Boyer and Shannon's article in the NEJM The Serotonin Syndrome is an excellent review/introduction to a syndrome every anesthesiologist should be familiar with but that had not been defined when I was in training. Excess serotonergic agonism can be triggered not only by certain drug overdoses, but also by many drugs anesthesiologist give frequently (fentanyl!).
Rumor has it that Apple will release its next iteration of MacOS X, code named 'Tiger', in April. One component of it that is not a rumor is its new built-in search engine called Spotlight (tech preview pdf). The list of supported files types includes (but is not limited to):
How might this be useful to a clinician? For years now, I've been dropping files onto my hard drive because they contains information I want to have access to in the future. I have an entire textbook of anesthesiology as html files. Literally hundreds if not thousands of pdf files of articles I've saved from NEJM, Anesthesia & Analgesia, and other journals. Every lecture I've ever given. All the CME I've ever done (if available electronically).
I have tried mightily to keep it all organized. Seth Dillingham actually made some software for me to be able to use a local webserver to organize, index and serve all those files on my local machine. Extended to something we called the Reference Laptop Project, we endeavored to put everything an anesthesia resident could need during their training on a $1,000 20 GB Apple iBook, complete with automatic updating of reference materials via wireless LAN. I've installed Plone and learned some Python to be able to make a system that works for me. But now, finally, coming to OS X, is the core technology that will allow me to do what I want as a feature of the operating system itself, or perhaps even as a custom application.
Underneath it all, there's even an API that lets applications access Spotlight's power. Imagine a new application that imposes a structure on the information you already have or will add! As an example, imagine an outline of relevant topics in anesthesiology. For each topic, the application would use Spotlight to create Smart Folders for, say, information on malignant hyperthermia, and airway management, and peri-operative beta blockade. I have a great deal of information on each of these topics already on my hard drive. Some in the Documents folder, some under Sites. Some exists as HTML files, some as PDF, some as powerpoint. And as I add more information, the Smart 'Chapter' will automatically update. Perhaps the very capable makers of Delicious Library will explore creating 'Delicious Reference' just for me.
The future is here. It's just not evenly distributed yet. --William Gibson
Polite Dissent is a blog I just discovered thanks to Grand Rounds. He/she has the same take on some of the techniques used by drug detail people as I do:
I'll just add my own to this very good list: use the people around you as billboards. It seems the people who make a paralytic called rocuronium have dropped off a thousand or so yellow operating room caps that say "Roc Solid" (Roc is our abbreviation for rocuronium, aka Zemuron). Many OR nurses and techs are now wearing these caps. My reaction? Even if I was planning on using rocuronium for the case, I'll draw up some tasty vecuronium or cis-atracurium instead. And besides, the vecuronium people gave me a nice nerve stimulator once...
Grand Rounds XXV is up at Respectful Insolence. Just don't have a mouth full of coffee when you read it.
ABC News Online--WHO warns of human bird flu mutation.:
See the WHO web site for details.
In a letter to ambulatory surgery centers dated March 7, 2005 and available on a DOH web site, the department has decided to place the issue under further study and to grant exceptions to the prior directive to allow some centers to resume certain laparoscopic procedures:
A PDF of the letter is uploaded here. On balance, I think this is a fair approach (for now), and a great improvement over the wholesale banning of all laparoscopic procedures at centers that provide a very high standard of care.
43 Folders has a wonderful post on a way to capture information on the go which they're calling the Hipster PDA. Now, I have tried to use all manner of PDA to keep track of info on the go at the hospital, starting with the Newton all the way up to my current Treo 610. Which one worked best? It was the system I used as an intern--3X5 index cards held together with a binder clip.
I have improved on it slightly over time, only because, as an anesthesiologist I have less stuff to remind myself about. My 'Palmster PDA' consists of the palm of my left hand on which I can conveniently write down who needs an epidural, which of my colleagues needs lunch or a break, or when I need to re-dose the antibiotic for my current patient.
I've lectured on a variety of topics. I've been asked to give inservices to OR nurses and anesthesia techs alike. No topic is more frequently requested than how to use an iPod. Honest. iPods are becoming more commonplace in the operating room all the time. I've finally found a nice demo on the web of how to operate an iPod which allows self-paced learning:
The Medical Informatics Weblog: Consequences of Physician Report Cards:
This is a very timely JAMA article as the Pennsylvania Health Care Cost Containment Council has just published its Guide to Coronary Bypass Graft Surgery 2003 in which it assigns higher than expected adjusted mortality mortality scores to three surgeons that I feel are head and shoulders above the rest in the list. In other words, it dinged the surgeons I think are the best. (as an aside, none practice an Pennsylvania any longer)
Why Mothers Die 2000-2002 - Report on confidential enquiries into maternal deaths in the United Kingdom
Chapter 9--Anaesthesia
The anesthesia chapter concludes:
I would like to think that many of the problems pointed out in this report would not happen in the United States, but that would be intellectually dishonest. If you provide anesthesia for obstetrical patients as I do, it's worth reading over this report for the lessons that are applicable in the US.
In a post titled Natural Danger Stuart Henochowicz takes on the issue of misinformation about vaccines that seems to be accumulating in the lay press.
My wife has seen a number of families that have decided to withhold vaccinations from their children over mercury and other health concerns. As health professionals, we need to take this bull(shit) by the horns and make sure people know the facts. As Stuart points out, although herd immunity may give them a free pass, society will pay the price if the proportion of such unvaccinated individuals becomes too great.
Health Affairs: U.S. Health Spending Projections For 2004–2014
Gulp.
Kaisernetwork.org--Frist Indicates Willingness To Compromise With Democrats on Malpractice Legislation:
Kaisernetwork.org--Capitol Hill Watch | Senate Committee Approves Bill To Establish Medical Error Reporting Database - :
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....
"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:
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.
'Good guys' show just how easy it is to steal ID:
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]
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:
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)
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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.
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:
The site also contains links to quality information for each facility (example).
[Via Kaisernetwork.org]
[Via Kaisernetwork.org]
NEJM--Fatal Avian Influenza A (H5N1) in a Child Presenting with Diarrhea Followed by Coma:
NEJM --The Risk of Cesarean Delivery with Neuraxial Analgesia Given Early versus Late in Labor
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...
