Thursday, December 22, 2005

More on why anesthesia is (or is not) safer

Walter Olson responded to my earlier post and I feel I need to clarify what I meant. I thank him for pointing out (gently) the error of my words.

First off, I trained in the early 1990's after the advent of improved monitoring such as pulse oximetry and end tidal gas monitoring. My statement that 'overdose risk is not and was never a cause of patient morbidity and mortality in my field' was overly broad and, as Olson points out, incorrect.

The point I tried to make (though not well) was that overdose is not something we presently worry about and does not explain the apparent increase in awareness under anesthesia. What can explain it (in part) is the use of muscle paralyzing drugs (even when they are not absolutely necessary) often together with medical errors such as empty vaporizers (inhaled anesthetic delivery source), incorrectly installed vaporizers, or other human error.

Though Google turns up many hits on anesthesia and overdose, these tend to be written by non-anesthesiologists for the lay public and should not be taken as evidence that anesthetic overdoses is a cause of malpractice claims (though, admittedly, it is a term that most juries readily understand)

Walter, if you're reading this, I'd love to be able to read more about how the legal system portrays us during trials. Any pointers?

More proof: people don't change (doctors are people)

Disciplinary Action by Medical Boards and Prior Behavior in Medical School

"Conclusions In this case-control study, disciplinary action among practicing physicians by medical boards was strongly associated with unprofessional behavior in medical school. Students with the strongest association were those who were described as irresponsible or as having diminished ability to improve their behavior. Professionalism should have a central role in medical academics and throughout one's medical career."

Another report of H5N1 resistance to Tamiflu

NEJM Case Report: Oseltamivir Resistance during Treatment of Influenza A (H5N1) Infection [free full text]

Tight glycemic control in Type I diabetes reduces risk of cardiovascular disease

NEJM:Intensive Diabetes Treatment and Cardiovascular Disease in Patients with Type 1 Diabetes

"Results During the mean 17 years of follow-up, 46 cardiovascular disease events occurred in 31 patients who had received intensive treatment in the DCCT, as compared with 98 events in 52 patients who had received conventional treatment. Intensive treatment reduced the risk of any cardiovascular disease event by 42 percent (95 percent confidence interval, 9 to 63 percent; P=0.02) and the risk of nonfatal myocardial infarction, stroke, or death from cardiovascular disease by 57 percent (95 percent confidence interval, 12 to 79 percent; P=0.02). The decrease in glycosylated hemoglobin values during the DCCT was significantly associated with most of the positive effects of intensive treatment on the risk of cardiovascular disease. Microalbuminuria and albuminuria were associated with a significant increase in the risk of cardiovascular disease, but differences between treatment groups remained significant (P≤0.05) after adjusting for these factors."

Misconceptions about why anesthesia is safer

Walter Olson has taught me much about the legal system as it pertains to medicine via the PointOfLaw forum. I have to take exception with a post made today however. In pointing to an article that considers whether the lessons of patient safety in anesthesiology are generalizable to other fields of medicine, he writes:

"Incidentally, because anesthesiologists are now more vigilant than ever not to court an overdose risk by giving patients any more than the minimum they need, there is apparently a rising incidence of the phenomenon of "anesthesia awareness", in which underdosed patients are actually aware of the surgery in progress and perhaps end up undergoing psychological trauma as a result. So what happens next? You guessed it."

Overdose risk is not and was never a cause of patient morbidity and mortality in my field. Second, it is not at all clear whether the 'rising incidence of the phenomenon of anesthesia awareness' is anything but a) better reporting (i.e. you don't find what you don't look for) b) realization among patients that there's something else they can sue for or c) an effort by one medical device company which makes depth of anesthesia monitors to panic hospitals and anesthesia groups into buying their product (a product which, by the way, has not been shown to decrease the incidence of awareness).

The specialty is actively engaged in evaluating this 'problem' with the same approach it has used to improve patient safety in other areas such as airway management and positioning injuries.



Tuesday, December 6, 2005

For OR Nurses: iPod 101

iPod 101

"Just in time for the Holiday season Apple has posted iPod 101...[which] covers everything you might want to know about the iPod, but were afraid to ask (or perhaps didn't know you should want to ask)."

[Via TUAW]



Sunday, December 4, 2005

Sales of Impotence Drugs Fall, Defying Expectations - New York Times

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Sales of Impotence Drugs Fall, Defying Expectations - New York Times:

"Seven years after Pfizer made Viagra a cultural touchstone and commercial blockbuster, the market for impotence medicines appears to have fallen well short of what was once predicted."

[Via New York Times]



Thursday, December 1, 2005

CDC MMWR: Severe Clostridium difficile

  • Categories: Data
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Severe Clostridium difficile--Associated Disease in Populations Previously at Low Risk --- Four States, 2005

Greg Pierce: Pragmatic Security

Greg's "Pragmatic Security," for the Rest of You ;-):

" Greg has just published a very pragmatic set of instructions to help "friends and family of geeks" deal with security issues on the internet. Very good recommendations, all of them, and so I'd like to ask all of my friends and family to go check them out. He obviously spent a lot of time writing that essay, and I believe that most will find it an 'easy read'.

He admits it's not a complete solution to everyone. It's a plan to get started. I think it's a good plan.

The most important issue he left out, in my opinion, is the huge number of "phishing" email messages being sent out these days (these are attempts to trick you out of your username and password). Nobody is safe from these, many of them are just too good. I wrote up a little blurb and posted it in a reply to Greg's message, so please include it in your reading. "

[Via Truer Words - A Journal]

How do you mark a surgical site?

The American Academy of Orthopaedic Surgeons has a policy on marking surgical sites titled Guidelines for Implementation of the Universal Protocol for the Prevention of Wrong Site, Wrong Procedure and Wrong Person Surgery. It's worth reviewing and comparing to your institutions policy. For example:

  • Make the mark at or near the incision site. Do NOT mark any non-operative site(s) unless necessary for some other aspect of care.
  • The mark should be unambiguous (e.g., use initials or "YES" or a line representing the proposed incision; consider that "X" may be ambiguous).
  • The person performing the procedure should do the site marking.

There's much more to the guideline, but your current policies are most likely to be at variance with the above three points. One of the surgery centers I work at, for instance, marks the surgical site with an 'X'. I've explained to them that 'X' is ambiguous (does X mark the spot, or does X mark 'not this one'?) and even explained the details of a malpractice case in which marking with an X came into play. Another hospital was in the habit of marking both sides ('L' and 'R'). Also confusing. Finally, several centers have the nurse preparing the patient for surgery to mark the site. Also not a good idea.



Wednesday, November 30, 2005

NYT: Gimme an Rx! Cheerleaders Pep Up Drug Sales

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Interesting New York Times article on pharmaceutical reps:

"Exaggerated motions, exaggerated smiles, exaggerated enthusiasm - they learn those things, and they can get people to do what they want."

Approximately two dozen Kentucky cheerleaders, mostly women but a few men, have become drug reps in recent years.

While there are no statistics on how many drug representatives are former or current cheerleaders, demand for them led to the formation of an employment firm, Spirited Sales Leaders, in Memphis. It maintains a database of thousands of potential candidates."

This reminds me of the drug rep on the TV show Scrubs (played by Heather Locklear).



Friday, November 25, 2005

How much caffeine does that drink have?

I've written before about caffeine addiction in surgical patients. In recent years there's been an explosion of caffeine-containing beverages. Having some idea of the caffeine content of the major ones can help you choose an appropriate dose.

The Energy Fiend web site has a nice Caffeine Database. I found it via a recent NYT article.

caffeinetable.jpg



Thursday, November 24, 2005

NEJM: The Origins of Pandemic Influenza--Lessons from the 1918 Virus

The Origins of Pandemic Influenza--Lessons from the 1918 Virus [free full text]

"...monitoring of the sequences of viruses isolated in instances of bird-to-human transmission for genetic changes in key regions may enable us to track viruses years before they develop the capacity to replicate with high efficiency in humans. Knowledge of the genetic sequences of influenza viruses that predate the 1918 pandemic would be extremely helpful in determining the events that may lead to the adaptation of avian viruses to humans before the occurrence of pandemic influenza. We could then conduct worldwide surveillance for similar events involving contemporary avian viruses. "

How To: Awake Fiberoptic Intubation

This definitely falls in the "don't try this at home" category, but if this technique is different than the one you use, give it a try. It will surely result in a net gain in style points.

How To Do An Awake Fiberoptic Intubation

Technorati Tags: Anesthesia



Wednesday, November 23, 2005

C-section rate in USA reaches 29.1% in 2004

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" Despite the evidence of risks associated with cesarean section, the rate of birth by cesarean section in 2004 in the USA registered at 29.1 percent, the highest ever recorded. According to the Centers for Disease Control and Prevention (CDC) in a recent report, this figure is an 8 percent increase from 2003, and a 41 percent increase since 1996. "

One of the OB practices at our hospital has a policy that they will not do vaginal births after C-section (VBAC)...largely due to concern about lawsuits.

[Via UK Medical News Today]

MMWR Available Via Really Simple Syndication (RSS) Feeds

"MMWR now offers RSS feeds, a free, automated method to receive all MMWR publications. Through RSS, new reports and publications are fed to your desktop or browser-based news reader when they are posted online. Headlines are presented in the RSS feeds, with links to the full reports and publications on the MMWR website. RSS feeds to MMWR publications are available at http://www.cdc.gov/mmwr/rss/rss.html"

[CDC]



Tuesday, November 22, 2005

Translations of phrases often seen in dissertations and scholarly articles

  • Categories: Humor
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  • "It has long been known" ... I didn't look up the original reference.
  • "A definite trend is evident" ... These data are practically meaningless.
  • "While it has not been possible to provide definite answers to the
  • questions" ... An unsuccessful experiment but I still hope to get it published.
  • "Three of the samples were chosen for detailed study" ... The other results didn't make any sense.
  • "Typical results are shown" ... This is the prettiest graph.
  • "These results will be in a subsequent report" ... I might get around to this sometime, if pushed/funded.
  • "In my experience" ... Once.
  • "In case after case" ... Twice.
  • "In a series of cases" ... Thrice.
  • "It is believed that" ... I think.
  • "It is generally believed that" ... A couple of others think so, too.
  • "Correct within an order of magnitude" ... Wrong.
  • "According to statistical analysis" ... Rumor has it.
  • "A statistically-oriented projection of the significance of these findings" ... A wild guess.
  • "A careful analysis of obtainable data" ... Three pages of notes were obliterated when I knocked over a glass iced tea.
  • "It is clear that much additional work will be required before a complete understanding of this phenomenon occurs" ... I don't understand it.
  • "After additional study by my colleagues" ... They don't understand it either.
  • "Thanks are due to Joe Blotz for assistance with the experiment and to Cindy Adams for valuable discussions" ... Mr. Blotz did the work and Ms.
  • Adams explained to me what it meant.
  • "A highly significant area for exploratory study" ... A totally useless topic selected by my committee.
  • "It is hoped that this study will stimulate further investigation in this field" ... I quit.



Sunday, November 20, 2005

Trial lawyers blocking avian flu bill

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ATLA blocking avian flu bill:

" The Washington Post's Jeffrey Birnbaum reports: "Legislation that would pour billions of dollars into the production of vaccines against avian flu and other pandemic diseases is threatened by the trial lawyers' lobby, which objects to proposed limits on lawsuits against drug manufacturers. "

All in the name of protecting patients, I'm sure.

[Via PointOfLaw Forum]

EFF: Legal Guide for Bloggers

Electronic Frontier Foundation: Legal Guide for Bloggers

"The goal here is to give you a basic roadmap to the legal issues you may confront as a blogger, to let you know you have rights, and to encourage you to blog freely with the knowledge that your legitimate speech is protected."

[Via O'Reilly Radar]

More on pre-emptive positioning

A fellow anesthesiologist wrote a reply to my post about pre-emptive positioning with the following:

"We've started doing the same thing at my surgicenter. At first I thought it was pretty ballsy when one of my colleagues suggested that we do simple one level laminectomies under LMA general and induce in the prone position. But now that we've started it I am very comfortable with the idea."

I'm not ready to try this yet (do you want to be my first patient?). Lateral or semi-sitting to supine is a matter of seconds. Prone to supine would take significantly longer I believe. Other experiences?

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