Sunday, May 14, 2006
RangelMD on Tort Reform in Texas
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Texas enacted caps on medical malpractice awards in 2003. The debate there on whether these caps are good or have been responsible for the drop in new malpractice cases by 60%-80% continues.
"Obviously the need is to reduce legal costs, increase ease and access to the system, increase efficiency and speed of proceedings so that justified compensation finds its way to the plaintiff with all deliberate speed, and establish much more consistency in finding fault and awarding compensation. One solution is the establishment of special health courts where neutral expert witnesses would be hired by the court, judges or panels would hand down judgments, and guidelines would be in place for the determining of fault and compensation.
It's easy to see why trial lawyers oppose special health courts because their roles would be significantly reduced. A system like this would be far less susceptible to such intangibles as the fickle mood of a jury or the charisma of the lawyer. We've been talking for years about reducing costs and improving access to health care. Maybe it's about time we started doing the same with our tort system. Proposition 12 may have been the first small step in that direction."
[RangelMD]
Friday, May 12, 2006
Wet taps and the number '3'
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Wet taps are accidental dural punctures that happen while attempting to place a needle into the epidural space. The published frequency of wet taps is about 1 in 800 epidural placements, depending on the experience of the operator. If I'm placing an epidural catheter in a pregnant woman and get a wet tap, she has a greater than 50% chance of a dural puncture headache (unless, of course, she is morbidly obese, in which her risk is almost zero).
It seems my wet taps come in three's (hence the title of this post). I remember as a third year anesthesiology resident being on call on OB for the first time after spending three months on the transplant anesthesia service and getting three consecutive wet taps that night on OB. Bam, bam, bam (or should I say 'splash, splash, splash'). I felt terrible, of course, but could not recall doing anything different that would have caused them! My grandmother used to say that accidents happen in threes. She was referring to airplane crashes, but I have to wonder, is it true of wet taps?
In the last ten years of doing anesthesia I've had no accidental dural punctures that I know of. That all changed about a month ago. I did a lumbar epidural steroid injection on a co-worker's husband and must have scored the dura. That's one. I had a wet tap during a labor epidural on a patient who, in retrospect, had a non-union of the ligamentum flavum. That's two. I'm just waiting for number three. I'm on call on OB tonight. Is number three around the corner?
[here's a nice review, btw]
Tuesday, May 2, 2006
Don't Touch My Oxygen!
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Most days are nice. Occasionally I get into a head-butting contest with a nurse or surgeon (but much less often than when I was younger). Of late, it seems to be an almost daily occurrence. Today's example? I arrived at a surgery center to start cases to find the oxygen failure alarm triggered on all our anesthesia machines. After telling colleagues and putting all rooms on hold, I figure out that a valve leak the day before had required a valve to be removed and the resulting system did not have enough oxygen pressure to keep the alarms from triggering. This was fixed in about 15 minutes and we proceeded.
Several hours later a nurse manager told me they were going to switch the oxygen system back to the way it was. I told her that, in my opinion, this should not be done until all cases for the day were finished. 'But it will only take a minute' was her reply. I told here once more that in my opinion as an anesthesiologist, no one should mess with a system that was presently working and that the safest thing to do was wait until rooms were down. She left and had the technicians make the switch.
She will now learn the hard way that you do not touch my oxygen while cases are under way. When it comes to patient safety, our opinions are not equal...
VeinViewer
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"
VeinViewer Shipped!
"The VeinViewer, a device that reveals the underlying venous anatomy for easy IV placement, is now being shipped, according to RedHerring.com....Note to nurses on the floor: call VeinViewer and not an on-call anesthesiologist.
Company website | Video of VeinViewer
"
[Via Medgadget]
Friday, April 21, 2006
Archives of Surgery: Incidence, Patterns, and Prevention of Wrong-Site Surgery
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Incidence, Patterns, and Prevention of Wrong-Site Surgery [free]
"Results Among 2 826 367 operations at insured institutions during the study period, 25 nonspine wrong-site operations were identified, producing an incidence of 1 in 112 994 operations (95% confidence interval, 1 in 76 336 to 1 in 174 825). Medical records were available for review in 13 cases. Among reviewed claims, patient injury was permanent-significant in 1, temporary-major in 2, and temporary-minor or temporary-insignificant in 10. Under optimal conditions, the Joint Commission on Accreditation of Healthcare Organizations Universal Protocol might have prevented 8 (62%) of 13 cases. Hospital protocol design varied significantly. The protocols mandated 2 to 4 personnel to perform 12 separate operative-site checks on average (range, 5-20). Five protocols required site marking in cases that involved nonmidline organs or structures; 6 required it in all cases."
The facilities I work at use 'Time Out' and are gradually standardizing on the use of the word 'yes' to mark the site (which I believe to be the best). Administrators tend to add things to the Time Out so they can say they did something about a problem. Our time outs now require confirmation of a negative pregnancy test before GYN surgery as well as 'Implants Available' for cases that will use implants; a list which will no doubt get longer as more errors occur.
The article contains this jewel from a well known author on errors in medicine--James Reason:
"First, written checklists, although designed for easy use, are prone to several types of error: skipped steps due to interruptions and distractions and stating that an item has been completed (checking the box) when in fact it has not. Second, redundant checks can achieve an exponential decrease in risk of error but only if each checkpoint is independent. Third, increasing the number of involved caregivers can foster routine violations because the multiple checks begin to seem like "busy work." Finally, efforts to keep up with the pace of patient flow may lead to viewing violations of protocol as acceptable or necessary. Simplification of protocols would improve adherence and efficiency and allow surgical teams to focus their limited time and energy on prevention of more common or harmful errors."
Thursday, April 20, 2006
Identity Theft Disclosure Law: Congress About To Fail Us Again
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Bruce Schneier, in Identity-Theft Disclosure Laws explains why pending federal legislation on protecting consumers form identity theft is a step backward from many existing state laws.
"...this federal law pre-empts the 23 existing state laws -- and others being considered -- many of which contain stronger individual protections. So while [the Data Accountability and Trust Act] might look like a law protecting consumers nationwide, it is actually a law protecting companies with large databases from state laws protecting consumers.
So in its current form, this legislation would make things worse, not better."
Tuesday, April 11, 2006
Two New Google Modules
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Seth Dillingham and I have created two modules for the Google personalized home page : Allowable Blood Loss and BMI Calculator. Despite having been submitted a week ago they are still not included in their directory, but I thought it safe to post about them here....
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BMI calculates the Body Mass Index using the US or metric system. Furthermore, it can be used to convert from one system to the other.
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The Allowable Blood Loss Calculator gives a fairly good estimate of how much blood a patient would have to lose to cause a drop in hematrocrit to a specified amount assuming euvolemia is maintained.
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Pet Peave: popular press articles that don't link to their sources
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The New York Times Online has an article titled 'Blasting of Kidney Stones Has Risks, Study Reports'. The article mentions the journal (The Journal of Urology) and the first author (Dr. Amy Krambeck). Would it have been so difficult to link to the abstract in the online version?
" SWL has revolutionized the management of nephrolithiasis and it is a preferred treatment for uncomplicated renal and proximal ureteral calculi. Since its introduction in 1982, conflicting reports of early adverse effects have been published. However, to our knowledge the long-term medical effects associated with SWL are unknown. We evaluated these adverse medical effects associated with SWL for renal and proximal ureteral stones.
Materials and Methods
Chart review identified 630 patients treated with SWL at our institution in 1985. Questionnaires were sent to 578 patients who were alive in 2004. The response rate was 58.9%. Respondents were matched by age, sex and year of presentation to a cohort of patients with nephrolithiasis who were treated nonsurgically.
Results
At 19 years of followup hypertension was more prevalent in the SWL group (OR 1.47, 95% CI 1.03, 2.10, p = 0.034). The development of hypertension was related to bilateral treatment (p = 0.033). In the SWL group diabetes mellitus developed in 16.8% of patients. Patients treated with SWL were more likely to have diabetes mellitus than controls (OR 3.23, 95% CI 1.73 to 6.02, p <0.001). Multivariate analysis controlling for change in body mass index showed a persistent risk of diabetes mellitus in the SWL group (OR 3.75, 95% CI 1.56 to 9.02, p = 0.003). Diabetes mellitus was related to the number of administered shocks and treatment intensity (p = 0.005 and 0.007).
Conclusions
At 19 years of followup SWL for renal and proximal ureteral stones was associated with the development of hypertension and diabetes mellitus. The incidence of these conditions was significantly higher than in a cohort of conservatively treated patients with nephrolithiasis. "
Before people panic (or call lawyers), please consider that this is one study, retrospective, with a 59% response rate, using older lithotripsy technology (as the NYT article points out, modern machines use less energy and are able to focus it more precisely.
Thursday, April 6, 2006
I'm 41....and free of student loan debt!
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I turned 41 years old today. Perhaps more significant to me, however, is that I finally paid off my last outstanding student loan! I finished medical school in 1992 and residency in 1996 so it took about ten years.
My total debt amounted to about $70,000 for college and medical school combined (without interest). Here are some interesting numbers from back then:
"Median U.S. Medical Schools Tuition and Fees for First-Year Students in 1992-3:
- $20,597 for private schools
- $7,544 for in-state residents at public schools
- $16, 739 for out-of-state residents at public schools
Mean level of Educational debt of indebted graduates in 1992:
- 19.5% of medical students had no debt
- $47,088 for public schools
- $69,479 for private schools
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And here's the data from 2003:
"Average Educational Debt
- $115,218 – According to the Association of American Medical Colleges, the average educational debt of indebted graduates of the class of 2004 (including pre-med borrowing)
- 63% of graduates have debt of at least $100,000
- 81.4% of graduating medical students carry outstanding loans, combined with 62.4% with loans on college/premedical education
- $91,438 – Mean per capita debt for 2003 allopathic graduates
- $109,457 – Mean per capita debt for 2003 allopathic graduates excluding students without loans
- $123, 800 – Mean per capita debt for 2003 osteopathic graduates, up 2.3% from the previous year
- $7,277 – non-educational debt (allopathic)
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One final note: If I'd stayed in academic anesthesia it would have taken at least another ten years to pay these loans off...
Wednesday, April 5, 2006
Air Force Anesthesia: Ether and Pentothal?
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The U.S. Air Force physician recruitment web site has a web page for anesthesiologists which claims I can "administer such anesthetics as ether, sodium pentathol and nitrous oxide while maintaining life support of patients under your care."
Since ether hasn't been used in decades and few practicing anesthesiologists know how to administer it, that would explain why I'd have to "maintain life support of patients under [my] care." Seriously, doesn't anybody read this stuff before they post it on their site? There's not a single fact on that page to help me decide whether I'd like to learn more or 'contact an Air Force Advisor today.'
Tuesday, March 14, 2006
Wisconsin Limits Noneconomic Damages In Malpractice Suits
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Wisconsin Senate Approves Limits On Noneconomic Damages In Malpractice Suits:
"The Wisconsin state Senate on Wednesday voted 25-8 to approve a bill that would place a $750,000 limit on noneconomic damage awards in medical malpractice cases, the Milwaukee Journal Sentinel reports. Six Democrats joined all 19 Republicans in voting for the bill."
[Via UK Medical News Today]
Sunday, March 5, 2006
Vaccines, Mercury, and Autism--New Data
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My smart wife tells me that this article is really big news: Early Downward Trends in Neurodevelopmental Disorders Following Removal of Thimerosal-Containing Vaccines (pdf). I've quoted the entire abstract below:
"Contemporaneously with the epidemic rise in neurodevelopmental disorders (NDs), first observed in the United States during the 1990s, the childhood immunization schedule was expanded by the U.S. Centers for Disease Control and Prevention (CDC) to include several additional thimerosal-containing vaccines (TCVs). On July 7, 1999, a joint recommendation was made by the American Academy of Pediatrics (AAP) and the U.S. Public Health Service (PHS) to remove thimerosal from vaccines. A two-phase study was undertaken to evaluate trends in diagnosis of new NDs entered into the Vaccine Adverse Event Reporting System (VAERS) and the California Department of Developmental Services (CDDS) databases on a reporting quarter basis, from 1994 through 2005. Significant increasing trends in newly diagnosed NDs were observed in both databases 1994 through mid-2002. Significant decreasing trends in newly diagnosed NDs were observed in both databases from mid-2002 through 2005. The results indicate that the trends in newly diagnosed NDs correspond directly to the expansion and subsequent contraction of the cumulative mercury dose to which children were exposed from TCVs through the U.S. immunization schedule."
The big news is the last sentence: trends in newly diagnosed ND's [ed: autistic spectrum disorders] correspond directly to the expansion and subsequent contraction of the cumulative mercury dose to which children were exposed from TCVs through the U.S. immunization schedule.
There were suspicions during the time that vaccines contained Thimerisol that it was responsible for an associated increase is the so-called autistic spectrum disorders. The suspicion was based on reports of increases in autism in the community. These were explained away by the observation that diagnosis had become much better during the same time period and the fact that scientific data supporting such a link were of very poor quality. Nonetheless, many parents chose to forgo immunization of their children out of concern that vaccination would increase their risk of autism or related disorders. Skipping immunization did not increase their risk of infectious disease because of herd immunity, up until enough members of a population are unprotected and disease can once again propagate among the non-immunized.
There are ongoing flame wars among blogs about this issue, but his article should cause many of those involved to rethink their position.
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Apr Jun
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