Wednesday, July 19, 2006

Dr. Anna Pou Is Not a Murderer

I just learned that a former colleague and friend has been charged with second degree murder in the death of four patients at a New Orleans hospital after Katrina. I worked with Dr. Anna Pou in the operating room when we were both in Galveston, Texas for three years in the late nineties. She worked as a head and neck surgeon specializing in cancer surgery and I provided anesthesia for many of her cases. After reading the story my only reaction is that this entire case is about an attorney general making a name for himself. Dr. Pou is a wonderful, caring, highly skilled surgeon. Her concern has always been for the comfort and well-being of her patients.

When I spoke to her by telephone several months ago to express my support, we were unfortunately not able to discuss the events leading up to the criminal charges filed Monday. I don't believe any of us can truly imagine the conditions at Memorial Medical Center in the days following the hurricane. The fact that she was there, taking care of patients rather than safely evacuated with her husband, reflects the deep committment she felt to her patients and is consistent with what I know about her.

In my mind, this case is all about whether or not the intent of administering morphine was to alleviate suffering or to cause death. If the purpose of administering morphine was to treat pain or aleviate suffering, then doing so is permissible even if respiratory depression and hastening of death is a forseable consequence. This ethical position is termed the 'Principle of Double Effect.'In normal practice a hospital ethics committee would be asked to help make these evaluations. Dr. Pou had no such resource available to her.

I'll be writing more about his case as information comes out.

Sunday, June 11, 2006

VA Physicians Data Apparently Also Lost

A laptop containing names, social security numbers, and dates of birth on 26 million veterans was stolen from a VA employee's home on May third. Though extremely concerning, I had no reason to think my data was on that laptop. After all, I'm not a Veteran. A letter arrived yesterday informing me that "[a]s a result of this incident, information identifiable with you was potentially exposed to others." I've worked at the Veterans Administration providing anesthesia care. I can only assume that the laptop contained more than just data on 'veterans and some spouses' but some physicians as well.

I must say I'm surprised by this breach of security. In my experience with the VA, their IT security policies were among the most rigorous and thorough.

Friday, June 9, 2006

Two Google Firefox Extension: Browser Sync and Notebook

Let's say you're like me use hospital computers a great deal. There are some neat tools you should know about to make hospital computers feel more like home. Here are my suggestions:

1. Use a USB thumb drive and install Portable Firefox.

Every hospital computer I've ever used has Internet Explorer as the default browser (sigh). Most don't allow you to install your own software. Having a USB thumb drive with your own lean, mean, pop-up blocking copy of Firefox gives you the browser preferred by nine out of ten dweebs. Any extensions you install are on the USB drive and travel with you. Lifehacker has a nice article on this. Speaking of extensions...

2. If you haven't already done so, get a Google account.

3. Install the Google Browser Sync Extension for Firefox.

I may get around when it comes to using lots of computers, but I do have a first love--my Apple MacBook. (The mooing sounds it makes are just so endearing). And that's where I spend most of my computer time and subsequently have the best organized set of bookmarks. The Browser Sync Extension synchronizes bookmarks, history, persistent cookies, and saved passwords between computers. For more on the security implications, see Lifehacker...

4. Install the Google Notebook Extension for Firefox.

I will occasionally find web content when I'm at the hospital that I want to look at when I get back home. The Notebook extension adds an additional contextual menu option to 'Note This...' which adds the page title, URL, and selected text to my Google Notebook where I can read it later.

5. Set up your Google Home Page and add the Body Mass Index and Allowable Blood Loss modules!

Sunday, June 4, 2006

NEJM CME: Body-Mass Index and Symptoms of Gastroesophageal Reflux in Women

CME: Body-Mass Index and Symptoms of Gastroesophageal Reflux in Women

"Conclusions: BMI is associated with symptoms of gastroesophagealreflux disease in both normal-weight and overweight women. Even moderate weight gain among persons of normal weight may cause or exacerbate symptoms of reflux."

Thursday, May 25, 2006

Top 10 Causes of Death Worldwide

Top 10 Causes of Death Worldwide:

"[F]or high-income countries:

1. Heart disease
2. Stroke
3. Lung cancer
4. Lower respiratory infections
5. Chronic obstructive pulmonary disease (COPD)
6. Colon and rectum cancers
7. Alzheimer's disease and other dementias
8. Type 2 diabetes
9. Breast cancer
10. Stomach cancer

Here is the list for low- and middle-income countries:

1. Heart disease
2. Stroke
3. Lower respiratory infections
5. Fetus/newborn (perinatal) conditions
6. Chronic obstructive pulmonary disease (COPD)
7. Diarrhea
8. Tuberculosis
9. Malaria
10. Road traffic accidents "

[Via WebMD Health Headlines]

Wednesday, May 24, 2006

Pennsylvania's Health Care Crisis has NOT 'turned the corner'

Our Governor is quoted as saying that Pennsylvania's health care crisis has turned a corner. It has not and as evidence I point you to the following article about a Cardiology group in Philadelphia that will no longer provide coverage at one health center there:

"Frankford Health Care System, which is already getting ready to discontinue maternity services at its Torresdale division, is losing another group of specialists at its Frankford campus in another departure tied in part to Pennsylvania's high medical malpractice insurance costs. --Philadelphia Business Journal"

Imagine you're, say, a plastic surgeon. There used to be fifteen of you on staff at a hospital so you took ER call only two days per months (as a precondition for maintaining staff privileges). Well, because of a malpractice crisis that has NOT turned the corner there are only three of you now. That's ten days of ER call each month. Kinda forces you to ponder whether maintaining staff privileges is worth is, doesn't it? And if you decide it's not, then patients loose access to yet another specialist at the hospital. See where this goes?

If it's not one virus, it's another

Bird flu has been very much in the news, but now another type of virus is also threatening: chikungunya virus (named with a Swahili word meaning 'bent up').

"The chikungunya virus has infected around one-third of the population (about 250,000 people) on the French island of Réunion since early 2005. It has also hit the neighbouring islands of Mauritius, Seychelles, Madagascar and Mayotte, and reared its head in India."

With only a little over 200 deaths it's not near as big a killer as H5N1 might be, but it would wreak havoc nonetheless. Fevers over 102 and arthralgias. Yuck.

Sunday, May 14, 2006

RangelMD on Tort Reform in Texas

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."


Friday, May 12, 2006

Wet taps and the number '3'

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!

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 Shipped!

"The VeinViewer, a device that reveals the underlying venous anatomy for easy IV placement, is now being shipped, according to 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

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."

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