Thursday, January 19, 2006
Or Their Designee...
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If you read your consent for surgery, you'll see those words right after your surgeon's name. Maybe you've noticed them. Probably you haven't.
Ghost surgery is defined as "substitution of an authorized surgeon by an unauthorized surgeon or the allowance of unauthorized surgical trainees to operate without adequate supervision". Now, that definition is sufficiently vague to allow all manner of stuff to go on, but I would wager that if you asked the patient wether they were under the impression their surgeon would do the entire surgery, that they would say 'yes.' If I ask surgeon W to do my surgery, I'd like surgeon W to sew the skin closed, too. Residents can practice closing just fine in partial-task simulators.
Wednesday, January 18, 2006
Anesthesia Blood Loss
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Anesthesia-related blood loss almost never exceeds surgical blood loss...but it can. I recently had a case where the IV tubing became disconnected from the IV hub during a case. The blood pressure cuff was on the same arm, and the intermittent tourniquet effect of the cuff cycling served to increase venous pressure sufficiently to cause blood to flow backward and out the now disconnected IV.
But wait, there's more. The patient was receiving the medication that kept her asleep through her IV and the disconnect put her at very real risk of waking up or having awareness in the middle of her surgery. This apparently did not happen in this case based on my interview of the patient in the recovery room, but it surely could have.
This misadventure would have been entirely avoided by the use of IV tubing with a locking hub (often called a Leur-Lock connector) connecting the IV tubing to the IV hub. In our case, someone decided the locking connectors were not worth the extra cost and our connections were just slip fit (no lock). How many times should this happen before the equipment is changed?
This has happened many times to my colleagues and I (though usually not with such blood loss), each time we complained, were told it was being looked in to, but kept getting the same connectors. I took the above rather striking photograph to some clinical managers, who agreed we needed to change, and said that they had already ordered the new tubing. Until it arrives, I'm starting IV's myself so that I can use locking connectors.
Wednesday, January 11, 2006
Medpundit Looks At His Financials
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Ugh: I just spent the better part of the afternoon...:
"Ugh: I just spent the better part of the afternoon doing my least favorite task - reveiwing the financials of my practice. It doesn't look pretty. With Congress electing to decrease my pay by 4%, and my malpractice premium set to increase by 30% you can see it's not going to be a good year. The cost of supplies has been steadily going up, too, as have the cost of services. My medical waste haulers upped their fees by 20% in the past six months due to rising gas prices.
The Medicare cut may not sound like much, but it translates into a loss of about $2-3 per patient visit. And it isn't just limited to Medicare patients. Insurance companies base their rate of reimbursement as a percentage of Medicare fees. They might, say, pay 110% of whatever the fee Medicare pays. A practice that sees 25-30 patients a day will make $50-$90 less a day in 2006. That adds up quickly. Assuming a five-day work week, that adds up to $13,000 to $23,000 less over the course of the year. And despite what you might read in the newspapers, the majority of patients who pass through a doctor's office have health insurance - so the cut goes across the board.
How does that translate into day to day life? It means that my staff didn't get a cost of living raise this year. It means that I'll have to drop their health insurance if the premiums increase. And it means that I'm working harder - double booking patients when I can and adding an extra half day to my work week. Hopefully, I'll break even and avoid a decline in my own wages."
Wednesday, January 4, 2006
Antibiotic Resistance In Terms I Can Understand
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Penicillin and Amoxicillin's days are numbered
"Researchers from the University of Rochester started with the analysis of data from 11,426 children who has suffered a common throat infection.
They found that 25 per cent of children given penicillin, along with 18 per cent given amoxicillin treatment needed further treatment within weeks.
The data, taken from 47 studies from the past 35 years looked at the effectiveness of various drugs on treating strep throat in children.
Additional results revealed that of those given older-generation cephalosporin antibiotics, 14 per cent had to return for more treatment, while just 7 per cent prescribed newer versions like cefpodoxime and cefdinir, given for just four or five days, had to go back to the doctor. "
Monday, January 2, 2006
Baxter Moves Ahead With Generic Sevoflurane
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Baxter moves ahead with drug despite fight (Chicago Sun-Times):
"Unfazed by a continuing legal battle with Abbott Laboratories , Deerfield-based Baxter International will launch its generic inhaled anesthetic sevoflurane in the United States and Japan in the first half of this year."
[Via Yahoo Search: anesthesia]
Sunday, January 1, 2006
Prilosec and C.Diff?
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Reading a blog far afield of medicine, then to the Washington Post, I cam across an interesting nugget on C. Diff. The JAMA published an article on December 21, 2005 titled Use of Gastric AcidâSuppressive Agents and the Risk of Community-Acquired Clostridium difficileâAssociated Disease [abstract]. In two population-based case-control studies:
" The incidence of C difficile in patients diagnosed by their general practitioners in the General Practice Research Database increased from less than 1 case per 100 000 in 1994 to 22 per 100 000 in 2004. The adjusted rate ratio of C difficileâassociated disease with current use of proton pump inhibitors was 2.9 (95% confidence interval [CI], 2.4-3.4) and with H2-receptor antagonists the rate ratio was 2.0 (95% CI, 1.6-2.7). An elevated rate was also found with the use of nonsteroidal anti-inflammatory drugs (rate ratio, 1.3; 95% CI, 1.2-1.5). "
A teleconference is planned for January 18th to discuss these results as part of the new Author-in-the-room series.
QA On New Medicare Part B Prescription Drug Plan
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Deconstructing drug plan
- Who is eligible for the new Medicare drug benefit?
- What does the basic Part D plan include?
- Do I have to enroll in a Medicare drug plan?
- Do I have to decide today?
- What if I miss the deadline?
- My drug costs are really low and I don't have any coverage. Do I really need this?
More at http://www.medicare.gov/pdphome.asp
Wednesday, December 28, 2005
Gastric Bypass Surgeries Soaring (HealthDay)
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Gastric Bypass Surgeries Soaring (HealthDay):
"HealthDay - TUESDAY, Dec. 20 (HealthDay News) -- The number of gastric bypass and other bariatric surgeries conducted in the United States more than quadrupled between 1998 to 2002, from 12,775 procedures to 70,256, researchers report."
And from 2002 to the present, I'm sure they've continued to go up. Would I have one? Ask me when I'm 400 pounds and have tried other methods of weight loss without sustained results...
[Via Yahoo! News: Health]
Epocrates Online Free
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A reminder from The Palmdoc Chronicles that Epocrates Online Free is online and, well, free.
Medscape CME: Women With Migraine
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Women With Migraine: Effective Strategies for Positive Outcomes:
"Migraine is a female-skewed disorder affecting women about 3 times more often than men. Learn about common diagnostic errors in migraine and how triptans are improving symptoms for many sufferers. (CME)"
As an aside, I have had very good success treating perioperative migraines with IV metoclopramide (reglan).
[Via Medscape Headlines]
Tuesday, December 27, 2005
Insurance Companies Trying To Curb Anesthesiologist Participation in Colonoscopies
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Propofol sedation for colonoscopies is in the news today.
Colonoscopy anesthesia popular but pricey (UPI):
"NEW YORK, Dec. 27 (UPI) -- An increasingly popular and potent anesthetic makes colonoscopies more comfortable for patients but it sharply boosts the cost, reports say."
I've given lots of propofol anesthetics for colonoscopies. Patients go off to sleep before they start, wake up when it's over and ask 'when are we going to start?' The recovery is faster and cleaner than traditional opiate/benzodiazepine sedation, allowing a center to increase the number of patients it can perform an exam on in a day.
A similar report on CNN/Money goes as far as to call the insurance company involved (Wellpoint) and ask if their executives will forego propofol. Answer?
""They'll be covered by the same clinical guidelines," the Wellpoint spokeswoman said."
I have to wonder, wouldn't the same logic apply here as applies to providing epidurals for labor? Are labor epidurals medically necessary? The American College of Gynecology, together with the American Society of Anesthesiologists has opined that "there is no other circumstance where it is considered acceptable for a person to experience untreated severe pain that is amenable to safe intervention." Ask a nurse that works with colonoscopy patients how she'd like hers done. I'll bet I know the answer.
It's not just insurance companies that are clamping down on anesthetists administering propofol to colonoscopy patients. Apparently, a group representing the gastroenterologists have asked for propofol labeling to be changed by the FDA to allow them to administer it (see safepropofol.org for more info). This same group is against Wellpoint's policy change as outlined here.
[Via Yahoo Search: anesthesia]
Saturday, December 24, 2005
Mythbusters: On Being An Organ Donor
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The Iowa Charles City Press has a nice piece titled Myth busters on being an organ donor which addresses the following myths:
"Myth: Doctors will not try to save my life if they know I want to be a donor.
Myth: People can recover from brain death.
Myth: Minorities should refuse to donate because organ distribution discriminates by race.
Myth: The rich and famous on the U.S. waiting list for organs get preferential treatment.
Myth: I am too old to donate organs and tissues.
Myth: My family will be charged for donating my organs.
Myth: Donation will disfigure my body.
Myth: Organs are sold, with enormous profits going to the medical community.
Myth: Marrow donation is painful. "
Please read and pass along...and 'yes' I'm an organ donor.
Thursday, December 22, 2005
More on why anesthesia is (or is not) safer
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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)
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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
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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
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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 (Pâ¤0.05) after adjusting for these factors."
Misconceptions about why anesthesia is safer
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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.
