Monday, November 29, 2004

Cocoa, Flavanols and Cardiovascular Risk

Cocoa, Flavanols and Cardiovascular Risk:

""The Kuna Indians in Panama, living in their indigenous island home in the Caribbean, do not show the typical rise in blood pressure with age, and hypertension is very rare.[34] In a study that began with the search for protective genes, the observation that migration to Panama City led to a loss of the protection against hypertension made it clear that an environmental factor was involved. Examination of their diet uncovered the fact that they drank large volumes of a flavanol-rich cocoa.[2] Subsequent in vitro studies suggesting that cocoa extracts can induce endothelium-dependent relaxation[4] led to studies in healthy volunteers,[9] and in patients with vascular risk or disease.[1] In the studies of Heiss et al. ingestion of flavanol-rich cocoa led to an increase in flow-mediated vasodilation of the brachial artery following five minutes of ischaemia, a response that correlated with biochemical evidence of increased nitric oxide bioavailability.[8] In the normal volunteers studied by Fisher et al. flavanol-rich cocoa induced striking dilatation of the vessels of the finger, which was reversed completely by an arginine analogue that blocks nitric oxide synthesis (figure 1).[9]""


""Endothelial dysfunction with a consequent reduction in nitric oxide production has achieved a central conceptual role in the pathogenesis of atherosclerosis and coronary artery disease, diabetes mellitus and hypertension. Recent evidence that flavanol-rich cocoa activates vascular nitric oxide synthesis in the intact human raises an interesting possibility of a therapeutic potential.""

Potentially very good news for Hershey foods, what, what?

[Via Medscape Headlines]

Abortion Surveillance --- United States, 2001

Abortion Surveillance --- United States, 2001:

""A total of 853,485 legal induced abortions were reported to CDC for 2001 from 49 reporting areas, representing a 0.5% decrease from the 857,475 legal induced abortions reported by the same 49 reporting areas for 2000. The abortion ratio, defined as the number of abortions per 1,000 live births, was 246 in 2001, compared with 245 reported for 2000. This represents a 0.4% increase in the abortion ratio. The abortion rate was 16 per 1,000 women aged 15--44 years for 2001, the same as for 2000. For both the 48 and 49 reporting areas, the abortion rate remained relatively constant during 1997--2001.""

These numbers exclude Alaska, California, and New Hampshire.

I post this not because I am anti-choice, but because I was surprised by the abortion ratio of 246 abortions per 1,000 live births--much higher than I would have guessed. My sincere (but admittedly naive) hope is that abortions are not being relied on as a means of birth control.

[Via MMWR]

Saturday, November 27, 2004

Bird Flu Pandemic inevitable, 7 million people could die, WHO

Bird Flu Pandemic inevitable, 7 million people could die, WHO:

""The World Health Organization is urging countries to prepare for an ‘inevitable flu pandemic' it believes will probably come from a mutated bird flu virus. Dr Klaus Stohr, WHO Influenza Program Coordinator, says as many as seven million people could be killed.

Stohr is urging health ministries in Asian countries to prepare and take measures for a probable flu pandemic. Dr Stohr insists it is only a matter of time - we have gone beyond wondering whether there will be one, the stage now is trying to forecast ‘when' a pandemic will hit.

Dr Stohr says the next pandemic will most likely come from a mutation of the bird (avian) flu virus. He said "Even with the best-case scenarios, the most optimistic scenarios, the pandemic will cause a public health emergency. There are estimates which would put the number of deaths in the range of between two and seven million."

The H5N1 bird flu strain, the most dangerous, has hit Thailand and Vietnam hard. Millions of poultry have had to be destroyed - 30 people have died.

The virus only kills humans who have close contact with infected poultry. The concern among health experts is that the virus could mutate and spread from human to human. If the virus were to infect a pig, the jump (mutation) from pig to human would be much more likely (emphasis mine).

If the strain were to mutate and have the ability to spread among humans, nobody would be immune - the consequences could be catastrophic. According to Stohr, this could happen at any time.

WHO experts say that countries in Asia which have the weakest health systems are precisely the ones that need the most support as they are the most likely places to host the beginnings of a pandemic. ""

That bolded phrase--The concern among health experts is that the virus could mutate and spread from human to human. If the virus were to infect a pig, the jump (mutation) from pig to human would be much more likely--deserves further explanation. I'm reading the book The Great Influenza, by John M. Barry, who gives a nice summary of why pigs can make it fly (so to speak):

""The virus may also adapt indirectly, through an intermediary. Some virologists theorize that pigs provide a perfect "mixing bowl", because the sialic-acid receptors on their cells can bind to both bird and human viruses. Whenever an avian virus infects swine at the same time at the same time that a human virus does, reassortment of the two viruses can occur. An an entirely new virus can emerge that can infect man. In 1918 veterinarians noted oubreaks of influenza in pigs and other mammals, and pigs to day still get influenza from direct descendents of the 1918 virus. But it is not clear whether pigs caught the disease form man or man caught it from pigs.""

For more information, see The World Health Organization page on pandemic preparedness.

Lancet: Risk of cardiovascular events and rofecoxib

Lancet: Risk of cardiovascular events and rofecoxib: cumulative meta-analysis (pdf)

""Findings: We identified 18 randomised controlled trials and 11 observational studies. By the end of 2000 (52 myocardial infarctions, 20742 patients) the relative risk from randomised controlled trials was 2·30 (95% CI 1·22-4·33, p=0·010), and 1 year later (64 events, 21432 patients) it was 2·24 (1·24-4·02, p=0·007). There was little evidence that the relative risk differed depending on the control group (placebo, non-naproxen NSAID, or naproxen; p=0·41) or trial duration (p=0·82). In observational studies, the cardioprotective effect of naproxen was small (combined estimate 0·86 [95% CI 0·75-0·99]) and could not have explained the findings of the VIGOR trial.""

Friday, November 26, 2004

Common Good Promoting Special Health Courts

Common Good is planning a brochure for mass distribution to 'advance the concept of a special health court.' I've written about this organization before. Their proposal, which has some pretty big names behind it, calls for the creation of special health courts. Some of the details include:

  • Full-time judges
  • Neutral experts
  • Speedy processing at lower cost
  • Schedule for non-economic damages
  • Liberalized standard for patient recovery

Common Good is accepting donations (tax deductible) to help with the mass distribution of their brochures.

Making The Flu Vaccine Go Further

NEJM: Dose Sparing with Intradermal Injection of Influenza Vaccine (free full text)

NEJM: Serum Antibody Responses after Intradermal Vaccination against Influenza (free full text)

Tuesday, November 23, 2004

New Female Sterilization Technique Quicker, Easier and Cheaper

New Female Sterilization Technique Quicker, Easier and Cheaper:

""Mayo Clinic gynecologists have discovered that hysteroscopic sterilization, a new method of plugging the fallopian tubes to prevent conception, will save patients money compared to laparoscopic tubal ligation, the most commonly used method of sterilization for women. This technique involves inserting a nickel-titanium and stainless steel springlike device into the fallopian tubes using a hysteroscope, a tiny, fiberoptic camera. The metal device encapsulates and holds in place white polyester fibers able to cause scarring and thus block the fallopian tubes within 12 weeks, preventing the possibility of future pregnancy.""

Of course, it's still not as easy as a man having a vasectomy, but this technique would not require laparoscopy and would thus be safer for the woman.

[Via Science Blog - Science News Stories]

Sunday, November 21, 2004

Should Anyone Be Giving Light Water Fuel to Iran?

From the Nonproliferation Policy Education Center--A Fresh Examination Of The Proliferation Dangers Of Light Water Reactors (pdf):

""What emerges from this discussion is that Light Water Reactors are not the proliferationresistant technology they have been made out to be. Forgotten from the earlier days of nuclear energy is that LWRs can produce large quantities of near-weapons-grade plutonium, and that a country bent on making bombs would not have much trouble extracting it quickly in a small reprocessing operation, and possibly even keep the operation secret until it had an arsenal. ""

Saturday, November 20, 2004

Be A Firemonger


""After some initial problems, the Firemonger project is now finally ready. The goal of the project is to create CD images which contain Firefox and which users can download, burn and give away to friends and family. The first CD is now available and includes Firefox, Thunderbird and various plugins, extensions and themes.""

[Via rakaz]

Mythbusting HIPAA

A question came up this week about whether or not we could administer eye drops in the waiting room to patients having cataract surgery. This led me to Google, which led me to 'HIPAA Myth Buster'. In reading through this and related sites, I discovered that many things that we do in the name of 'HIPAA compliance' just are not necessary.

Here is but one example:

""HIPAA doesn't allow my staff to call patient names in the waiting room, so now we have to call patients by number.

"Actually, HIPAA does permit the staff to call out patient names in waiting rooms. The regulations provide that when a physician makes the good faith effort described above, he or she is permitted to disclose information "incident to a use or disclosure otherwise permitted" by the regulations.

"The government says that means that a physician or staff member can call out names in the waiting room, hang charts outside doors, or use a whiteboard to list patients in the building or office. However, one should refrain from unnecessary disclosures. For instance, calling out names in the waiting room is fine, but calling out names and diagnoses would be problematic.""

I still don't know whether we can administer eye drops (would it be an 'incidental disclosure'?) but I do know, as I long suspected, that some of what we do is stupid and driven by the vendors that want to sell us their 'solutions.'

Google Scholar

Google Scholar:

"" Google Scholar enables you to search specifically for scholarly literature, including peer-reviewed papers, theses, books, preprints, abstracts and technical reports from all broad areas of research. Use Google Scholar to find articles from a wide variety of academic publishers, professional societies, preprint repositories and universities, as well as scholarly articles available across the web.""

[Via The Volokh Conspiracy]

Brain imaging study of drunk drivers pinpoints neurological changes

Alcohol Intoxication Effects on Simulated Driving: Exploring Alcohol-Dose Effects on Brain Activation Using Functional MRI

""The areas most profoundly affected by alcohol were the orbital frontal and anterior cingulate areas, which help control motor functions. The medial frontal regions of the brain involved in making decisions, and working memory, were not affected until the person was beyond the legal limit of intoxication. A function of working memory might be to find one's way home, the researchers said.

Impairment of the cerebellum area of the brain, which related strongly to speeding, was clearly correlated with the alcohol dose. Changes in the frontal and parietal cortex, which govern alertness and attention, were correlated with weaving while driving. ""

[Via Medical News Today]

Friday, November 19, 2004


The British Medical Journal has an rss feed!

"Dispelling malpractice myths"

"Dispelling malpractice myths" by the president of Johns Hopkins University:

""News reports of recent efforts to reduce malpractice insurance costs have missed what is needed: genuine reform of the medical justice system.

A good way to start is by jettisoning some commonly held misperceptions about the current malpractice system. Call them the "Myths of Malpractice..."""

[Via PointOfLaw Forum]

Thursday, November 18, 2004

Prevalence of Overweight and Obesity Among Adults with Diagnosed Diabetes --- United States, 1988--1994 and 1999--2002

Prevalence of Overweight and Obesity Among Adults with Diagnosed Diabetes --- United States, 1988--1994 and 1999--2002:

""Obesity in persons with diabetes is associated with poorer control of blood glucose levels, blood pressure, and cholesterol (1), placing persons with diabetes at higher risk for both cardiovascular and microvascular disease (2). Conversely, intentional weight loss is associated with reduced mortality among overweight persons with diabetes (3). CDC analyzed the prevalence of overweight and obesity among U.S. adults aged >20 years with previously diagnosed diabetes by using data from two surveys: the Third National Health and Nutrition Examination Survey (NHANES III), 1988--1994, and NHANES 1999--2002. This report summarizes the results of that analysis, which indicated that most adults with diagnosed diabetes were overweight or obese. During 1999--2002, the prevalence of overweight or obesity was 85.2%, and the prevalence of obesity was 54.8%. Encouraging patients to achieve and maintain a healthy weight should be a priority for all diabetes-care programs.""

[Via MMWR]

Recommended Adult Immunization Schedule

From the CDC: QuickGuide: Recommended Adult Immunization Schedule --- United States, October 2004--September 2005. (PDF)

Wednesday, November 17, 2004

Do you have the flu, or something else?

Many people complain they're down with the 'flu' without really knowing whether it's influenza or not. While browsing my new Google ad sense banner (see left lower gutter) , I found a link to QuickVue, a test for influenza which I never knew existed (or had forgotten existed). It uses a nasal swab (and obtaining a sample is therefore less noxious than getting a Rapidstrep test) and takes about ten minutes to give a result. I have no information on cost.

Tuesday, November 16, 2004

"I'd rather be judged by 12 than carried by 6"

Here's a Seal's perspective on all the attention being paid to the issue of a Marine supposedly shooting a wounded terrorist in Fallujah:

""Here is your situation Marine. You just took fire from unlawful combatants shooting from a religious building attempting to use the sanctuary status of their position as protection. But you're in Fallujah now, and the Marine Corps has decided that they're not playing that game this time. That was Najaf. So you set the mosque on fire and you hose down the terrorists with small arms, launch some AT-4s (Rockets), some 40MM grenades into the building and things quiet down. So you run over there, and find some tangos wounded and pretending to be dead. You are aware that suicide martyrdom is like really popular with these kind of idiots, and like taking some Marines with them would be really cool. So you can either risk your life and your fireteam's lives by having them cover you while you bend down and search a guy that you think is pretending to be dead for some reason. Also, you don't know who or what is in the next room, and you're already speaking english to each other and its loud because your hearing is poor from shooting people for several days. So you know that there are many other rooms to enter, and that if anyone is still alive in those rooms, they know that Americans are in the mosque. Meanwhile (3 seconds later), you still have this terrorist that was just shooting at you from a mosque playing possum. What do you do?

You double tap his head, and you go to the next room, that's what."

Would Specter Be Bad News For Tort Reformers?

There's (another) good reason for physicians to take an interest in who is appointed Chair of the Senate Judiciary Committee--his record suggests Specter would be bad for tort reform.

"" A brief look at Mr. Specter's record makes that clear. In May of 1995, weeks into the new Republican majority, Mr. Specter tried to derail a product-liability reform bill. He voted against limits on attorney fees for medical liability suits and against limiting punitive damages to three times economic damages (not a hard cap, since economic damages would not be capped).

"Mr. Specter also voted against an amendment to limit non-economic damages to $500,000 and against another to protect OB/GYNs from being sued for problems they didn't cause. Mr. Specter also voted against the final bill. " --Washington Times"

More at

[Via Overlawyered ]

Monday, November 15, 2004

Family Presence--A Really, Really Bad Idea

There's a movement gaining steam to allow family members of very ill patients to watch resuscitation efforts by the medical team. This Fox News article states: "Better access to information and witnessing for themselves the measures taken, they argue, often help survivors through the grieving process."

I couldn't disagree more. As an anesthesiologist, I frequently find myself in situations where family members want to be present--at cesarean sections, at surgery for their children, etc. I just don't see how being present to witness the invasiveness of a modern 'code' is 'more holistic patient care.' We cram tubes down people throats, stick them with big needles to gain venous access, shock them with lots of electricity. During all of this they are often naked, sometimes vomit and, unfortunately, don't survive a majority of the time. Plus there's frequently chaos. The person 'running the code' is usually a medicine resident whose crisis management skills are, um, developing, shall we say?

Really, really bad idea.

Sunday, November 14, 2004

45,800,000 American Adults (Still!) Smoke

""In 2002, a total of 45,800,000 US adults (22.5%) were current smokers, a decrease from 24.1% in 1998, and an estimated 46 million adults were former smokers (1). For the first time, more adults had quit smoking than were still smoking""

Many more details in the MMWR Report: Great American Smokeout --- November 18, 2004

[Via Medical News Today]

Vioxx Non-Cox2 Effect Demonstrated

It's worth pointing out that discussion of a drugs action typically focus on one known effect. That there may be others and that those can be harmful is amply demonstrated by the Vioxx example. An article just published in the journal 'Atherosclerosis' may explain what the second effect is in the case of Vioxx:

Sulfone COX-2 inhibitors increase susceptibility of human LDL and plasma to oxidative modification: comparison to sulfonamide COX-2 inhibitors and NSAIDs

Bottom line: "Abnormal changes in the structure or shape of lipids caused by Vioxx, especially in LDL, may explain why they are more susceptible to oxidative damage, and therefore, contribute to cardiovascular damage. Similar effects on susceptibility of lipids to oxidative damage have been observed with cigarette smoking, diabetes and in patients who have had a recent heart attack."

[Via Medical News Today]

Thursday, November 11, 2004

And now for a little humor...


Flu Vaccine Shortage A Blessing In Disguise?

The flu vaccine shortage of 2004 has focused national (if not world) attention on how we produce influenza vaccines, which companies produce them, and how vulnerable our present system is to interuptions. We haven't seen a major flu pandemic like those of 1918 or 1957 or 1968 yet. It's quite possible that changes to the system that result from the current shortage will make us more prepared for the next pandemic, whenever it comes. We may be seeing the early stages of it in Thailand and Vietnam in the form of bird flu....

Veteran's Day

It's Veteran's Day. Allow me to point you to a moving tribute to America's fighting men and women:

Weathering the Influenza Vaccine Crisis

NEJM: Weathering the Influenza Vaccine Crisis

""Influenza vaccine is especially vulnerable to interruptions in supply, because of the unique features of influenza-vaccine production. Unlike any other vaccine, influenza vaccine must be reformulated to keep pace with antigenic changes in the hemagglutinin and neuraminidase proteins of influenzaviruses — essentially necessitating the manufacture of a brand new product from scratch every year. The process is a long one, beginning with the identification of new antigenic variants in the autumn of the previous year and the selection of the strains for inclusion in the vaccine, and proceeding to the generation of appropriate reference reagents, the production and purification of the vaccine antigens, and packaging and distribution, all within a period of six to eight months.""

Wednesday, November 10, 2004

How NOT To Catch A Terrorist

The Atlantic has reprinted key portions of a letter to the House and Senate Intelligence Committees by 'Anonymous', the author of several books on how the nation is dealing with (or not dealing with) terrorism. He makes the point that it's not just about organizational factors, 'walls', or budgets. People make bad decisions, and he gives ten examples.

Many People Won't Do What They're Told

The New York Academy of Medicine: News & Publications: Terrorism Response Plans Will Not Protect Many Americans, New Academy Study Finds:

""Called Redefining Readiness: Terrorism Planning Through the Eyes of the Public and funded by the W. K. Kellogg Foundation, this year-long study gave the American people their first opportunity to describe how they would react to two kinds of terrorist attacks: a smallpox outbreak and a dirty bomb explosion. The rigorous study involved in-depth conversations with government and private-sector planners, 14 group discussions with diverse community residents around the country, and a telephone survey of 2,545 randomly selected adults in the continental United States. ""

Bottom Line: only about 40% would actually do as they are told and go to a smallpox vaccination center for fear of a) catching the illness form the crowds there and b) concern over side effects. The public would do worse in dealing with a dirty-bomb (radiation) attack.

[Via The Atlantic Monthly]

Shortage of 200,000 Doctors Predicted in US by 2020

Annals of Internal Medicine (free): Weighing the Evidence for Expanding Physician Supply

"Summary: "Taken together, this body of information indicates that physician shortages are emerging and that they will probably worsen over the next 2 decades. By 2020 or 2025, the deficit could be as great as 200 000 physicians—20% of the needed workforce..."


"... the data, forecasts, and signals discussed earlier indicate that physician shortages are upon us and are likely to worsen over time. The picture that emerges is uncomplicated and unambiguous. In simple numeric terms, the number of physicians is no longer keeping up with population growth. The ability to fully service the population is further compromised by the increasing complexity of the care that physicians provide and the decreasing time commitment that many physicians are willing to make. These limitations collide with economic trends that predict a growing demand for physician services. Recruiters, medical leaders, and patients are already experiencing these shortages, and colleagues in other English-speaking countries see a situation in the United States that is all too familiar to them.""

Missing from the article is any mention of 'malpractice', 'tort reform', or 'liability reform'. These issues do effect how long someone chooses to practice and where. If one believes that there's a physician shortage coming, states would be wise to become 'friendlier' to physicians by enacting tort reform in order to insure they remain a viable choice for physicians looking for a place to practice. Of course, Pennsylvania won't be among them, at least not while Ed [trial lawyer] Rendell is governor, as he's already been quoted as saying that malpractice reform is "the next governor's problem."

[Via Medscape]

Tuesday, November 9, 2004

Liberal Fluid Administration to Improves Recovery After Lap Chole

Liberal Versus Restrictive Fluid Administration to Improve Recovery:

""Results: Intraoperative administration of 40 mL/kg compared with 15 mL/kg LR led to significant improvements in postoperative pulmonary function and exercise capacity and a reduced stress response (aldosterone, antidiuretic hormone, and angiotensin II). Nausea, general well-being, thirst, dizziness, drowsiness, fatigue, and balance function were also significantly improved, as well as significantly more patients fulfilled discharge criteria and were discharged on the day of surgery with the high-volume fluid substitution.Conclusions: Intraoperative administration of 40 mL/kg compared with 15 mL/kg LR improves postoperative organ functions and recovery and shortens hospital stay after laparoscopic cholecystectomy.""

Yawn. This is a 'me too' study, but does provide yet more support to the idea more fluid is good during anesthesia. It's important to note that this is for a 'closed' procedure, not an open one. Insensible loses are minimal with this technique.

Obesity Triples Prescription Drug Costs - Health - Obesity Triples Prescription Drug Costs:

""For normal-weight men, monthly prescription drug costs for heart disease-related drugs were $9.89 and for other drugs, $12.96. For overweight men, monthly prescription drug costs for heart disease-related drugs were $18.41 and for other drugs, $20.86. For obese men, monthly prescription drug costs for heart disease-related drugs were $42.02 and for other drugs, $38.29.""

Data apparently presented during an ongoing AHA meeting.

Public Service Announcement: Firefox 1.0 is out

The mozilla foundation has released version 1.0 of Firefox--their small, speedy, secure, highly configurable web client that should take the place of Internet Explorer wherever possible. It's available for all platforms at and it's FREE!

Anatomy of a Near Miss

Medical errors are insidious. Many, many errors occur that do not lead to a bad outcome, but they are errors nonetheless. Given a different patient or set of circumstances, those same errors could result in injury, death, or at the very least less than optimal care. The following example serves to reinforce this point.

A thin, elderly woman is admitted the morning of her planned multi-level spinal laminectomy, instrumentation, and fusion. She is healthy, active, and appears younger than her stated age. She meets her anesthesiologist for the first time twenty minutes before the case. Upon review of her records, she appears to be free of cardia or pulmonary disease, but he notes laboratory results on the chart which indicate a macrocytic anemia (blood count of 30--normal is greater than 35 or so). The patient does not recall being told this before. No mention is made of this finding in the surgeon's history and physical examination, or elsewhere in the chart. Someone did think to do serum B12 and folate levels, both of which were found to be normal but no note is present to indicate the differential or planned workup. The finding is discussed with the surgeon and the case proceeds.

Error number one: the abnormal laboratory value should have triggered further evaluation. Some evaluation was attempted, but there was nothing in the chart to indicate by whome, or what their conclusion was. Significant blood loss is likely in this case. Starting with a lower hematocrit means less blood can be lost before a transfusion becomes necessary.

Error number two: the anesthesiologist should have cancelled this case due to a new anemia of unknown etiology. The severity of the anemia is such that a blood transfusion will almost certainly be needed. If time had been taken to evaluate and treat the anemia, the blood count may have risen sufficiently to reduce the likelihood of needing a transfusion. Even if the blood count could not be improved, directed donation or intraopoerative blood salvage techniques could have been used. Why didn't the anesthesiologist cancel the case? No good reasons, just all the usual ones. He was afraid the surgeon would be angry. He kne w the patient had been dealing with severe pain and was holding out just for this surgery.

Intra-operative blood loss was approximately 700 cc. Euvolemia was maintained with Hespan and lactated Ringer's solution. The patient was warm, urine output was good, and both blood pressure and heart rate were stable. Her hemoglobin near the end of the case was now 7, and a unit of blood was ordered from the blood bank. When no blood arrived within 30 minutes, the blood bank was called to inquire if there was a problem. No blood sample from the patient was available in the blood bank to cross-match bank blood against. A sample was immediately drawn into a red-top vial and sent. The case ends, patient is extubated successfully, and transported to the recovery room where her vital signs remain stable and urine output good. The anesthesiologist continues with other scheduled cases after giving report and asking the recovery room nurse to administer one unit of blood when it become available.

After another thirty minutes pass, the blood bank calls the recovery room to inform them that the sample was received in the wrong vial. The blood bank used to require a red-topped vial, but now want a lavender-topped vile (the former contains no anticoagulant, the later does). A phlebotomist is called to draw the new sample and the patient received a blood transfusion fully two hours after the anesthesiologist made the decision to administer blood.

Error numbers three through ten: 'what we have here is a failure to communicate.' There was a failure to communicate:

  • that blood had not been drawn pre-operatively as ordered (even though the pre-op checklist indicated it had)
    As an interesting aside, this was the first morning the nurses in the pre-op area were asked to use a computerized nursing record rather than their preferred paper method of charting.
  • that the blood bank had no specimen to crossmatch blood against after receiving a call for blood.
  • that a change had been made in what kind of specimen was needed for crossmatch.
  • you can fill in the remainder.

    The only reason this patient did not suffer harm from this incident is that she was physiologically very healthy. Imagine a patient with stable but significant coronary disease. That patient would not have tolerated a hemoglobin of seven so well. Imagine a more significant blood loss. It's better to be lucky than good. It's even better to be both.

    This example demonstrates what is so often true of medical misadventures: it is a series of events in combination which conspire against the practitioner and the patient to cause harm.

    My response to this event is to draft a 'Go/No-Go' list. My personal decisions on whether to do a case is heavily influenced by what I know the surgeon reaction will be. I'm not saying that's the right reaction, mind you. It's just my reaction (in wanting to please people as I do). A Go/No-Go list is similar to what NASA uses to decide whether or not to launch a space craft. If any item is 'No-Go' the launch is scrubbed. On my anesthesia Go/No-Go list, if I discover an item in a patient chart that's on my list, launch is scrubbed and the case is rescheduled. New, unexplained anemia is certainly on that list, especially in light of a surgery likely to result in significant blood loss. I need to spend some serious time adding to this list. I'll post it as a work in progress.

    Saturday, November 6, 2004

    Cold-Eeze Lawsuit Over Anosmia

    Colde-Eze subject of lawsuit for allegedly ruining the sense of smell. Recall I've posted about how well I think Cold-Eeze works. I guess I'll stick to the lozenges...

    [Via medpundit]

    Summary of Medical Liability Ballot Initiatives

    Human Events Online: Medical Liability

    ""Voters in four states--Oregon, Florida, Nevada, and Wyoming--considered ballot initiatives to reform the broken medical liability systems in their states. In Oregon, Ballot Measure 35, which would have amended the constitution to establish a $500,000 cap on non-economic damages in medical liability cases, lost by 50.53% to 49.47%. In Florida, Ballot Measure 3 to amend the state constitution and limit contingency fees attorneys receive in medical liability cases passed 63.5% to 36.5%. In Nevada, Ballot Measure 3, which would amend Nevada's existing medical liability reform law by deleting exceptions to the $350,000 cap on noneconomic damages in medical liability cases, passed by 58.72% to 40.14%. In Wyoming, Amendment D, which would amend to the Constitution to allow the state legislature to enact caps on noneconomic damages, failed by a 2-to-1 margin.""

    Friday, November 5, 2004

    Americans flock to Canada's immigration Web site

    From Reuter's News Agency:

    ":The number of U.S. citizens visiting Canada's main immigration Web site has shot up six-fold as Americans flirt with the idea of abandoning their homeland after President George W. Bush's election win this week.

    "When we looked at the first day after the election, November 3, our Web site hit a new high, almost double the previous record high," immigration ministry spokeswoman Maria Iadinardi said on Friday.

    On an average day some 20,000 people in the United States log onto the Web site, -- a figure which rocketed to 115,016 on Wednesday. The number of U.S. visits settled down to 65,803 on Thursday, still well above the norm.

    Bush's victory sparked speculation that disconsolate Democrats and others might decide to start a new life in Canada, a land that tilts more to the left than the United States.""

    [Via Drudge]

    Fallujah: Why Now?

    Blackhawk pilot 2Slick has a great post on the timing of the Fallujah offensive relative to our elections:

    ""The ground commander has a large staff of smart people that determine every aspect of the upcoming offensive. He has his intell staffers work specifically on what we call Intelligence Preparation of the Battlefield (IPB). This consists of many things- among them, finding answers to the questions- What is motivating our enemy? What are their objectives?

    Our IPB determined (to nobody's surprise and I can tell you this because it's already been reported in the press), among other things, that these insurgents and terrorists were aiming primarily to influence our election and thwart the Iraqi election. It doesn't take a rocket scientist to figure out how they planned on influencing our elections- kill as many Americans as humanly possible.

    They did anything and everything to lure us into the fight before Election Day- but we resisted. Because WE were calling the shots, and WE had total control of the situation. Our commanders and staffers up there wisely determined that if we hold off the offensive until after Election Day, it would leave the insurgents with one less thing that drives their will to fight. Almost like a morale issue. Instead of two primary goals, now they only have one- having failed to achieve their first. When you think about it- it's brilliant strategy. We won half the battle by not even fighting!""

    Thursday, November 4, 2004

    Gulf War Syndrome Cause Probably Found

    Gulf War Syndrome Cause Probably Found:

    ""The New Scientist is reporting that after extensive studies by researchers at the Veterans Administration, the cause of Gulf War Syndrome has been possibly traced to exposure to Sarin gas.""

    [Via The Command Post]

    Why Exit Polls Were Wrong--Another Theory

    TCS: Tech Central Station - The Poll Vaulters:

    ""When a voter is confronted by a pollster in the service of the news media, therefore, what would a rational observer expect an unsatisfied media consumer to do? Would we expect an angry conservative to "spend" the time to help, without compensation, an industry that has by and large ignored that voter's attitudes regarding matters as emotionally charged as the selection of a president?

    Clearly, this is an irrational expectation. I personally know numbers of people who have hung up on pollsters and gone out of their way to avoid people carrying clipboards.""

    Changing Shot Technique May Extend Flu Vaccine (Los Angeles Times)

    Changing Shot Technique May Extend Flu Vaccine (Los Angeles Times):

    ""Los Angeles Times - Supplies of the influenza vaccine could be expanded by up to five times by changing how the shot is given — administering a small dose under the skin rather than a larger dose into muscle, two teams of researchers reported Wednesday.""

    [Via Yahoo! News: Top Stories]

    Wednesday, November 3, 2004

    Phrases of the Moment

    Michelle Malkin: New, Nauseating Phrases of the Moment:


    Well, now that the talking heads don't have to say "Too Close To Call" anymore, a new batch of mindlessly repeated phrases are polluting the airwaves

    "The Country is Deeply Divided."

    "It's Time to Heal."

    "We Need to Heal."

    "The President Must Reach Out."

    Oh, blecch. Yes, civility is all well and good. But it is hard to stomach the sanctimony from liberals who had nothing to say when Teresa Heinz Kerry was insulting the First Lady, when the MSM/ULM was mauling John O'Neill, when Ted Kennedy was smearing the President, when John Ashcroft-haters were celebrating his hospitalization, and when left-wing bigots were mocking Condoleezza Rice and gloating over Ronald Reagan's death.

    Yes, the country is divided. Divided between gracious winners and mud-slinging, hypocritical whiners who have nothing else to do now but point to their emotional boo-boos and decry the dirtiness of politics.


    [Via Michelle Malkin]

    Ballot measure results

    Ballot measure results:

    ""...voters gave doctors and the business community some major victories in yesterday's ballot measures. Limits on malpractice lawyers' fees passed resoundingly in Florida, in a stinging rebuke to the trial bar. Among three other states considering med-mal ballot measures, doctors won decisively in Nevada and lost in Wyoming, while Oregon's measure was slightly trailing but too close to call..""

    [Via Overlawyered]

    Monday, November 1, 2004

    Why I'm Not Getting A Flu Shot

    As a physician, excuse me, 'health care worker involved in direct patient care', I am entitled to receive a flu vaccine under the national guidelines published by the CDC. I know the nurses that work in the operating room are scrambling to 'get theirs.'

    There's just one problem, though. People with influenza don't come to the operating room. Even if they did, we all wear masks, often wear gloves, and try to be diligent about washing our hands and using alcohol rubs--all the things one is encouraged to do to reduce the risk of transmission. It's hard for me to see why we'd be a population at risk compared to, say, floor nurses or ER staff.

    The right things to do is skip it in order to leave more doses available for 'at-risk' groups.

    Poland Attracts Plastic Surgery 'Tourism'

    Poland Attracts Plastic Surgery 'Tourism'

    ""A rising number of Germans and others from western Europe are traveling to Poland - and other new EU members such as Hungary and Slovakia - to pay less for plastic surgery, fertility treatment and dental work."


    "Breast enlargement, for instance, starts at around $3,200 in Poland, but runs between $6,150 and $9,800 in Germany. A nose job costs $2,000 to $2,500 in Poland, $4,900 to $7,400 in Germany.""

    [Via My Way News: ]

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