Saturday, February 18, 2006
Saturday, February 11, 2006
Tight Brain Checklist
The anesthetist can have a significant impact on the operating conditions a neurosurgeon has to work with. One example is a situation where the surgeon (or anesthetist) notices the brain no longer appears relaxed but begins to get 'tight' within the craniotomy window. Rather that a knee-jerk response of further hyperventilating the patient and/or giving Mannitol, it is prudent to first consider possible causes as follows:
- Are the pressures controlled?
- Is the metabolic rate controlled?
- Are vasodilators in use?
- Are there any unexpected mass lesions?
Are the pressures controlled?
- Arterial Pressure
- pO2 (remember that hypoxemia is a potent stimulus for cerebral vasodilation
- Intrathoracic pressure
- Airway pressure
- Jugular venous pressure (includes external venous compression by C-spine collar or twill used to secure endotracheal tube)
Is the metabolic rate controlled?
- Light anesthesia
Are vasodilators in use?
- Potent agents (Isoflurane, Desflurane, Sevoflurane, Enflurane)
Are there any unexpected mass lesions?
- Pre-existing pneumocephalus exacerbated by nitrous oxide
- Cerebral hemorrhage remote to the site of surgery
As taught to me by John Drummond, M.D. at UCSD
Wednesday, February 8, 2006
Aspect Medical Fearmongering Pays Off
- Categories: News
- Printer Friendly|#| Trackback
Aspect Medical is the company that sells the 'awareness' monitors for anesthesia. Their product is the one featured so prominently in photos accompanying every print story I've seen on intra-operative awareness. This Yahoo Finance headlines seems to indicate it's paying off:
Aspect Medical Systems Inc. ended 2005 with a large jump in both revenue and net income, as demand for its anesthesia monitoring systems expanded at a healthy clip."
Full disclosure: I still don't use a BIS monitor
[Via Yahoo Search: anesthesia]
Tuesday, February 7, 2006
Smoking Cessation Before Surgery Encouraged
Add to all of this another bonus: smokers who have quit around the time of surgery may have fewer problems with nicotine withdrawal after the operation than they would have if they had tried to quit at other times. This may be due to medications and therapies commonly used during surgery and recovery, which may suppress nicotine withdrawal symptoms. Even if patients do have problems with nicotine withdrawal after surgery, they can safely receive help such as nicotine patches."
I think this is noteworthy because, in terms of complications, we used to think that one would need to quit smoking for at least six weeks before surgery for there to be any benefit. Though that may still be true, this review seems to indicate that if someone were to quit around time of surgery, their chances of success are better.[via Newswise]
Sunday, February 5, 2006
Pennsylvania Doctor's Advocate
- Categories: Medical Malpractice
- Printer Friendly|#| Trackback
An organization called Doctor's Advocate is announcing it's first successful effort to stop a 'frivolous' lawsuit in Pennsylvania: Doctor's Advocate Terminates First Frivolous Medical Malpractice Lawsuit; Case Against OB-GYN Dropped in Seven Weeks:
Here's the background on the organization: "Doctor's Advocate works to reverse the medical malpractice crisis and keep doctors in Pennsylvania by raising public awareness, lobbying for legislation to produce tort reform, and combating frivolous lawsuits with an inexpensive legal service."
Looks like being a member costs $1200 per year.
Are Lower Back Tattoos A Contraindication To Labor Epidurals?
My Google News section on 'epidurals' came up with an interesting hit: Lower-back tattoos are popular with women, but do they make having epidurals during childbirth more dangerous?. It's a very good question because, at least in my practice, lower back tattoos are extremely common in laboring women. So common, in fact, that Saturday Night Live has a commercial parody for a product called Turlington's Lower Back Tattoo Remover (quicktime | windows media).
I was taught to avoid putting an epidural needle through tattooed skin and have gone to great lengths to do so. For example, one patient had a very large tattoo of what appeared to be the face of the devil on her lower back. On closer inspection, I noticed that the devil's right nares (which was free of tattoo ink) was right over her L3-4 interspace. I wished I'd taken a picture of that epidural catheter snaking out of the devil's nose.
I can't seem to find much science on the subject save for one abstract which makes a very reasonable suggestion to avoid coring out tattooed skin by making a small incision, if necessary. This may sound like a lot of trouble, but all it takes is a 16 gauge (or similarly large) hypodermic needle inserted into the skin first, then the epidural needle through that 'incision'.
High Tech Noise Canceling Stethoscope
Also via A Chance To Cut is a Chance to Cure, a pointer to a new stethoscope: 3M Littmann Electronic Stethoscope Model 3000
Listening to a patient's heart and lungs before anesthesia is something I don't do nearly enough. This may just be the gadget that makes it fun again...
Music Not To Play in the OR
A Chance To Cut is a Chance to Cure points to a cartoon or music that may not be right for the operating room.
It reminded me of a post at my first blog (which I'm reposting below):
A colleague pointed out to me that there are certain songs one should probably not play, or at least not while the patient is awake. What follows is his list of songs not to play while the patient is awake (with iTunes Music Store links where possible):
- Don't Fear The Reaper
- American Pie
- Stairway to Heaven
- Hurts So Good
- Knocking On Heaven's Door
- First Cut Is The Deepest
- Everybody Hurts
- Like A Surgeon
- Maxwell's Hammer
Wednesday, February 1, 2006
Pandora's Box Of Music
It looks to me like this would solve the OR's music problems. Staff could pre-program their favorite station and just log in from an operating room computer...as long as that wouldn't interfere with online shopping...
Sunday, January 29, 2006
Tuesday, January 24, 2006
No Trasylol For Me or My Patients, Please
Trasylol (Aprotinin) is a very expensive drug used during many kinds of cardiac surgery to reduce blood loss. In today's print edition of the NEJM (but not online yet) is a very important article by Dennis Mangano (very, very smart anesthesiologist) which shows an "association between aprotinin and serious end-organ damage" including doubling the risk of renal failure requiring dialysis, a 55% increase in the risk of MI or heart failure, and a near doubling of the risk of stroke or encephalopathy. The good news is that there are alternative drugs which cost one tenth as much and are also very good at reducing the need for blood transfusion. More soon....
Saturday, January 21, 2006
In advocating for patient safety, be forceful but not 'disruptive'
Is whistleblowing worth it?
If you do decide to blow the whistle, chances are you won't be rewarded for your efforts. In fact, you're more likely to be labeled a troublemaker or "disruptive physician." And if you persist in pursuing your cause, you could risk losing your staff privileges or your job. "
Can damage caps influence premium growth and physician supply?
The Impact of Caps on Damages: How are Markets for Medical Liability Insurance and Medical Services Affected?
Insurance Profits Don't Explain Malpractice Crisis
The American Medical Association has released a new article which takes to task the so-called 'Angoff Report' which claimed that the medical liability insurance crisis is caused by insurance companies booming profits, overcharging physicians for coverage, and ballooning surpluses. It refers to two subsequent analyses which point up the flaws in the approach used by Angoff. Revised analysis shows the growth rate of insurance company surpluses was only 3.9% per year, and they were profitable in only one year (2004) when they made 5%
Thursday, January 19, 2006
Or Their Designee...
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.