about what “intimate” means, several points are raised:

• Sexual relationships with current or former patients are not allowed.⁷ A patient is vulnerable, and the power differential makes it difficult for the patient to resist the therapist’s requests.
  
• Nonsexual, intimate relationships likely would be seen as a boundary violation, akin to a sexual relationship. In the case presented, the boundary violation is obvious even though the relationship may not have been sexual.
  

Box 2

Inappropriate prescribing. There is no justification for a physician seeking drugs from a patient for personal use, as was reported in the second case. Interestingly, one study found that 17.6% of physicians had used opioids in the past year in an unsupervised fashion.¹⁰

Medical ethics prohibit this behavior and state that psychiatrists should not:⁷

• use the unique position afforded by the psychotherapeutic situation to influence the patient in any way that is not directly relevant to treatment goals
  
• exploit information furnished by patients.
  

In this case, the psychiatrist could face federal and state criminal charges because of his use of a patient’s narcotics and inappropriate prescribing.

State medical boards have varying procedures in place to handle a physician’s substance abuse.

These programs’ goal is to assist recovery, eliminate risk to the public, and allow the physician to return to work. Clinicians should be aware of such programs in their jurisdictions.

Drug brand names

• Alprazolam • Xanax
  
• Buspirone • BuSpar
  
• Diazepam • Valium
  

Did benzodiazepines prescribed to patient
with addiction cause delirium?

Maricopa County (AZ) Superior Court

A 40-year-old woman addicted to diazepam sought treatment from a psychiatric nurse who performed a psychological evaluation. The patient claimed that the nurse negligently prescribed benzodiazepines and other medications for anxiety, panic attacks, and depression.

The patient claimed that the prescriptions caused a drug-induced delirium, during which she put a nonlethal amount of the medication on her two minor daughters’ ice cream, then attempted suicide by overdosing with her prescriptions. The patient and her daughters survived.

The patient was charged with two counts of attempted murder and was incarcerated for 18 months while awaiting trail. She was acquitted of the charges but lost custody of her daughters.

The psychiatric nurse argued that the medication prescribed was appropriate and the patient was not in a drug-induced delirium when she tried to kill herself and her daughters. The defense alleged that other factors caused the patient to attempt suicide/homicide, including a pending divorce and financial problems.

• A defense verdict was returned
  

Woman claims she was prescribed narcotics
despite alprazolam addiction

Multnomah County (OR) Superior Court

The patient, age 57, began seeing a psychiatrist in March 1993 for anxiety and panic attacks. She had kicked a 10-year alprazolam addiction and had been drug-free for more than 6 months when she first visited the psychiatrist.

The patient claimed that over the next 11 years she developed an intimate friendship with the psychiatrist. The patient visited the psychiatrist’s office almost weekly—sometimes twice a week—and incurred almost $100,000 in fees. The patient says that the psychiatrist prescribed her narcotics, then sought the drugs from her for his personal use, and was negligent in his treatment.

• A $593,000 verdict was returned, which included $200,000 in punitive damages
  

Box 1

Dr. Grant’s observations

Should benzodiazepines or other addictive substances be prescribed to a patient with a history of substance abuse? Little evidence guides clinicians,^1,2 and limited research has examined whether former substance abusers are more likely than other patients to abuse benzodiazepines or if these medications increase the risk of substance abuse relapse.²

A psychiatrist can prescribe medication whenever a medical basis exists. In the first case a patient with anxiety and panic attacks was given benzodiazepines, an appropriate treatment for anxiety disorder.³ But what if the patient has a history of substance abuse? When is prescribing these medications negligent?

The fiduciary relationship between psychiatrist and patient states that the therapist is the patient’s ally and should always act in the patient’s best interest. With limited data, clinicians have no clear rule for a standard of care.

On one hand, benzodiazepine misuse is a problem and these medications must be prescribed cautiously. In 2004 roughly 300,000 Americans reported using prescription sedatives for nonmedical purposes.⁴ Many addiction specialists believe benzodiazepines are contraindicated for patients with current alcohol or drug abuse problems and for those in recovery. In this scenario, the clinician could choose an appropriate alternative to a benzodiazepine such as an antidepressant, buspirone, beta blocker, or anticonvulsant. Explain to the patient that these medications’ clinical effect is slower than that of benzodiazepines. Also consider psychotherapy to address anxiety.

On the other hand, benzodiazepines might be underused because of fear of addiction.⁵ Clinicians must consider whether their prescribing practices are designed to protect themselves or are in the patients’ best interests (Box 1). Of course, when treating a patient with a benzodiazepine addiction, the risk-benefit analysis shifts and abuse concerns may be more appropriate.

In the first case, the patient attempted suicide by overdosing on the prescribed medication. This fact might support the patient’s argument that she was not an appropriate candidate for benzodiazepines and the psychiatric nurse could be held liable—even though in this case she was not. One court found that a psychiatrist writing prescriptions for large amounts of controlled substances to someone addicted to drugs could be held liable for the patient’s suicide.⁶

 

In the second case, a psychiatrist prescribed narcotics to a patient with a history of addiction. The code of medical ethics is clear: A psychiatrist who regularly practices outside his or her area of professional competence should be considered as having acted in an unethical manner.⁷ So if you wish to prescribe narcotics, you must follow internal medicine’s ethical standards (Box 2).

Responsibility of care

Although the nurse in the first case could be liable for her actions, the psychiatrist who supervised the nurse might also be partially responsible. The law assumes that those who work under a physician’s supervision act as his or her agents. Nurses working for a physician are the physician’s agents, and the physician is responsible for a nurse’s acts. This legal principle is respondeat superior, or “let the master reply.”

Generally, the physician’s lack of knowledge about what the nurse prescribes is not a defense for a malpractice claim. In fact, the law requires that the physician know whether his or her agents meet the profession’s standard of care. In cases where a nurse prescribes an inappropriate medication, the psychiatrist can be charged with negligent supervision—that is, failing to provide to the nurse proper guidance and instruction.

Ethical conduct

Relationships with patients. The second case raises several egregious issues in patient care. Although intimate relationships with patients are prohibited, the fact that these cases still come before licensing boards and courts suggests that physicians are not getting the message. Although the report of this case is vague about what “intimate” means, several points are raised:

• Sexual relationships with current or former patients are not allowed.⁷ A patient is vulnerable, and the power differential makes it difficult for the patient to resist the therapist’s requests.
  
• Nonsexual, intimate relationships likely would be seen as a boundary violation, akin to a sexual relationship. In the case presented, the boundary violation is obvious even though the relationship may not have been sexual.
  

Box 2

Inappropriate prescribing. There is no justification for a physician seeking drugs from a patient for personal use, as was reported in the second case. Interestingly, one study found that 17.6% of physicians had used opioids in the past year in an unsupervised fashion.¹⁰

Medical ethics prohibit this behavior and state that psychiatrists should not:⁷

• use the unique position afforded by the psychotherapeutic situation to influence the patient in any way that is not directly relevant to treatment goals
  
• exploit information furnished by patients.
  

In this case, the psychiatrist could face federal and state criminal charges because of his use of a patient’s narcotics and inappropriate prescribing.

State medical boards have varying procedures in place to handle a physician’s substance abuse.

These programs’ goal is to assist recovery, eliminate risk to the public, and allow the physician to return to work. Clinicians should be aware of such programs in their jurisdictions.

Drug brand names

• Alprazolam • Xanax
  
• Buspirone • BuSpar
  
• Diazepam • Valium
  

In August the FDA called for new warnings on stimulants used for attention-deficit/hyperactivity disorder (ADHD). Amphetamines now carry black box warnings that say, “Misuse of amphetamines may cause sudden death and serious cardiovascular adverse events.” Amphetamines and methylphenidates used for ADHD include expanded information about cardiovascular risks at usual dosages for patients with heart conditions.

To examine the clinical implications of these warnings, Current Psychiatry hosted a conversation between ADHD experts Anthony Rostain, MD, MA, and Lenard Adler, MD.

Dr. Rostain: Changes to warnings on ADHD medications have many psychiatrists looking for guidance on using stimulants. Can you give us some background and discuss the labeling changes?

Dr. Adler: Stimulants have been used for more than 40 years as ADHD treatments, and they’ve been shown to be highly effective. The FDA, which monitors issues of cardiovascular safety and stimulants in an ongoing way, examined specific isolated cases and changed some of the warnings as a result.

Dr. Rostain: What should practicing psychiatrists be concerned about if they’re thinking of prescribing stimulants for an ADHD patient?

Dr. Adler: The take-home point is that stimulants—because of the way they work—have been known to have minor effects of increasing blood pressure and pulse (Box 1).^1-3 Clinicians have known about issues regarding stimulant use by patients with pre-existing cardiovascular conditions, but now the warnings are more formal for the methylphenidate and amphetamine products.

Dr. Rostain: An FDA committee recommended black box warnings on all stimulants used for ADHD, but the FDA decided instead to clarify warnings in prescription information for some medications. What was the FDA process?

Dr. Adler: The discussion was internal at the FDA, so I can’t say what their thinking was. The black box warning on amphetamines notes two issues. One is the potential for abuse and diversion, and the other warns of potential for sudden death and serious cardiovascular effects if the drug is misused. A warning has also been placed on all methylphenidate products regarding cardiovascular risk for patients with pre-existing cardiovascular conditions, but it is not a black box warning.

Box 1

Dr. Rostain: How were the warnings clarified?

Dr. Adler: The FDA has changed the language. Now physicians are warned that sudden death can occur at usual doses in patients with a pre-existing structural cardiac abnormality or other serious heart problem. So, stimulants generally should not be used in children or adolescents with known serious structural cardiac abnormalities, cardiomyopathy, serious heart rhythm abnormalities, or other serious cardiac problems that may place them at increased vulnerability to the sympathomimetic effects of a stimulant drug.

 

Dr. Rostain: What about adults?

Dr. Adler: The language is the same for adults. Adults have a greater likelihood than children of having a history of serious structural cardiac abnormalities, cardiomyopathy, serious heart rhythm abnormalities, coronary artery disease, or other cardiac problems. Adults with such abnormalities generally should not be treated with stimulant drugs.

Dr. Rostain: What’s the impact for clinicians?

Dr. Adler: Clinicians have known that stimulants should not be used in patients with significant pre-existing cardiovascular conditions. That generally includes structural abnormalities such as serious heart murmurs and abnormalities of the electro-conduction of the impulse through the heart. When patients present with a history of cardiac abnormalities, clinicians should speak to the pediatrician, primary care physician (PCP), or cardiologist, go over the risk factors, and decide whether these medications can be prescribed for the patient.

Dr. Rostain: Should psychiatrists perform screening tests before prescribing stimulants? When should they consult with a specialist?

Dr. Adler: There is no recommendation in the prescribing information. But clearly a clinician should determine whether a patient has structural cardiac abnormalities or serious heart problems. That means taking a history about heart murmur, syncope, or other serious heart problems. Also, you want to know if the patient is hypertensive. The burden is on the prescribing clinician.

Dr. Rostain: Suppose you have a patient with hypertension or a history of a heart condition, should that patient first be evaluated by a cardiologist? What about a screening ECG?

Dr. Adler: There are no specific recommendations. If clinicians have questions about prescribing the medication, they should consult with the patient’s PCP or cardiologist.

Dr. Rostain: Let’s say the patient has some heart issues, but the PCP or pediatrician gives the goahead to prescribe stimulants. What sort of monitoring do you recommend?

Dr. Adler: I can’t answer that directly. Clearly, you’re going to want to partner with the PCP to establish a plan of how to carefully monitor this patient. FDA guidelines recommend ongoing blood pressure monitoring, especially if the patient is hypertensive, but do not specify how often.

Dr. Rostain: What alternatives do psychiatrists have when treating ADHD in patients in whom stimulants may pose some risk?

Dr. Adler: The only approved nonstimulant ADHD medication is atomoxetine, the labeling of which carries language about possible effects on blood pressure. The FDA warning about structural cardiac abnormalities has not been extended to atomoxetine, but blood pressure needs to be monitored. Whether our medical colleagues feel comfortable using a nonstimulant in patients with structural cardiac abnormalities has not been determined.

Dr. Rostain: In the absence of guidelines in the new warnings on stimulants, are there any studies to help clinicians with treatment and monitoring?

Dr. Adler: There’s very little data. A group at Massachusetts General Hospital has been studying the effects of ADHD medication on adults with hypertension (Box 2).⁴ That’s a different issue than a structural cardiac abnormality, but at least we have some data. This group found that you can safely give stimulants to hypertensive patients by partnering with medical colleagues and monitoring the patient carefully. Antihypertensive dosages may need to be adjusted during psychostimulant treatment.

Dr. Rostain: How do you choose a medication if your patient has a structural heart abnormality?

Dr. Adler: Again, we don’t have a lot of data. The decision would depend on the cardiac abnormality and the consulting physician’s comfort level. Keep in mind that psychostimulants have a short duration of effect, so the effects of the medication can dissipate fairly quickly. Again, the decision to medicate a patient with pre-existing cardiac abnormalities must be done with medical guidance.

Box 2

 

Dr. Rostain: So are you saying clinicians should make decisions about prescribing stimulants for patients with ADHD on a case-by-case basis?

Dr. Adler: Exactly.

Dr. Rostain: What about children and adolescents who have unknown structural heart defects? A lot of parents are concerned about reports of sudden cardiac death in young athletes, such as when playing soccer or basketball. Is there any way for practitioners to protect children with ADHD from an unexpected event?

Dr. Adler: In general, stimulants are safe medications, but we don’t have guidelines to help us determine who will need an ECG and who will not. Children are less likely to have had an ECG in the past than an adult, so it’s important to do a history, obtain input from the pediatrician or PCP, and clearly review the risks and benefits of medication therapy with the patient’s family.

Dr. Rostain: What would you advise clinicians to tell parents of children with ADHD or adult patients who have concerns about the new labeling on stimulants?

Dr. Adler: It would be a shame if patients were not receiving treatment for ADHD because of unfounded medical concerns. When these medications are used appropriately, they have dramatic and positive affects on ADHD.

ADHD is common and highly impairing. Deciding not to treat it has serious consequences in terms of divorce, separation, underperformance in school and on the job, unemployment, smoking, substance use, and issues with motor vehicle accidents and driving.

The goal of treatment is for our patients to get better, and ADHD is highly treatable with medication. But we must be cognizant of the warnings and prescribe medications appropriately. The message is that we’ve got to work collaboratively with our partners in medicine and, in the absence of guidelines, use good common sense.

Related resources

• Wilens TE, Hammerness PG, Biederman J, et al. Blood pressure changes associated with medication treatment of adults with attention-deficit/hyperactivity disorder. J Clin Psychiatry 2005;66:253-9.

Drug brand names

• Atomoxetine • Strattera
• Bupropion • Wellbutrin
• Desipramine • Norpramin
• Methylphenidate • Concerta, Ritalin
• Mixed amphetamine salts • Adderall
• Pemoline • Cylert

Disclosures

Dr. Adler is a consultant to and receives grant/research support from Abbott Laboratories, Cephalon, Cortex Pharmaceuticals, Eli Lilly and Company, New River Pharmaceuticals, Novartis Pharmaceuticals Corp., Ortho-McNeil, Pfizer, and Shire. He also receives grant/research support from Bristol-Myers Squibb and Merck and Co., and is a speaker for Eli Lilly and Company.

Dr. Rostain is a consultant to Shire and a speaker for Eli Lilly and Company and Ortho-McNeil.

In August the FDA called for new warnings on stimulants used for attention-deficit/hyperactivity disorder (ADHD). Amphetamines now carry black box warnings that say, “Misuse of amphetamines may cause sudden death and serious cardiovascular adverse events.” Amphetamines and methylphenidates used for ADHD include expanded information about cardiovascular risks at usual dosages for patients with heart conditions.

To examine the clinical implications of these warnings, Current Psychiatry hosted a conversation between ADHD experts Anthony Rostain, MD, MA, and Lenard Adler, MD.

Dr. Rostain: Changes to warnings on ADHD medications have many psychiatrists looking for guidance on using stimulants. Can you give us some background and discuss the labeling changes?

Dr. Adler: Stimulants have been used for more than 40 years as ADHD treatments, and they’ve been shown to be highly effective. The FDA, which monitors issues of cardiovascular safety and stimulants in an ongoing way, examined specific isolated cases and changed some of the warnings as a result.

Dr. Rostain: What should practicing psychiatrists be concerned about if they’re thinking of prescribing stimulants for an ADHD patient?

Dr. Adler: The take-home point is that stimulants—because of the way they work—have been known to have minor effects of increasing blood pressure and pulse (Box 1).^1-3 Clinicians have known about issues regarding stimulant use by patients with pre-existing cardiovascular conditions, but now the warnings are more formal for the methylphenidate and amphetamine products.

Dr. Rostain: An FDA committee recommended black box warnings on all stimulants used for ADHD, but the FDA decided instead to clarify warnings in prescription information for some medications. What was the FDA process?

Dr. Adler: The discussion was internal at the FDA, so I can’t say what their thinking was. The black box warning on amphetamines notes two issues. One is the potential for abuse and diversion, and the other warns of potential for sudden death and serious cardiovascular effects if the drug is misused. A warning has also been placed on all methylphenidate products regarding cardiovascular risk for patients with pre-existing cardiovascular conditions, but it is not a black box warning.

Box 1

Dr. Rostain: How were the warnings clarified?

Dr. Adler: The FDA has changed the language. Now physicians are warned that sudden death can occur at usual doses in patients with a pre-existing structural cardiac abnormality or other serious heart problem. So, stimulants generally should not be used in children or adolescents with known serious structural cardiac abnormalities, cardiomyopathy, serious heart rhythm abnormalities, or other serious cardiac problems that may place them at increased vulnerability to the sympathomimetic effects of a stimulant drug.

 

Dr. Rostain: What about adults?

Dr. Adler: The language is the same for adults. Adults have a greater likelihood than children of having a history of serious structural cardiac abnormalities, cardiomyopathy, serious heart rhythm abnormalities, coronary artery disease, or other cardiac problems. Adults with such abnormalities generally should not be treated with stimulant drugs.

Dr. Rostain: What’s the impact for clinicians?

Dr. Adler: Clinicians have known that stimulants should not be used in patients with significant pre-existing cardiovascular conditions. That generally includes structural abnormalities such as serious heart murmurs and abnormalities of the electro-conduction of the impulse through the heart. When patients present with a history of cardiac abnormalities, clinicians should speak to the pediatrician, primary care physician (PCP), or cardiologist, go over the risk factors, and decide whether these medications can be prescribed for the patient.

Dr. Rostain: Should psychiatrists perform screening tests before prescribing stimulants? When should they consult with a specialist?

Dr. Adler: There is no recommendation in the prescribing information. But clearly a clinician should determine whether a patient has structural cardiac abnormalities or serious heart problems. That means taking a history about heart murmur, syncope, or other serious heart problems. Also, you want to know if the patient is hypertensive. The burden is on the prescribing clinician.

Dr. Rostain: Suppose you have a patient with hypertension or a history of a heart condition, should that patient first be evaluated by a cardiologist? What about a screening ECG?

Dr. Adler: There are no specific recommendations. If clinicians have questions about prescribing the medication, they should consult with the patient’s PCP or cardiologist.

Dr. Rostain: Let’s say the patient has some heart issues, but the PCP or pediatrician gives the goahead to prescribe stimulants. What sort of monitoring do you recommend?

Dr. Adler: I can’t answer that directly. Clearly, you’re going to want to partner with the PCP to establish a plan of how to carefully monitor this patient. FDA guidelines recommend ongoing blood pressure monitoring, especially if the patient is hypertensive, but do not specify how often.

Dr. Rostain: What alternatives do psychiatrists have when treating ADHD in patients in whom stimulants may pose some risk?

Dr. Adler: The only approved nonstimulant ADHD medication is atomoxetine, the labeling of which carries language about possible effects on blood pressure. The FDA warning about structural cardiac abnormalities has not been extended to atomoxetine, but blood pressure needs to be monitored. Whether our medical colleagues feel comfortable using a nonstimulant in patients with structural cardiac abnormalities has not been determined.

Dr. Rostain: In the absence of guidelines in the new warnings on stimulants, are there any studies to help clinicians with treatment and monitoring?

Dr. Adler: There’s very little data. A group at Massachusetts General Hospital has been studying the effects of ADHD medication on adults with hypertension (Box 2).⁴ That’s a different issue than a structural cardiac abnormality, but at least we have some data. This group found that you can safely give stimulants to hypertensive patients by partnering with medical colleagues and monitoring the patient carefully. Antihypertensive dosages may need to be adjusted during psychostimulant treatment.

Dr. Rostain: How do you choose a medication if your patient has a structural heart abnormality?

Dr. Adler: Again, we don’t have a lot of data. The decision would depend on the cardiac abnormality and the consulting physician’s comfort level. Keep in mind that psychostimulants have a short duration of effect, so the effects of the medication can dissipate fairly quickly. Again, the decision to medicate a patient with pre-existing cardiac abnormalities must be done with medical guidance.

Box 2

 

Dr. Rostain: So are you saying clinicians should make decisions about prescribing stimulants for patients with ADHD on a case-by-case basis?

Dr. Adler: Exactly.

Dr. Rostain: What about children and adolescents who have unknown structural heart defects? A lot of parents are concerned about reports of sudden cardiac death in young athletes, such as when playing soccer or basketball. Is there any way for practitioners to protect children with ADHD from an unexpected event?

Dr. Adler: In general, stimulants are safe medications, but we don’t have guidelines to help us determine who will need an ECG and who will not. Children are less likely to have had an ECG in the past than an adult, so it’s important to do a history, obtain input from the pediatrician or PCP, and clearly review the risks and benefits of medication therapy with the patient’s family.

Dr. Rostain: What would you advise clinicians to tell parents of children with ADHD or adult patients who have concerns about the new labeling on stimulants?

Dr. Adler: It would be a shame if patients were not receiving treatment for ADHD because of unfounded medical concerns. When these medications are used appropriately, they have dramatic and positive affects on ADHD.

ADHD is common and highly impairing. Deciding not to treat it has serious consequences in terms of divorce, separation, underperformance in school and on the job, unemployment, smoking, substance use, and issues with motor vehicle accidents and driving.

The goal of treatment is for our patients to get better, and ADHD is highly treatable with medication. But we must be cognizant of the warnings and prescribe medications appropriately. The message is that we’ve got to work collaboratively with our partners in medicine and, in the absence of guidelines, use good common sense.

Related resources

• Wilens TE, Hammerness PG, Biederman J, et al. Blood pressure changes associated with medication treatment of adults with attention-deficit/hyperactivity disorder. J Clin Psychiatry 2005;66:253-9.

Drug brand names

• Atomoxetine • Strattera
• Bupropion • Wellbutrin
• Desipramine • Norpramin
• Methylphenidate • Concerta, Ritalin
• Mixed amphetamine salts • Adderall
• Pemoline • Cylert

Disclosures

Dr. Adler is a consultant to and receives grant/research support from Abbott Laboratories, Cephalon, Cortex Pharmaceuticals, Eli Lilly and Company, New River Pharmaceuticals, Novartis Pharmaceuticals Corp., Ortho-McNeil, Pfizer, and Shire. He also receives grant/research support from Bristol-Myers Squibb and Merck and Co., and is a speaker for Eli Lilly and Company.

Dr. Rostain is a consultant to Shire and a speaker for Eli Lilly and Company and Ortho-McNeil.

In August the FDA called for new warnings on stimulants used for attention-deficit/hyperactivity disorder (ADHD). Amphetamines now carry black box warnings that say, “Misuse of amphetamines may cause sudden death and serious cardiovascular adverse events.” Amphetamines and methylphenidates used for ADHD include expanded information about cardiovascular risks at usual dosages for patients with heart conditions.

To examine the clinical implications of these warnings, Current Psychiatry hosted a conversation between ADHD experts Anthony Rostain, MD, MA, and Lenard Adler, MD.

Dr. Rostain: Changes to warnings on ADHD medications have many psychiatrists looking for guidance on using stimulants. Can you give us some background and discuss the labeling changes?

Dr. Adler: Stimulants have been used for more than 40 years as ADHD treatments, and they’ve been shown to be highly effective. The FDA, which monitors issues of cardiovascular safety and stimulants in an ongoing way, examined specific isolated cases and changed some of the warnings as a result.

Dr. Rostain: What should practicing psychiatrists be concerned about if they’re thinking of prescribing stimulants for an ADHD patient?

Dr. Adler: The take-home point is that stimulants—because of the way they work—have been known to have minor effects of increasing blood pressure and pulse (Box 1).^1-3 Clinicians have known about issues regarding stimulant use by patients with pre-existing cardiovascular conditions, but now the warnings are more formal for the methylphenidate and amphetamine products.

Dr. Rostain: An FDA committee recommended black box warnings on all stimulants used for ADHD, but the FDA decided instead to clarify warnings in prescription information for some medications. What was the FDA process?

Dr. Adler: The discussion was internal at the FDA, so I can’t say what their thinking was. The black box warning on amphetamines notes two issues. One is the potential for abuse and diversion, and the other warns of potential for sudden death and serious cardiovascular effects if the drug is misused. A warning has also been placed on all methylphenidate products regarding cardiovascular risk for patients with pre-existing cardiovascular conditions, but it is not a black box warning.

Box 1

Dr. Rostain: How were the warnings clarified?

Dr. Adler: The FDA has changed the language. Now physicians are warned that sudden death can occur at usual doses in patients with a pre-existing structural cardiac abnormality or other serious heart problem. So, stimulants generally should not be used in children or adolescents with known serious structural cardiac abnormalities, cardiomyopathy, serious heart rhythm abnormalities, or other serious cardiac problems that may place them at increased vulnerability to the sympathomimetic effects of a stimulant drug.

 

Dr. Rostain: What about adults?

Dr. Adler: The language is the same for adults. Adults have a greater likelihood than children of having a history of serious structural cardiac abnormalities, cardiomyopathy, serious heart rhythm abnormalities, coronary artery disease, or other cardiac problems. Adults with such abnormalities generally should not be treated with stimulant drugs.

Dr. Rostain: What’s the impact for clinicians?

Dr. Adler: Clinicians have known that stimulants should not be used in patients with significant pre-existing cardiovascular conditions. That generally includes structural abnormalities such as serious heart murmurs and abnormalities of the electro-conduction of the impulse through the heart. When patients present with a history of cardiac abnormalities, clinicians should speak to the pediatrician, primary care physician (PCP), or cardiologist, go over the risk factors, and decide whether these medications can be prescribed for the patient.

Dr. Rostain: Should psychiatrists perform screening tests before prescribing stimulants? When should they consult with a specialist?

Dr. Adler: There is no recommendation in the prescribing information. But clearly a clinician should determine whether a patient has structural cardiac abnormalities or serious heart problems. That means taking a history about heart murmur, syncope, or other serious heart problems. Also, you want to know if the patient is hypertensive. The burden is on the prescribing clinician.

Dr. Rostain: Suppose you have a patient with hypertension or a history of a heart condition, should that patient first be evaluated by a cardiologist? What about a screening ECG?

Dr. Adler: There are no specific recommendations. If clinicians have questions about prescribing the medication, they should consult with the patient’s PCP or cardiologist.

Dr. Rostain: Let’s say the patient has some heart issues, but the PCP or pediatrician gives the goahead to prescribe stimulants. What sort of monitoring do you recommend?

Dr. Adler: I can’t answer that directly. Clearly, you’re going to want to partner with the PCP to establish a plan of how to carefully monitor this patient. FDA guidelines recommend ongoing blood pressure monitoring, especially if the patient is hypertensive, but do not specify how often.

Dr. Rostain: What alternatives do psychiatrists have when treating ADHD in patients in whom stimulants may pose some risk?

Dr. Adler: The only approved nonstimulant ADHD medication is atomoxetine, the labeling of which carries language about possible effects on blood pressure. The FDA warning about structural cardiac abnormalities has not been extended to atomoxetine, but blood pressure needs to be monitored. Whether our medical colleagues feel comfortable using a nonstimulant in patients with structural cardiac abnormalities has not been determined.

Dr. Rostain: In the absence of guidelines in the new warnings on stimulants, are there any studies to help clinicians with treatment and monitoring?

Dr. Adler: There’s very little data. A group at Massachusetts General Hospital has been studying the effects of ADHD medication on adults with hypertension (Box 2).⁴ That’s a different issue than a structural cardiac abnormality, but at least we have some data. This group found that you can safely give stimulants to hypertensive patients by partnering with medical colleagues and monitoring the patient carefully. Antihypertensive dosages may need to be adjusted during psychostimulant treatment.

Dr. Rostain: How do you choose a medication if your patient has a structural heart abnormality?

Dr. Adler: Again, we don’t have a lot of data. The decision would depend on the cardiac abnormality and the consulting physician’s comfort level. Keep in mind that psychostimulants have a short duration of effect, so the effects of the medication can dissipate fairly quickly. Again, the decision to medicate a patient with pre-existing cardiac abnormalities must be done with medical guidance.

Box 2

 

Dr. Rostain: So are you saying clinicians should make decisions about prescribing stimulants for patients with ADHD on a case-by-case basis?

Dr. Adler: Exactly.

Dr. Rostain: What about children and adolescents who have unknown structural heart defects? A lot of parents are concerned about reports of sudden cardiac death in young athletes, such as when playing soccer or basketball. Is there any way for practitioners to protect children with ADHD from an unexpected event?

Dr. Adler: In general, stimulants are safe medications, but we don’t have guidelines to help us determine who will need an ECG and who will not. Children are less likely to have had an ECG in the past than an adult, so it’s important to do a history, obtain input from the pediatrician or PCP, and clearly review the risks and benefits of medication therapy with the patient’s family.

Dr. Rostain: What would you advise clinicians to tell parents of children with ADHD or adult patients who have concerns about the new labeling on stimulants?

Dr. Adler: It would be a shame if patients were not receiving treatment for ADHD because of unfounded medical concerns. When these medications are used appropriately, they have dramatic and positive affects on ADHD.

ADHD is common and highly impairing. Deciding not to treat it has serious consequences in terms of divorce, separation, underperformance in school and on the job, unemployment, smoking, substance use, and issues with motor vehicle accidents and driving.

The goal of treatment is for our patients to get better, and ADHD is highly treatable with medication. But we must be cognizant of the warnings and prescribe medications appropriately. The message is that we’ve got to work collaboratively with our partners in medicine and, in the absence of guidelines, use good common sense.

Related resources

• Wilens TE, Hammerness PG, Biederman J, et al. Blood pressure changes associated with medication treatment of adults with attention-deficit/hyperactivity disorder. J Clin Psychiatry 2005;66:253-9.

Drug brand names

• Atomoxetine • Strattera
• Bupropion • Wellbutrin
• Desipramine • Norpramin
• Methylphenidate • Concerta, Ritalin
• Mixed amphetamine salts • Adderall
• Pemoline • Cylert

Disclosures

Dr. Adler is a consultant to and receives grant/research support from Abbott Laboratories, Cephalon, Cortex Pharmaceuticals, Eli Lilly and Company, New River Pharmaceuticals, Novartis Pharmaceuticals Corp., Ortho-McNeil, Pfizer, and Shire. He also receives grant/research support from Bristol-Myers Squibb and Merck and Co., and is a speaker for Eli Lilly and Company.

Dr. Rostain is a consultant to Shire and a speaker for Eli Lilly and Company and Ortho-McNeil.

Thomas “Stonewall” Jackson and a small group of men rode at dusk along the still-steaming battlefield perimeter on May 2, 1863. During daylight the Confederates had won a stunning victory at Chancellorsville, Va. Despite marked manpower and hardware inferiority, the leadership of Generals Robert Lee and Stonewall Jackson sent Union General “Fighting” Joe Hooker literally running from the battlefield. Jackson’s evening patrol was to ensure stability and set his plan for the next day.

Encountering other Confederate soldiers on the path in the waning light, the Jackson patrol exchanged words with the men, but the North Carolina contingent of soldiers did not believe the approaching mounted men were Confederate, so they fired into their midst. General Jackson fell, having suffered two gunshot wounds. The large caliber (.58), soft-lead minie ball was heavy, and it expanded when it went through tissue, resulting in shattered bone and tearing of internal soft tissues. Minie ball injuries to an arm or a leg usually meant amputation, and torso or head wounds were most often fatal.

Friendly fire was the source of General Jackson’s mortal upper-arm wound. He was attended by the 27-year-old surgeon, Doctor Hunter McGuire, medical director of the left wing of the Army of Northern Virginia, under General Jackson’s command. Jackson had sustained a minor wound to his right hand and a severe, heavily bleeding wound to his left upper arm. Dr. McGuire amputated the left arm about two inches below the shoulder, administering chloroform anesthesia. Post-operatively, Dr. McGuire diagnosed his patient with pneumonia. Jackson remained ill and died a week later from, presumably, pneumonia. Interestingly, some historians wonder if he actually died of a pulmonary embolus because he had been in bed rest for a week and died of a respiratory event. Either way, he succumbed to complications of his initial injury.

Civil War-era surgery was a gruesome event; it is remarkable that so many of the soldiers actually survived the ordeal. Anesthesia was administered by placing a handkerchief over the nose and mouth and dropping chloroform on the cloth until the patient was unconscious. The surgeon then had about 10-15 minutes to accomplish the surgery with the patient asleep. The most common Civil War surgery was the amputation of an extremity and this was usually accomplished in about 10 minutes. First-person reports and photographic documentation confirm the mounds of discarded limbs outside Civil War field hospitals. It is interesting to note that the use of anesthesia without a protected airway—as in the case of Stonewall Jackson—was the likely etiology of his post-operative (aspiration) pneumonia.

Although the English surgeon Joseph Lister was on his way to setting the standard for antiseptic surgery, this concept did not make its way to the United States until after the 1860s. The Civil War ended in 1865. During the Civil War, surgical instruments were rinsed during and between cases in a tub of increasingly bloody cold water. The surgeon made his way from patient to patient in pus- and blood-splattered garments; it is little wonder that fever was a common and dreaded post-operative event. Surgical fever was often the result of pyemia, (literally pus in the blood), which presumably was the same diagnosis as sepsis. Other deadly complications included erysipelas, osteomyelitis, gangrene, tetanus, and pneumonia. Physicians had almost no way of treating penetrating torso injuries. Surgery was occasionally attempted, but usually fatal. Lacking any modality to localize the intra-abdominal or chest injury pre-operatively and realizing the need to complete the surgery in just minutes, torso surgery was usually not an option.

Those who survived their wounds—and their treatments—must have been a hardy lot. One wonders how many lives would have been saved with just a rudimentary understanding of aseptic technique. Today we face the same issues: amputation, post-operative pneumonia and pulmonary embolism, and wound infections. The problems of yesterday still remain the problems of today and tomorrow. TH

Thomas “Stonewall” Jackson and a small group of men rode at dusk along the still-steaming battlefield perimeter on May 2, 1863. During daylight the Confederates had won a stunning victory at Chancellorsville, Va. Despite marked manpower and hardware inferiority, the leadership of Generals Robert Lee and Stonewall Jackson sent Union General “Fighting” Joe Hooker literally running from the battlefield. Jackson’s evening patrol was to ensure stability and set his plan for the next day.

Encountering other Confederate soldiers on the path in the waning light, the Jackson patrol exchanged words with the men, but the North Carolina contingent of soldiers did not believe the approaching mounted men were Confederate, so they fired into their midst. General Jackson fell, having suffered two gunshot wounds. The large caliber (.58), soft-lead minie ball was heavy, and it expanded when it went through tissue, resulting in shattered bone and tearing of internal soft tissues. Minie ball injuries to an arm or a leg usually meant amputation, and torso or head wounds were most often fatal.

Friendly fire was the source of General Jackson’s mortal upper-arm wound. He was attended by the 27-year-old surgeon, Doctor Hunter McGuire, medical director of the left wing of the Army of Northern Virginia, under General Jackson’s command. Jackson had sustained a minor wound to his right hand and a severe, heavily bleeding wound to his left upper arm. Dr. McGuire amputated the left arm about two inches below the shoulder, administering chloroform anesthesia. Post-operatively, Dr. McGuire diagnosed his patient with pneumonia. Jackson remained ill and died a week later from, presumably, pneumonia. Interestingly, some historians wonder if he actually died of a pulmonary embolus because he had been in bed rest for a week and died of a respiratory event. Either way, he succumbed to complications of his initial injury.

Civil War-era surgery was a gruesome event; it is remarkable that so many of the soldiers actually survived the ordeal. Anesthesia was administered by placing a handkerchief over the nose and mouth and dropping chloroform on the cloth until the patient was unconscious. The surgeon then had about 10-15 minutes to accomplish the surgery with the patient asleep. The most common Civil War surgery was the amputation of an extremity and this was usually accomplished in about 10 minutes. First-person reports and photographic documentation confirm the mounds of discarded limbs outside Civil War field hospitals. It is interesting to note that the use of anesthesia without a protected airway—as in the case of Stonewall Jackson—was the likely etiology of his post-operative (aspiration) pneumonia.

Although the English surgeon Joseph Lister was on his way to setting the standard for antiseptic surgery, this concept did not make its way to the United States until after the 1860s. The Civil War ended in 1865. During the Civil War, surgical instruments were rinsed during and between cases in a tub of increasingly bloody cold water. The surgeon made his way from patient to patient in pus- and blood-splattered garments; it is little wonder that fever was a common and dreaded post-operative event. Surgical fever was often the result of pyemia, (literally pus in the blood), which presumably was the same diagnosis as sepsis. Other deadly complications included erysipelas, osteomyelitis, gangrene, tetanus, and pneumonia. Physicians had almost no way of treating penetrating torso injuries. Surgery was occasionally attempted, but usually fatal. Lacking any modality to localize the intra-abdominal or chest injury pre-operatively and realizing the need to complete the surgery in just minutes, torso surgery was usually not an option.

Those who survived their wounds—and their treatments—must have been a hardy lot. One wonders how many lives would have been saved with just a rudimentary understanding of aseptic technique. Today we face the same issues: amputation, post-operative pneumonia and pulmonary embolism, and wound infections. The problems of yesterday still remain the problems of today and tomorrow. TH

Thomas “Stonewall” Jackson and a small group of men rode at dusk along the still-steaming battlefield perimeter on May 2, 1863. During daylight the Confederates had won a stunning victory at Chancellorsville, Va. Despite marked manpower and hardware inferiority, the leadership of Generals Robert Lee and Stonewall Jackson sent Union General “Fighting” Joe Hooker literally running from the battlefield. Jackson’s evening patrol was to ensure stability and set his plan for the next day.

Encountering other Confederate soldiers on the path in the waning light, the Jackson patrol exchanged words with the men, but the North Carolina contingent of soldiers did not believe the approaching mounted men were Confederate, so they fired into their midst. General Jackson fell, having suffered two gunshot wounds. The large caliber (.58), soft-lead minie ball was heavy, and it expanded when it went through tissue, resulting in shattered bone and tearing of internal soft tissues. Minie ball injuries to an arm or a leg usually meant amputation, and torso or head wounds were most often fatal.

Friendly fire was the source of General Jackson’s mortal upper-arm wound. He was attended by the 27-year-old surgeon, Doctor Hunter McGuire, medical director of the left wing of the Army of Northern Virginia, under General Jackson’s command. Jackson had sustained a minor wound to his right hand and a severe, heavily bleeding wound to his left upper arm. Dr. McGuire amputated the left arm about two inches below the shoulder, administering chloroform anesthesia. Post-operatively, Dr. McGuire diagnosed his patient with pneumonia. Jackson remained ill and died a week later from, presumably, pneumonia. Interestingly, some historians wonder if he actually died of a pulmonary embolus because he had been in bed rest for a week and died of a respiratory event. Either way, he succumbed to complications of his initial injury.

Civil War-era surgery was a gruesome event; it is remarkable that so many of the soldiers actually survived the ordeal. Anesthesia was administered by placing a handkerchief over the nose and mouth and dropping chloroform on the cloth until the patient was unconscious. The surgeon then had about 10-15 minutes to accomplish the surgery with the patient asleep. The most common Civil War surgery was the amputation of an extremity and this was usually accomplished in about 10 minutes. First-person reports and photographic documentation confirm the mounds of discarded limbs outside Civil War field hospitals. It is interesting to note that the use of anesthesia without a protected airway—as in the case of Stonewall Jackson—was the likely etiology of his post-operative (aspiration) pneumonia.

Although the English surgeon Joseph Lister was on his way to setting the standard for antiseptic surgery, this concept did not make its way to the United States until after the 1860s. The Civil War ended in 1865. During the Civil War, surgical instruments were rinsed during and between cases in a tub of increasingly bloody cold water. The surgeon made his way from patient to patient in pus- and blood-splattered garments; it is little wonder that fever was a common and dreaded post-operative event. Surgical fever was often the result of pyemia, (literally pus in the blood), which presumably was the same diagnosis as sepsis. Other deadly complications included erysipelas, osteomyelitis, gangrene, tetanus, and pneumonia. Physicians had almost no way of treating penetrating torso injuries. Surgery was occasionally attempted, but usually fatal. Lacking any modality to localize the intra-abdominal or chest injury pre-operatively and realizing the need to complete the surgery in just minutes, torso surgery was usually not an option.

Those who survived their wounds—and their treatments—must have been a hardy lot. One wonders how many lives would have been saved with just a rudimentary understanding of aseptic technique. Today we face the same issues: amputation, post-operative pneumonia and pulmonary embolism, and wound infections. The problems of yesterday still remain the problems of today and tomorrow. TH

The Aspen were turning a golden brown, the cattle were fattened for market, and Doc Marsden was drunk again. His head lay on the two planks that served as a bar in what could only charitably be called a saloon. There were two places for a man to drink in Timberline, and this was Doc’s preferred watering hole.

Earlier that day Doc had been busy enough. There’d been a big brawl at the Triple H, and Billy Harkness had shot his younger brother, Lukas, after a lucky punch had broken Billy’s overlarge nose. It wasn’t a bad wound; Lukas had ducked, and the bullet had skimmed his back and lodged in his calf.

Doc had dressed the back wound with a poultice and fished the 0.45 slug from the gastrocnemius. He knew that much anatomy, but not much more. His hands had shaken ’till he had swigged a few swallows of what passed for bourbon. It was nervous work whittling on a Harkness. Luckily Lukas and Billy were a sight more intoxicated than Doc, and their big brother Boone Harkness was somewhere up the trail. The eldest Harkness brother had restless snake eyes. Boone never missed a thing, especially a target. He made Doc Marsden sweat. Doc gave Lukas a spoonful of laudanum, and his patient was soon snoring peacefully on the door they had used as an operating table. Doc took a small swig himself.

After he was sure that the Harkness boy was settled down and Doc’s helper Marty Johnson was there to watch over Lukas, Doc headed for the saloon and started drinking again. He pondered how he had ended up in Timberline. This hadn’t been his plan when he’d left Philadelphia all those years ago.

Back in Philadelphia his name had been Antonio Lombano. His parents had been immigrants, and he had been lucky to work for a butcher. He’d grown sick of slicing meat, and when the war came he enlisted. Anything to get away from the smell of blood and hanging beefs.

When he enlisted with the 37th infantry he’d expected to learn to shoot a gun and maybe even to die. He might have to kill a couple of Rebs, but at least he would leave Philadelphia. Instead, when they learned he had worked as a butcher, he was relegated to the cook’s tent. He was back to slicing meat. For two months the only flank he outmaneuvered was with his cutting blade.

He had been disemboweling a steer one day when a group of surgeons walked by, looking for an eyeball to dissect. They watched approvingly as he wielded his blade. Three days later he had been reassigned to the medical service as a surgeon’s assistant.

Antonio was assigned to work with Dr. Marsden, a fine surgeon from Boston. He watched with admiration as the surgeon amputated shattered arms and legs, sometimes twenty in a session. Antonio’s job was to help staunch the flow of blood with tourniquet or cautery, to brush the maggots from open wounds, and to count and burn the severed limbs. He was handling meat again.

During the months with Dr. Marsden, Antonio kept his eyes open and watched the doctor’s technique. When things got too busy, he would take up the knife as well. He became expert at sounding bullet wounds and was competent at below-the-knee amputations.

 

The war dragged on, and Antonio grew tired of endless surgery that seemed to be alleviated only by weeks of boredom. Dr. Marsden had been lying sick in his bunk for a week, febrile, jaundiced, and vomiting blood. Antonio suspected he’d picked up yellow jack in Texas. One day, he walked into the tent and found the surgeon dead. Without further thought, Antonio loaded the surgeon’s books and surgical kit into a bag, mounted a blue roan, and rode away from the war.

Fourteen years later, he sat with his head on a bar, vertiginous from the cheap liquor. He had become Old Doc Marsden, who liked a drink but sure was handy with a blade. He had pulled a thousand arrowheads, had sounded even more bullet wounds, and set countless fractures. He kept to the rough mining towns and frontier spaces where there was no shortage of injuries and no questions were asked. Timberline was just his speed. Recently, a second doctor had come to town. He did not mind the competition; in fact, he was glad to have someone to whom he could send the tougher cases.

 

Time passes.

 

It was a cool fall morning. There was a frost on the ground, and Doc Marsden was hung-over, sitting on his porch rolling his first morning cigarette. Boone Harkness had returned to town those many months ago with a wife, and she was pregnant. The new doctor in town had taken her case. Doc was glad; he wanted nothing to do with either Snake-Eye Harkness or his bride. He’d seen her only once, walking in town, and that was enough. She seemed a tiny china doll next to the tough man with the narrow hips and wide shoulders.

A rider approached his house. Some cowboy had probably been shot last night, or had stumbled down drunk and broken his leg. But it was Billy Harkness. He told Doc he was wanted on the Harkness ranch, pronto. The new doctor, Jenkins, was having trouble with Helena Harkness and wanted Doc’s help. That could only mean things were bad, real bad. Doc had foaled a few in his time, but he was no hand at tricky birthing. Doc Marsden said he’d be by shortly. Billy looked at him with pity. Snake-Eye had said now.

Doc ran into his home and took a quick drink from his whisky bottle, then grabbed his bag and his Colt. They rode out in the cool morning air, Billy leading the way. Doc Marsden thought about the gun in his holster. It would not be hard to put a slug in Billy’s back and make for the high country. He might get away. But then he’d spend the rest of his days looking over his shoulder. He might as well face his doom straight up. He was a fake and a drunk, but he was no coward. He had never shot a man, and he wouldn’t start now.

Halfway to the Harkness spread, Billy pulled up. He had another chore to run, he said; he’d be up at the big house later that day. This was Doc’s chance. He might not be willing to shoot Billy and run for it, but he was mounted, and the road was open to the north and west. He thought about the scene in the ranch house: thin-legged Helena trying to squeeze out that big Harkness baby, bleeding, crying, dying. If she died so would Doc, no question about that.

Doc turned north and headed up the road a mile, then stopped. He looked out over the prairie. He thought about the immigrant boy, the butcher shop, the war, the bullets and arrows. Philadelphia was a lifetime away. Antonio Lombano was long dead. He was Doc Marsden. He took a deep breath of mountain air, thought about the bottle in his saddlebag, and left it there. He turned the blue roan with the double snake brand south and headed toward the Harkness ranch. TH

 

Jamie Newman, MD, FACP, is the physician editor of The Hospitalist, consultant, Hospital Internal Medicine, and assistant professor of internal medicine and medical history, Mayo Clinic College of Medicine at the Mayo Clinic College of Medicine, Rochester, Minn.

The Aspen were turning a golden brown, the cattle were fattened for market, and Doc Marsden was drunk again. His head lay on the two planks that served as a bar in what could only charitably be called a saloon. There were two places for a man to drink in Timberline, and this was Doc’s preferred watering hole.

Earlier that day Doc had been busy enough. There’d been a big brawl at the Triple H, and Billy Harkness had shot his younger brother, Lukas, after a lucky punch had broken Billy’s overlarge nose. It wasn’t a bad wound; Lukas had ducked, and the bullet had skimmed his back and lodged in his calf.

Doc had dressed the back wound with a poultice and fished the 0.45 slug from the gastrocnemius. He knew that much anatomy, but not much more. His hands had shaken ’till he had swigged a few swallows of what passed for bourbon. It was nervous work whittling on a Harkness. Luckily Lukas and Billy were a sight more intoxicated than Doc, and their big brother Boone Harkness was somewhere up the trail. The eldest Harkness brother had restless snake eyes. Boone never missed a thing, especially a target. He made Doc Marsden sweat. Doc gave Lukas a spoonful of laudanum, and his patient was soon snoring peacefully on the door they had used as an operating table. Doc took a small swig himself.

After he was sure that the Harkness boy was settled down and Doc’s helper Marty Johnson was there to watch over Lukas, Doc headed for the saloon and started drinking again. He pondered how he had ended up in Timberline. This hadn’t been his plan when he’d left Philadelphia all those years ago.

Back in Philadelphia his name had been Antonio Lombano. His parents had been immigrants, and he had been lucky to work for a butcher. He’d grown sick of slicing meat, and when the war came he enlisted. Anything to get away from the smell of blood and hanging beefs.

When he enlisted with the 37th infantry he’d expected to learn to shoot a gun and maybe even to die. He might have to kill a couple of Rebs, but at least he would leave Philadelphia. Instead, when they learned he had worked as a butcher, he was relegated to the cook’s tent. He was back to slicing meat. For two months the only flank he outmaneuvered was with his cutting blade.

He had been disemboweling a steer one day when a group of surgeons walked by, looking for an eyeball to dissect. They watched approvingly as he wielded his blade. Three days later he had been reassigned to the medical service as a surgeon’s assistant.

Antonio was assigned to work with Dr. Marsden, a fine surgeon from Boston. He watched with admiration as the surgeon amputated shattered arms and legs, sometimes twenty in a session. Antonio’s job was to help staunch the flow of blood with tourniquet or cautery, to brush the maggots from open wounds, and to count and burn the severed limbs. He was handling meat again.

During the months with Dr. Marsden, Antonio kept his eyes open and watched the doctor’s technique. When things got too busy, he would take up the knife as well. He became expert at sounding bullet wounds and was competent at below-the-knee amputations.

 

The war dragged on, and Antonio grew tired of endless surgery that seemed to be alleviated only by weeks of boredom. Dr. Marsden had been lying sick in his bunk for a week, febrile, jaundiced, and vomiting blood. Antonio suspected he’d picked up yellow jack in Texas. One day, he walked into the tent and found the surgeon dead. Without further thought, Antonio loaded the surgeon’s books and surgical kit into a bag, mounted a blue roan, and rode away from the war.

Fourteen years later, he sat with his head on a bar, vertiginous from the cheap liquor. He had become Old Doc Marsden, who liked a drink but sure was handy with a blade. He had pulled a thousand arrowheads, had sounded even more bullet wounds, and set countless fractures. He kept to the rough mining towns and frontier spaces where there was no shortage of injuries and no questions were asked. Timberline was just his speed. Recently, a second doctor had come to town. He did not mind the competition; in fact, he was glad to have someone to whom he could send the tougher cases.

 

Time passes.

 

It was a cool fall morning. There was a frost on the ground, and Doc Marsden was hung-over, sitting on his porch rolling his first morning cigarette. Boone Harkness had returned to town those many months ago with a wife, and she was pregnant. The new doctor in town had taken her case. Doc was glad; he wanted nothing to do with either Snake-Eye Harkness or his bride. He’d seen her only once, walking in town, and that was enough. She seemed a tiny china doll next to the tough man with the narrow hips and wide shoulders.

A rider approached his house. Some cowboy had probably been shot last night, or had stumbled down drunk and broken his leg. But it was Billy Harkness. He told Doc he was wanted on the Harkness ranch, pronto. The new doctor, Jenkins, was having trouble with Helena Harkness and wanted Doc’s help. That could only mean things were bad, real bad. Doc had foaled a few in his time, but he was no hand at tricky birthing. Doc Marsden said he’d be by shortly. Billy looked at him with pity. Snake-Eye had said now.

Doc ran into his home and took a quick drink from his whisky bottle, then grabbed his bag and his Colt. They rode out in the cool morning air, Billy leading the way. Doc Marsden thought about the gun in his holster. It would not be hard to put a slug in Billy’s back and make for the high country. He might get away. But then he’d spend the rest of his days looking over his shoulder. He might as well face his doom straight up. He was a fake and a drunk, but he was no coward. He had never shot a man, and he wouldn’t start now.

Halfway to the Harkness spread, Billy pulled up. He had another chore to run, he said; he’d be up at the big house later that day. This was Doc’s chance. He might not be willing to shoot Billy and run for it, but he was mounted, and the road was open to the north and west. He thought about the scene in the ranch house: thin-legged Helena trying to squeeze out that big Harkness baby, bleeding, crying, dying. If she died so would Doc, no question about that.

Doc turned north and headed up the road a mile, then stopped. He looked out over the prairie. He thought about the immigrant boy, the butcher shop, the war, the bullets and arrows. Philadelphia was a lifetime away. Antonio Lombano was long dead. He was Doc Marsden. He took a deep breath of mountain air, thought about the bottle in his saddlebag, and left it there. He turned the blue roan with the double snake brand south and headed toward the Harkness ranch. TH

 

Jamie Newman, MD, FACP, is the physician editor of The Hospitalist, consultant, Hospital Internal Medicine, and assistant professor of internal medicine and medical history, Mayo Clinic College of Medicine at the Mayo Clinic College of Medicine, Rochester, Minn.

The Aspen were turning a golden brown, the cattle were fattened for market, and Doc Marsden was drunk again. His head lay on the two planks that served as a bar in what could only charitably be called a saloon. There were two places for a man to drink in Timberline, and this was Doc’s preferred watering hole.

Earlier that day Doc had been busy enough. There’d been a big brawl at the Triple H, and Billy Harkness had shot his younger brother, Lukas, after a lucky punch had broken Billy’s overlarge nose. It wasn’t a bad wound; Lukas had ducked, and the bullet had skimmed his back and lodged in his calf.

Doc had dressed the back wound with a poultice and fished the 0.45 slug from the gastrocnemius. He knew that much anatomy, but not much more. His hands had shaken ’till he had swigged a few swallows of what passed for bourbon. It was nervous work whittling on a Harkness. Luckily Lukas and Billy were a sight more intoxicated than Doc, and their big brother Boone Harkness was somewhere up the trail. The eldest Harkness brother had restless snake eyes. Boone never missed a thing, especially a target. He made Doc Marsden sweat. Doc gave Lukas a spoonful of laudanum, and his patient was soon snoring peacefully on the door they had used as an operating table. Doc took a small swig himself.

After he was sure that the Harkness boy was settled down and Doc’s helper Marty Johnson was there to watch over Lukas, Doc headed for the saloon and started drinking again. He pondered how he had ended up in Timberline. This hadn’t been his plan when he’d left Philadelphia all those years ago.

Back in Philadelphia his name had been Antonio Lombano. His parents had been immigrants, and he had been lucky to work for a butcher. He’d grown sick of slicing meat, and when the war came he enlisted. Anything to get away from the smell of blood and hanging beefs.

When he enlisted with the 37th infantry he’d expected to learn to shoot a gun and maybe even to die. He might have to kill a couple of Rebs, but at least he would leave Philadelphia. Instead, when they learned he had worked as a butcher, he was relegated to the cook’s tent. He was back to slicing meat. For two months the only flank he outmaneuvered was with his cutting blade.

He had been disemboweling a steer one day when a group of surgeons walked by, looking for an eyeball to dissect. They watched approvingly as he wielded his blade. Three days later he had been reassigned to the medical service as a surgeon’s assistant.

Antonio was assigned to work with Dr. Marsden, a fine surgeon from Boston. He watched with admiration as the surgeon amputated shattered arms and legs, sometimes twenty in a session. Antonio’s job was to help staunch the flow of blood with tourniquet or cautery, to brush the maggots from open wounds, and to count and burn the severed limbs. He was handling meat again.

During the months with Dr. Marsden, Antonio kept his eyes open and watched the doctor’s technique. When things got too busy, he would take up the knife as well. He became expert at sounding bullet wounds and was competent at below-the-knee amputations.

 

The war dragged on, and Antonio grew tired of endless surgery that seemed to be alleviated only by weeks of boredom. Dr. Marsden had been lying sick in his bunk for a week, febrile, jaundiced, and vomiting blood. Antonio suspected he’d picked up yellow jack in Texas. One day, he walked into the tent and found the surgeon dead. Without further thought, Antonio loaded the surgeon’s books and surgical kit into a bag, mounted a blue roan, and rode away from the war.

Fourteen years later, he sat with his head on a bar, vertiginous from the cheap liquor. He had become Old Doc Marsden, who liked a drink but sure was handy with a blade. He had pulled a thousand arrowheads, had sounded even more bullet wounds, and set countless fractures. He kept to the rough mining towns and frontier spaces where there was no shortage of injuries and no questions were asked. Timberline was just his speed. Recently, a second doctor had come to town. He did not mind the competition; in fact, he was glad to have someone to whom he could send the tougher cases.

 

Time passes.

 

It was a cool fall morning. There was a frost on the ground, and Doc Marsden was hung-over, sitting on his porch rolling his first morning cigarette. Boone Harkness had returned to town those many months ago with a wife, and she was pregnant. The new doctor in town had taken her case. Doc was glad; he wanted nothing to do with either Snake-Eye Harkness or his bride. He’d seen her only once, walking in town, and that was enough. She seemed a tiny china doll next to the tough man with the narrow hips and wide shoulders.

A rider approached his house. Some cowboy had probably been shot last night, or had stumbled down drunk and broken his leg. But it was Billy Harkness. He told Doc he was wanted on the Harkness ranch, pronto. The new doctor, Jenkins, was having trouble with Helena Harkness and wanted Doc’s help. That could only mean things were bad, real bad. Doc had foaled a few in his time, but he was no hand at tricky birthing. Doc Marsden said he’d be by shortly. Billy looked at him with pity. Snake-Eye had said now.

Doc ran into his home and took a quick drink from his whisky bottle, then grabbed his bag and his Colt. They rode out in the cool morning air, Billy leading the way. Doc Marsden thought about the gun in his holster. It would not be hard to put a slug in Billy’s back and make for the high country. He might get away. But then he’d spend the rest of his days looking over his shoulder. He might as well face his doom straight up. He was a fake and a drunk, but he was no coward. He had never shot a man, and he wouldn’t start now.

Halfway to the Harkness spread, Billy pulled up. He had another chore to run, he said; he’d be up at the big house later that day. This was Doc’s chance. He might not be willing to shoot Billy and run for it, but he was mounted, and the road was open to the north and west. He thought about the scene in the ranch house: thin-legged Helena trying to squeeze out that big Harkness baby, bleeding, crying, dying. If she died so would Doc, no question about that.

Doc turned north and headed up the road a mile, then stopped. He looked out over the prairie. He thought about the immigrant boy, the butcher shop, the war, the bullets and arrows. Philadelphia was a lifetime away. Antonio Lombano was long dead. He was Doc Marsden. He took a deep breath of mountain air, thought about the bottle in his saddlebag, and left it there. He turned the blue roan with the double snake brand south and headed toward the Harkness ranch. TH

 

Jamie Newman, MD, FACP, is the physician editor of The Hospitalist, consultant, Hospital Internal Medicine, and assistant professor of internal medicine and medical history, Mayo Clinic College of Medicine at the Mayo Clinic College of Medicine, Rochester, Minn.