Wednesday, March 9, 2005
"If you're wrong, I'll sue you."
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That's what the patient was overheard to say after I finished a discussion with her about why she would not need prophylactic antibiotics before a nasal procedure. Her medical history was significant only for a 'heart murmur' (which I could not auscultate). No workup or echocardiogram had been done to rule in a structural cardiac abnormality. The patient denied signs or symptoms of valvular heart disease including mitral valve prolapse, and had a very good exercise tolerance. I quoted the AHA Recommendations which, it turns out, admit that....
"There are currently no randomized and carefully controlled human trials in patients with underlying structural heart disease to definitively establish that antibiotic prophylaxis provides protection against development of endocarditis during bacteremia-inducing procedures. Further, most cases of endocarditis are not attributable to an invasive procedure. "
"If you're wrong, I'll sue you" was reportedly spoken by the patient after I had left the bedside. As I saw it, I had three choices:
- Tell her I would not provide her an anesthetic for this elective surgery as she had revealed herself to be a litigious patient.
- Reschedule her surgery after an echocardiogram had been performed to elucidate the origin of the murmur.
- Give her the antibiotic and get on with things.
Part of why I had such a strong emotional reaction upon hearing this was almost certainly because I have been in practice over eight nearly nine years and have yet to be named in a suit (the average physician is sued once every eight years). And because some very talented surgeons have left Pennsylvania because of the malpractice environment (and have been replaced by considerably less talented surgeons).
After I talked it over with the surgeon (who asked me to proceed so as not to put him in a difficult position) I gave her the antibiotic and got on with things...but not until after I had listed for her every possible complication of both the antibiotic dose and the anesthetic she was about to receive, including brain damage and death.
Now, all the informed consent in the world isn't going to stop a patient from suing regardless of outcome if they want to sue. I decided to save my charm, humor, and best bedside manner for patients that have the good sense not to talk about bombs while they're waiting in line at airport security.
Monday, March 7, 2005
'Good guys' show just how easy it is to steal ID
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'Good guys' show just how easy it is to steal ID:
" Teams of hackers surfed the Web at Seattle University yesterday, harvesting Social Security and credit card numbers like a farmer cutting wheat. In less than an hour, they found millions of names, birth dates and numbers -- cyberburglar tools for the crime of identity theft -- using just one, familiar Internet search engine: Google. "
The problem is not Google. The problem is the sites that allowed these documents to be indexed. I wonder how successful we would be finding protected health information?
[Via HIPAA Blog]
Tuesday, March 1, 2005
Discovery Health: Anesthesia (Reporting) Nightmares
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I watched 'Anesthesia Nightmares' on the Discovery Health channel last night (listing). As an anesthesiologist, the awareness and recall of surgery are of grave concern to me, so I tuned in for what I hoped would be an informative, informed, hour of Discovery Health television. What I saw amounted to fearmongering.
Let me state at the outset that I do not doubt the ordeals described by the victims interviewed in the show. Awareness and recall under anesthesia happen. How often they happen has recently been answered by an article titled The incidence of awareness during anesthesia: a multicenter United States study. The study was funded by the company that makes depth of anesthesia monitors (Aspect), but I can't find fault with their data:
" Assuming that approximately 20 million anesthetics are administered in the United States annually, we can expect approximately 26,000 cases to occur each year. "
Before I point out some of the specific information I disagree with, let me make a few general points.
I. Not every occurrence of awareness is the kind of 'anesthesia nightmare' described in the show. This should have been pointed out during the report. From the article referenced above:
Summary of Awareness Descriptions (n = 25)
Variable
|
n
|
%
|
| Auditory perceptions |
12 |
48 |
| Unable to move or breathe |
12 |
48 |
| Anxiety/stress |
9 |
36 |
| Pain |
7 |
28 |
| Sensation of endotracheal tube |
6 |
24 |
| Feeling surgery without pain |
2 |
8 |
|
| More than one description may occur per case. |
|
II. We know the risk of awareness is higher in certain kinds of operations (trauma resuscitations, open heart surgery, and emergency cesarean sections are three that come to mind) and in certain kinds of patients (patient with significant coexisting medical conditions such as heart disease or renal failure). In those cases there is a trade-off between depth of anesthesia and patient well-being. There can also be awareness during an unanticipated difficult airway (the first dose of injected anesthetic begins to wear off before the inhaled anesthetic is started.
III. We sometimes are asked to do anesthetics which would not be our first choice. Certain orthopedic spine procedures require special monitoring which is in turn affected by anesthetic levels. We have to modify our preferred anesthetic to take into account this new requirement--and the risk of awareness is higher if we can't use inhaled agents, for example.
Let me now give some quotes from the show that I think are misleading and explain why I think so:
Narrator: "The gas was not working, but like all surgical patients, Joe had also been given a paralytic drug"
This is false. Most surgical patients do not receive a paralytic drug. Intra-abdominal, intrathoracic, intracranial cases do because the surgery could not be done without them, but that's not a majority of cases. We try to avoid giving paralytics unless they're clearly indicated.
Dr. Frank Sweeny: "There are a variety of theories about what anesthesia is, but really I can summarize it in three words: We Don't Know"
This is simply a poor choice of words on Dr. Sweeny's part or Discovery Health taking it his quote out of context. Although it is true we do not precisely understand the mechanisms of some anesthetics, we do know a great deal about how these drugs work as evidenced by the safe and uneventful conduct of the vast majority of anesthetics given each day.
Narrator: "Anesthesiologists have to find a delicate balance between three types of drugs: paralytics to prevent movement, analgesics to dull pain, and narcotics to induce unconsciousness"
Well, not quite. Anesthesiologist seek a balance between drugs that cause unconsciousness, amnesia, anxiolysis, attenuation of the stress response, and muscle relaxation (for a history, see this article). Narcotics are used to block pain and therefore attenuate the stress response (but so do drugs like beta blockers). Narcotics do not induce unconsciousness (very well). We use inhaled anesthetics (such successors to ether) and intravenous anesthetics (such as successors to sodium pentothal) for that. It is this line that makes me think that the creators of this show did not allow an anesthesiologist to screen the final product for accuracy.
Narrator: "What no one in the operating room realized is that the canisters of anesthetic gas were empty"
This can happen, but if the pre-anesthetic checklist is used properly, it won't. Checking anesthetic levels is on the checklist. In addition, one of our inhaled anesthetics (Desflurane) has a vaporizer with a built-in alarm for when the anesthetic level gets low that can then be refilled without having to turn the vaporizer off (thus eliminating the risk of forgetting to turn the vaporizer back on).
Narrator: "A muscle relaxant is used to keep the body still during surgery"
A muscle relaxant is used to relax (paralyze) the muscles. We keep the patient still by making sure they are sufficiently anesthetized. Reflexly giving more paralytic if a patient moves is the wrong response. First insure lack of awareness, lack of pain, adequate anesthetic levels, then consider re-dosing the muscle relaxant.
Narrator: "Studies have shown that mistakes happen in 3% of all operations."
That may be true, but it's far too vague to have any bearing here. Mistakes by whom? Of what magnitude? Did harm actually come to the patient?
Finally the show introduces the brain monitor called Bis (for Bispectral Index), and the person introducing it is a Dr. Don Mathews. What the series does not indicate is that Dr. Mathews is on the speakers buereau for Aspect medical, maker of the Bis monitor. Dr. Mathews narrates a case where the patient actually requires less anesthesia than he thought--and that's exactly my experience with the Bis monitor. After using it for several years, I have never deepened someone's anesthetic because of what the monitor showed, only lightened it. The Bis monitor, and others like it, is being studies intensely in the literature, but I don't think there's a consensus yet. Bis measures level of hypnosis. Not depth of anesthesia. Using Bis makes no difference in the incidence of painful awareness.
It's late and I want to get this posted, but reserve the right to add a Part II should the urge arise.
For more information, see the JCAHO Sentinel Event Alert on "Preventing, and managing the impact of, anesthesia awareness" published in October 2004.
Saturday, February 19, 2005
MayoClinic.com Anesthesia Information
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James T. Li, M.D. has written two 'Ask a Specialist' pieces at MayoClinic.com that are relevant to patients having anesthesia. I've read them both and do hereby confer upon them the WakingUpCosts seal of approval:
- Anesthesia: Options and considerations
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- Anesthesia: Safe for people with asthma?
Wisconsin Hospital Association Launches Web Site Detailing Retail Prices of Procedures
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"The Wisconsin Hospital Association on Thursday launched a Web site that allows consumers to compare prices at hospitals statewide for more than 60 'common medical problems,' the Milwaukee Journal Sentinel reports. The site does not list actual prices charged to insurers but rather the 'retail,' or list prices, as well as the overall discount insurers collectively receive off a facility's retail rates for all procedures combined."
The site also contains links to quality information for each facility (example).
[Via Kaisernetwork.org]
COX-2 Prescriptions Fell 43% Since Last Year
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"The number of COX-2 inhibitor prescriptions decreased by 43% between December 2003 and December 2004, according to a study released on Monday by the pharmaceutical information and consulting company IMS Health, the AP/Seattle Post-Intelligencer reports"
[Via Kaisernetwork.org]
Wednesday, February 16, 2005
New Manifestations of Avian Influenza A (H5N1)
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NEJM--Fatal Avian Influenza A (H5N1) in a Child Presenting with Diarrhea Followed by Coma:
" In southern Vietnam, a four-year-old boy presented with severe diarrhea, followed by seizures, coma, and death. The cerebrospinal fluid contained 1 white cell per cubic millimeter, normal glucose levels, and increased levels of protein (0.81 g per liter). The diagnosis of avian influenza A (H5N1) was established by isolation of the virus from cerebrospinal fluid, fecal, throat, and serum specimens. The patient's nine-year-old sister had died from a similar syndrome two weeks earlier. In both siblings, the clinical diagnosis was acute encephalitis. Neither patient had respiratory symptoms at presentation. These cases suggest that the spectrum of influenza H5N1 is wider than previously thought. "
NEJM -- The Risk of Cesarean Delivery with Neuraxial Analgesia Given Early versus Late in Labor
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NEJM --The Risk of Cesarean Delivery with Neuraxial Analgesia Given Early versus Late in Labor
" Analgesia was initiated in the intrathecal group by a combined spinal–epidural technique. Intrathecal fentanyl (25 µg) was injected, an epidural catheter placed, and an epidural test dose administered. At the second request for analgesia, the cervix was again examined. Epidural analgesia was then initiated as follows: if the cervix was less than 4.0 cm in diameter, a 15-ml epidural bolus of bupivacaine (0.625 mg per milliliter) with fentanyl (2 µg per milliliter) was given, and if the cervix was 4.0 cm or greater in diameter, a 15-ml epidural bolus of bupivacaine (1.25 mg per milliliter) was given (Figure 1). In both instances, patient-controlled epidural analgesia was then begun. "
Bottom Line: Intrathecal fentanyl in women not yet at 4 cm cervical dilation does not increase C-section rate when compared to systemic opioids. Lots of great information to digest over the next several days...
Monday, February 14, 2005
Truth in Advertising
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The availability of references and the sponsorship of original research cited in pharmaceutical advertisements (free full text):
" Results: In the 438 ads with medical claims, 126 contained no references and 312 contained 721 unique references. Of these ad references, 55% (396/721) cited journal articles and 19% (135/721) cited data on file. In contrast, in the sample of research article references, 88% (351/400) cited journal articles and 8% (33/400) cited books. Overall, 84% of the citations from the ads were available: 98% of journal articles, 86% of books, 71% of meeting abstracts or presentations and 20% of data-on-file references. In all, 99% of the sample of research article references were available. We determined that 58% of the original research cited in the pharmaceutical ads was sponsored by or had an author affiliated with the product's manufacturer, as compared with 8% of the articles cited in the research articles. "
[Via UK Medical News Today]
We shouldn't be surprised at these findings. It is just marketing, after all.
Grand Rounds XXI At Sumer's Radiology Site
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Sumer's Radiology Site: Grand Rounds XXI
Sunday, February 13, 2005
Using Passwords? Switch to Pass-phrases, Instead.
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Slashdot points to a very interesting blog entry by a Microsoft engineer in which he makes it perfectly clear how single
passwords are not secure any longer:
" So with all of these highly successful, highly effective attacks on passwords (dictionary attacks, brute-force attacks, pre-computation attacks) I've come to the conclusion that there is simply too much risk associated with passwords and that users of Windows should simply stop using them to avoid this risk. "
Instead, he recommends pass-phrases:
" Pass-phrase LENGTH, not complexity defeats these attacks. Short, but complex passwords should be shunned as they are not truly secure anymore and you are deceiving yourself if you think they are. Long pass-phrases (14 characters or more) are the future (along with 2-factor or more authN, but that's another blog for another day) and are the only way to go if you want to ensure that you won't get hacked via any type of password based attack of any kind. "
Think CPAP Mask After Major Abdominal Surgery
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JAMA just published Continuous positive airway pressure for treatment of postoperative hypoxemia: a randomized controlled trial and those of us giving anesthesia for open major abdominal surgery should take note. Here's the abstract:
" Results Patients who received oxygen plus continuous positive airway pressure had a lower intubation rate (1% vs 10%; P = .005; relative risk [RR], 0.099; 95% confidence interval [CI], 0.01-0.76) and had a lower occurrence rate of pneumonia (2% vs 10%, RR, 0.19; 95% CI, 0.04-0.88; P = .02), infection (3% vs 10%, RR, 0.27; 95% CI, 0.07-0.94; P = .03), and sepsis (2% vs 9%; RR, 0.22; 95% CI, 0.04-0.99; P = .03) than did patients treated with oxygen alone. Patients who received oxygen plus continuous positive airway pressure also spent fewer mean (SD) days in the intensive care unit (1.4 [1.6] vs 2.6 [4.2], P = .09) than patients treated with oxygen alone. The treatments did not affect the mean (SD) days that patients spent in the hospital (15 [13] vs 17 [15], respectively; P = .10). None of those treated with oxygen plus continuous positive airway pressure died in the hospital while 3 deaths occurred among those treated with oxygen alone (P = .12). "
I remember the first time someone suggested using CPAP for the struggling patient in the recovery room after major abdominal surgery. I snorted and mumbled something under my breath about how the patient needed an endotracheal tube and should have taken the offered thoracic epidural. I went back to bed, convinced that I'd be called in an hour or two to intubate the patient who would by then certainly be in extremis. You know what? They never called me that night and this paper helps me understand why.
I think I need to modify my internal algorithm for post-anesthesia management of these often difficult cases to reflect the option of CPAP as a middle ground between mask oxygen and endotracheal intubation.
Screening for AAA Recommended for Smokers Aged 65-75
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The U.S. Preventive Services Task Force (part of AHRQ) now 'recommends one-time screening for abdominal aortic aneurysm (AAA) by ultrasonography in men aged 65 to 75 who have ever smoked.'
" Rationale: The USPSTF found good evidence that screening for AAA and surgical repair of large AAAs (5.5 cm or more) in men aged 65 to 75 who have ever smoked (current and former smokers) leads to decreased AAA-specific mortality. There is good evidence that abdominal ultrasonography, performed in a setting with adequate quality assurance (i.e., in an accredited facility with credentialed technologists), is an accurate screening test for AAA. There is also good evidence of important harms of screening and early treatment, including an increased number of surgeries with associated clinically-significant morbidity and mortality, and short-term psychological harms. Based on the moderate magnitude of net benefit, the USPSTF concluded that the benefits of screening for AAA in men aged 65 to 75 who have ever smoked outweigh the harms. "
Patients should also be made aware that there is an alternative to open AAA repairs known as 'endovascular repair.' NEJM recently published A Randomized Trial Comparing Conventional and Endovascular Repair of Abdominal Aortic Aneurysms which concluded:
" On the basis of the overall results of this trial, endovascular repair is preferable to open repair in patients who have an abdominal aortic aneurysm that is at least 5 cm in diameter. Long-term follow-up is needed to determine whether this advantage is sustained. "
As an aside, wouldn't it be nice to be able to query our electronic medical record for all patients in our primary care practice who meet this criteria? Oh wait. We don't have EMR's (for the most part).
Saturday, February 12, 2005
Citation Classics in Anesthetic Journals
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I was listening to some friends talk about taking a large set of information and making it more useful to the user when I thought about a project I helped with to try to remedy this with regard to the body of published literature in medicine. PubMed is the National Library of Medicine's big online database of medical articles (no, I didn't help with that). Searching for a term on PubMed usually gets lots of results but doesn't necessarily get you any closer to finding that key reference that people consider the classic or definitive paper in the field.
As a teacher in academic anesthesia, I saw residents (note the past tense) had little hope of finding the 'right' paper to read unless I gave it to them. If I said 'read about airway management' they would no doubt find some things about airway management, but probably not the paper on airway management. Unless of course they were able to search a subset of articles in PubMed defined in advance to be especially relevant to their field of study. That's how we conceived of the idea of 'Key References'--make it easy to assemble a list of references for whatever purpose. To make it easy, we used a unique identifier for each article called the PubMed ID Number (PMID). Seth Dillingham then wrote a plugin for Conversant that could take that PMID and go to the PubMed system and (politely) request information about the reference such as title, authors, citation, and even the abstract.
'Citation classics in anesthetic journals' by Baltussen and Kindler is comprised of 'seminal advances in anesthesia' which give 'a historic perspective on the scientific progress of this specialty'. The advantage of having them available online as a compilation lies in the fact that they 1) are searchable and 2) linked to related articles in PubMed (something which even the online version of the original article even does not do).
See for yourself: Citation Classics in Anesthetic Journals
After looking up all 100 PMID's for these articles I wrote to the journal editors and suggested they require authors to include PMID's for references they cite in each article but (apparently) failed to make a convincing enough case. Sort of like in, oh, 1995 when I suggested to the editors of another journal that they could put their articles online using Highwire Press and was told that they had their hands full putting back issues on CD.
Thursday, February 10, 2005
Coming To A School Near You: Super Size Me
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" What happens when a man eats nothing but McDonald's food for 30 days? It's a lesson that schoolchildren across the country are about to find out.
Morgan Spurlock, director and star of "Super Size Me: A film of epic proportions," is releasing an edited version of the film for classrooms. The school version of the Academy-Award nominated film is scheduled to be released after the Feb. 27 Oscars (news - web sites) ceremony. "
Um. Can we show it in hospital waiting rooms?
[via Yahoo News]
"What the Doctor Saw"
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Published in the Fulton County (Georgia) Daily Report: What the Doctor Saw:--The court system through the eyes of a surgeon sued for malpractice (PDF--432k)
" Outstandingly reported account of a surgeon's professional liability trial from the standpoint of the defendant and his family as well as the lawyers on both sides. "
[Via Overlawyered]
Does it really cost 800 million dollars to develop a new pill?
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Estimating the Costs of New Drug Development: Is it really $802m?:
" Abstract:
This paper replicates DiMasi et al (2003) drug development cost estimates using their published survey cost estimates along with information from a publicly available data set. The results suggest that the expected cost of developing the average drug is even higher than the DiMasi et al (2003) estimate of $802m (in 2000 dollars). The paper estimates the capitalized out-of-pocket cost per new drug to be between $839m and $868m (in 2000 dollars). The paper similarly estimates the expected cost of the average new drug with certain characteristics such as primary indication. It is shown that the expected cost of developing the average HIV/AIDS drug is $479m, while the expected cost of developing the average rheumatoid arthritis drug is twice that, at $936m.
...[continues]..." "
PDF (184k)
[Via Marginal Revolution]
Tuesday, February 8, 2005
I want a Bluetooth pre-tracheal stethoscope
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During my anesthesiology training, attendings encouraged me to use a pre-tracheal stethoscope--basically a metal bell that rested on the base of the patient's neck over the trachea which could be used to listen to breath sounds during general anesthesia. This usually involved a hollow tube running from the stethoscope to an earpiece in the anesthetists ear. FM transmitter were available for wireless monitoring.
I still think this is usefull, especially for cases using a laryngeal mask airway (LMA). Trouble with an LMA is usually preceded by 'crowing'--a high pitched noise caused by the passage of air over partially closed vocal cords. This can progress to frank laryngospasm, airway obstruction, and the generation of very large negative intra-thoracic pressures and negative pressure pulmonary edema.
What would the modern equivalent be like? Bluetooth transmitter. Wireless ear phone. I wonder if I can do this with my PowerBook somehow? I'd need a box to convert the sound from the stethoscope to a digital signal (and amplify it), then run it into the PowerBook. On a PowerBook with built-in bluetooth, can I send the sound-in signal out via bluetooth? Sounds like a weekend project, to me...
medmusings: Grand Rounds XX
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All the way from Singapore......medmusings: Grand Rounds XX
