Thursday, March 31, 2005
Malpractice Payouts in Pennsylvania Rose in 2004
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Malpractice Payouts in Pennsylvania Rose in 2004:
"In 2004, insurers reported paying out $448 million, a 13.5 percent jump from $394.5 million reported in 2003, according to the U.S. Health Resources & Services Administration. The 2004 figure broke the previous record, which had been set in 2001.
The increase in 2004 came after two years of decline. One researcher said he thinks payouts are climbing steadily, but that the steep increase in 2004 also was bumped up by delayed reporting of some payments made the previous year."
[Via Point of Law Forum]
Saturday, March 26, 2005
CMJ Review: Clostridium difficile-associated diarrhea in adults
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The Canadian Medical Journal: Clostridium difficile-associated diarrhea in adults (free full-text)
Thursday, March 24, 2005
CDC: Disinfectants and Their Properties
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The CDC published (as an appendix to another report) a guide on which disinfectant work for what organisms:
"All surfaces should be cleaned thoroughly before disinfection. For basic disinfection, a 1:100 dilution of household bleach (i.e., 2.5 tablespoons/gallon) or a 1:1,000 dilution of quaternary ammonium compounds (e.g., Roccal-D® or Zephiran®) may be used. This appendix includes instructions for disinfection when a particular organism has been identified. All compounds require a contact time of >10 minutes."
Wednesday, March 23, 2005
C. difficile Outbreaks, Anyone?
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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:
"If your institution experiences an outbreak, consider using only soap and water for hand hygiene when caring for patients with Clostridium difficile-associated disease; alcohol-based hand rubs may not be as effective against spore-forming bacteria."
Has anyone else seen this at their facilities?
Tuesday, March 22, 2005
NEJM: Two Articles On Schiavo Case
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The NEJM will publish two article on the Schiavo case in an upcoming issue. Both are online now and free without a subscription:
Perspective
Terri Schiavo — A Tragedy Compounded
T.E. Quill
Legal Issues in Medicine
"Culture of Life" Politics at the Bedside — The Case of Terri Schiavo
G.J. Annas
Sunday, March 20, 2005
Take Your Web Searching To The Next Level
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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:
http://scholar.google.com/scholar?hl=en&lr=&safe=off&q=hyperthermia&btnG=Search
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.
Thursday, March 17, 2005
NEJM: The Serotonin Syndrome
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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!).
Why I'm Excited About Apple's 'Spotlight' Technology
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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):
- Plain text
- RTF
- PDF
- Mail
- Keynote presentations
- Microsoft Office Word documents
- Microsoft Office Excel spreadsheets
- Microsoft PowerPoint presentations
- iChat logs (if logging is enabled)
In other words, all the file formats in which clinical reference information might exist on my computer hard drive will be searchable
by content, not just by title.
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
Tuesday, March 15, 2005
Four Drug Rep Tricks Plus One Of My Own
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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:
- False agreements
- Fake Thanks
- Bring the Boss
- Appeal to Authority
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: Respectful Insolence
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Grand Rounds XXV is up at Respectful Insolence. Just don't have a mouth full of coffee when you read it.
Monday, March 14, 2005
WHO warns of human bird flu mutation
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ABC News Online--WHO warns of human bird flu mutation.:
" The World Health Organisation (WHO) says the bird flu virus may be changing into a form that humans can pass on.
The WHO is worried that bird flu, which has killed 47 people in Asia, could mutate into an easily spread form that sparks the next influenza pandemic.
The organisation has identified a cluster of human bird flu cases among relatives and possibly health workers in Vietnam.
"Such cases can provide the first signal that the virus is altering its behaviour in human populations and thus alert authorities to the need to intervene quickly," the WHO said in a statement.
The main concern of the WHO was a series of cases of the deadly H5N1 bird flu virus in a family in the northern Vietnam province of Thai Binh and the possible infection of two nurses who cared for one of the patients.
The WHO also says it has received confirmation of an additional 10 cases of human infections from Vietnam's Health Ministry.
The new cases were detected in early March or through re-examination of older cases, some of which dated back to late January and three of which had been fatal, the WHO said. "
See the WHO web site for details.
Sunday, March 13, 2005
Pennsylvania Department of Health Reconsiders Laparoscopy Decision
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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:
"Following its notification to providers that procedures such as laparoscopic cholecystectomies were not permitted in the ASF setting, some ASFs objected that some of these procedures were safe and should be allowed.
In response to these providers’ concerns, the DoH proceeded to meet on a number of occasions with the Pennsylvania Medical Society, the Federated Ambulatory Surgery Association and the Pennsylvania Ambulatory Surgery Association. We reviewed the applicable literature made available to us by provider organizations and through our own research. We worked with the Pennsylvania Health Care Cost Containment Council to collect available data into formats that would be helpful. We found that some ASFs were performing procedures that the DoH believes to be prohibited under its regulations. We also surveyed other states and found that Pennsylvania is more restrictive than other states, which tend to rely upon Medicare to control the types of procedures performed in ASFs.
The DoH agrees that providers have raised valid points and proposes to convene a group of stakeholders to review the current regulation and determine what changes are appropriate. This process, however, will take time and some providers that have been performing these procedures on a routine basis need more immediate relief. Therefore, the DoH has implemented the following two-pronged exceptions process.
In addition to the procedures allowed under the state regulations, the DoH has determined that ASFs should have the opportunity to perform procedures that are on the Medicare List since these procedures have been reviewed and approved by the federal government on a procedure-by-procedure basis for their safety in a freestanding ambulatory setting. This list is developed under § 1833(i)(1) of the Social Security Act, which requires CMS to specify surgical procedures that can be safely performed in a freestanding ambulatory surgical setting. The Medicare List is published in the Federal Register as an addendum to 42 CFR Part 416"
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.
The Hipster PDA
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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.
