CDC: Disinfectants and Their Properties
The CDC published (as an appendix to another report) a guide on which disinfectant work for what organisms:
The CDC published (as an appendix to another report) a guide on which disinfectant work for what organisms:
Our hospital has pulled all 3M Avagard hand disinfectant from the operating rooms, preferring instead that surgeons go back to the old fashioned surgical hand scrub. At the same time, we are apparently seeing more nosocomial Clostridium difficile infections. C. diff. is not a reportable pathogen, and this was felt to contribute to the outbreak Canada experienced recently. Avagard does not inactivate C. diff. spores. Co-incidence? I don't think so.
The CDC page for healthcare providers on C. diff. provides an interesting nugget:
Has anyone else seen this at their facilities?
The NEJM will publish two article on the Schiavo case in an upcoming issue. Both are online now and free without a subscription:
Terri Schiavo — A Tragedy Compounded
Legal Issues in Medicine
"Culture of Life" Politics at the Bedside — The Case of Terri Schiavo
There's more to search than Google--especially for medical topics. I often need to go search eMedicine, Cochrane, Pubmed, specific journals (NEJM and Anesthesia & Analgesia are two I use often) or even a Google sub-site (plain, news, images, scholar, maps) . One way to do this is to go to each home page, find their search box and, well, search! Ah, but there's a better way and it's called iSeek (MacOS X only).
What you're really doing when you use a search box on a site is submitting a search request in their syntax. If you know the syntax, you can submit a search request without actually going to the site. If you look at the address bar after you submit a search on a site, you're looking at their search syntax. For example, if I do a search on Google Scholar for 'hyperthermia,' I see the following url in the address bar:
Now, it's a bit much for us to memorize that string of text, but computers are very good at that sort of thing...and that's where iSeek comes in. Here's what iSeek looks like in my menu bar (it's the text field with the magnifying lens):
And here's what the iSeek menu looks like with all my favorite search sites:
To search at one of the listed sites, I select the site (in this case eMedicine), enter the search term in the text field, and hit 'return.' iSeek takes my search term, slaps on the right prefix and suffix to put the search term in the right format, and submits it. The results appear in a new tab in my web browser.
If the thought of figuring out the right text strings bother you, fear not. The makers of iSeek have an extensive list of search engines you can add directly from their site.
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
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
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.