Thursday, November 3, 2005
Pre-emptive Patient Positioning
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Many surgeries require the patient to be in a position other than supine (flat on their back) for the surgery to be done. Shoulder surgery, for example, is often done with the patient in a semi-sitting or 'beach chair' position. Certain hip surgeries are done with patients on their side as well. General anesthesia is induced with the patient supine, then people have to move the patient (who is now akin to a very heavy sack of potatoes) into the right position. It's time consuming, risks staff injury, and jeopardizes the airway. The few accidental extubations I've had have occurred when the patient was being moved. Does it have to be this way? If the case is amenable to an LMA, I think the answer is 'no.'
If I'm caring for a patient who will require a general anesthetic and an LMA would be suitable, I've taken to positioning the patient before induction of anesthesia. I then pre-oxygenate, perform an IV induction, and place the LMA. The OR staff and surgeons like it because a) it saves time and b) it saves their backs. I like it because there's no move during which my airway can potentially be compromised (and because it saves time and saves my back). There's a benefit to the patient, too. Namely, they can tell us while awake whether our positioning is comfortable for them. Is the axillary role in the right place? Do they need a pillow under their knees in? Is their bottom up against the back of the table in beach chair? Is their ear properly padded in the lateral position? Think Different (but always, Think Safe).
Saturday, October 15, 2005
Bird flu virus reported to resist Tamiflu
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More popular press stories on drug resistance in bird flu:
"An avian influenza virus isolated from an infected Vietnamese girl has been determined to be resistant to the drug oseltamivir, the compound better known by its trade name Tamiflu, and the drug officials hope will serve as the front line of defense for a feared influenza pandemic. [Science Blog - Science News Stories]"
The New England Journal of Medicine has a recent free article summarizing our current state of knowledge titled Avian Influenza A (H5N1) Infection in Humans:
"High-level antiviral resistance to oseltamivir results from the substitution of a single amino acid in N1 neuraminidase (His274Tyr). Such variants have been detected in up to 16 percent of children with human influenza A (H1N1) who have received oseltamivir. Not surprisingly, this resistant variant has been detected recently in several patients with influenza A (H5N1) who were treated with oseltamivir."
This is not to say, however, that we have no other neuraminidase inhibitor tricks up our sleeves.
Sunday, October 9, 2005
The Cervical Cancer Vaccine
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The Well Timed Period offers some (well referenced) Q's and A's about the cervical cancer vaccine:
"Q: Why do we need to vaccinate the population at large?
Q: Why are the vaccine trials focused on preferentially vaccinating young women?
Q: Why are HPV 16 and 18 the target of Merck's vaccine?
Q: Are the researchers working on the HPV vaccine aware of potential barriers to its acceptance?
"
She concludes:
" The HPV vaccine is an extremely significant development because it offers tremendous possibility in helping reduce the incidence of abnormal Pap smears, cervical cancer, and genital warts in the United States as well as worldwide. "
I Am A Propofologist
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I've decided to change my title from 'Anesthesiologist' to the more descriptive 'Propofologist.' Maybe it's because I've been doing lots of sedation for colonoscopies and esophagogastroduodenoscopies (EGD) for which I use propofol/lidocaine only. When someone asks for anesthesia services, especially outside the operating room, what they're really asking for is someone who can give propofol to the point of loss of consciousness--hence the (new) term. Your heard it here first.
Monday, August 22, 2005
NYT: Sick and Scared, and Waiting, Waiting, Waiting
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NYT: Sick and Scared, and Waiting, Waiting, Waiting
Medicine from the patient's side. A must read article no matter what specialty you're in.
Thursday, July 7, 2005
We are all Britons
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[Shape of Days]
Friday, July 1, 2005
My take on the rumored iPhone
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Podcasts. Everybody's talking about music, but I'd listen to podcasts (like this Make podcast on biodiesel). Any good medical podcasts out there yet?
Med Mal Costs 2004
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Med Mal Costs 2004:
"Where is the most expensive place to defend oneself against malpractice in 2004? Florida is tops and Wyoming is the least expensive."
Hmmm. From the summary, it looks like my state (Pennsylvania) is 5th for costs incurred...
[Via PointOfLaw Forum]
How to survive a deposition
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"Malpractice: How to survive a deposition"
"Be concise, be cool, be prepared, and don't try to outwit the plaintiff's attorney."
[Via Overlawyered]
Friday, June 17, 2005
Review: Chronic Stable Angina
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The NEJM has a very nice review article titled Chronic Stable Angina.
"It is useful to classify therapeutic drugs into two categories: antianginal (anti-ischemic) agents and vasculoprotective agents. Although medications for angina are widely used, therapy to slow the progression of coronary artery disease, to induce the stabilization of plaque, or to do both is a newer concept and these forms of treatment are underprescribed."
Medical Simulation Weblog
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I found a neat new weblog called SimBlog. Associated with the Society for Medical Simulation, it appears to be edited by Jeff Taekman, formerly of Penn State and the person I came to Hershey to work with. Jeff had moved to Duke by the time I arrived, and is now the Associate Dean for Technology in Education there.
Saturday, June 11, 2005
NEJM -- Two-Years after Endovascular Repair of Abdominal Aortic Aneurysms
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Very interesting Dutch study on Two-Year Outcomes after Conventional or Endovascular Repair of Abdominal Aortic Aneurysms in the NEJM. This is the first study to look at prolonged survival (2 years) after placing a tube stent into a dilated abdominal aorta (aneurysm) to prevent rupture. We know that early survival is better with the stent vs. open repair. But what about after the first month? This study shows that after two years, the survival is about the same:
" The cumulative rates of aneurysm-related death were 5.7 percent for open repair and 2.1 percent for endovascular repair. This advantage of endovascular repair over open repair was entirely accounted for by events occurring in the perioperative period, with no significant difference in subsequent aneurysm-related mortality. "
To try to explain this, the authors discuss the following possibilities:
"There may be two possible explanations for the convergence of survival curves in our study. One is that patients who have survived the stress of open repair may be somewhat less likely to die in the first few months after surgery than patients who have undergone endovascular repair, since the latter group has not been subjected to a conventional surgical procedure.
...[snip]...
Another possible explanation for the convergence of survival curves is the failure of endovascular repair to prevent rupture of the aneurysm."
I wonder about a third possibility: did patients having an open repair make lifestyle change that those having the less stressful endovascular repair did not? I ask because one of the frustrations in taking care of patients with vascular disease is the extent to which they do NOT change their eating or smoking habits and so need to come back for yet another procedure at yet another time. The study lists baseline characteristics (55% smoked in the open group and 64% smoked in the endovascular repair group. Half in each group had hyperlipidemia), but no characteristics are given at the two year point. Can the lack of survival advantage after endovascular repair be explained by differences in rates of smoking, hyperlipidemia, and other risk factors at two years?
And thanks to the power of Google, I've sent the lead author an e-mail with just this question!
8: 00 A.M., the lead author writes back:
"We haven't studied that in this 2-year analysis but it is part of our long-term study."
Malpractice Insurance for Bariatric Surgeons Increasing
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Other Perils of Overweight - New York Times:
" But after several years in which the surgery was seen as the last best hope by many obese people, a growing array of scientific data shows that the risks are greater than patients realized. One new study reported that almost one in 5 patients had complications after surgery. For one in 20 patients, the complications were serious, including heart attacks and strokes. Another recent study said the mortality rate for the most common type of bariatric surgery, gastric bypass, was one in 200 - a rate higher than for coronary angioplasty, which opens blocked heart vessels.
For thousands of patients, the weight-loss surgery has eliminated debilitating diseases and improved the quality of life. But the threat of malpractice lawsuits against doctors and hospitals, as well as the reluctance of health plans to cover the surgery costs, is creating difficulties for people now seeking treatment. "
The article points to an Annals of Internal Medicine article titled Meta-Analysis: Surgical Treatment of Obesity (Annals is another one of those nice free full-text journals).
[Via Common Good]
Friday, May 27, 2005
Medical Malpractice Law in the United States - Kaiser Family Foundation
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Medical Malpractice Law in the United States - Kaiser Family Foundation:
" The Kaiser Family Foundation today issued a new report that explains how medical malpractice law in the United States works and provides an overview of recent trends and reform approaches. The Foundation also posted state-specific data on medical malpractice claim payments on statehealthfacts.org, the free online source of current health and health policy data for all 50 states. "
Average U.S. Family of 4 Will Use $12,214 in Medical Products, Services in 2005
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Kaisernetwork.org--Average U.S. Family of 4 Will Use $12,214 in Medical Products, Services in 2005, Study Says - :
" The average U.S. family of four will use $12,214 worth of medical products and services in 2005, up 45% from $8,414 in 2001, according to a new report by Milliman, the Washington Times reports (Higgins, Washington Times, 5/26). The report -- the first on consumer health care costs culled from the new Milliman Medical Index -- was based on health insurance information for more than 15 million insured U.S. residents (Whitehouse, Dow Jones/Wall Street Journal, 5/26). The report examined medical costs for a family with two adults and two children under age 10 who were covered by a PPO. It focused solely on costs for medical care at the point of service and did not include health insurance premiums (Washington Times, 5/26). The report also did not examine over-the-counter drug spending and the cost of medical treatments not covered by health insurance (Croghan, New York Daily News, 5/26).
The report found that the average family will pay about 17% -- or $2,035 -- of its total health care costs in 2005, with a health plan paying the remainder. "
The whole report is available here ![pdf]()
.
Thursday, May 26, 2005
Face-Lift Played Major Part in Woman's Death
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Face-Lift Played Major Part in Woman's Death, City Finds - New York Times:
You may remember the story several weeks ago about an Irish citizen who died the morning after a face lift in a plastic surgeon's office in New York. I've kept a Google Alert on this subject and this popped up today:
" An investigation by the New York City Medical Examiner's Office has concluded that the death of a 42-year-old Irish woman earlier this year was caused in significant part by face-lift surgery she underwent in the Manhattan office of a doctor who has repeatedly been sued for malpractice. "
Not much (any) detail. Maybe more will come out soon.
[Via ]
