Tuesday, October 17, 2006

Status Report on Google Modules

A while ago Seth Dillingham wrote two Google modules for me: Allowable Blood Loss and BMI Calculator. Well, I still have a hard time finding them on Googles own module site, but I can find them both on googlemodules.com--the 'Unofficial Google Modules Site'.

I wanted to pass along another use for the allowable blood loss calculator--estimating surgical blood loss. Anesthetists are asked to estimate the volume of surgical blood loss that occurs during a procedure on their anesthetic record. Surgeons will often attempt to influence that figure downward by volunteering their own estimate of blood loss (often not grounded in reality) in the hope of getting me to go along with it.

In large blood loss cases where I've been following the hematocrit I use the formula to calculate the actual blood loss. For example, if a 100 kg male started with a hematocrit of 0.40 and wound up with a hematocrit of 0.32 I calculate their blood loss as 1600 cc. No arguments.

Monday, October 16, 2006

'Hospital Paralyzes New Mom'--I have questions

You've no doubt seen the headlines: "Hospital mistake paralyzes new mom," and "Hospital that overdosed preemies gave too much pre-delivery anesthesia to new mom." As is usually the case, 'coverage' of this sort of event raises more questions than it answers.

This new report appears completely unrelated to the previous reports out of this hospital describing heparin overdoses. Different department, different drugs, different delivery mode, different patient group. In fact, it has less to do with the hospital than with the anesthesiologist involved. So much for the headline.

The drugs used in labor epidurals are usually a dilute local anesthetic and a small amount of narcotic. Using both types of drugs in combination allows lower concentrations of each individual drug to be used, hence improving the margin of safety for each. In labor epidurals, our goal is relieve pain without causing significant weakness. That is why we use some local anesthetics over others, at low concentrations, and with narcotics (epidural narcotics relieve pain without paralyzing the patient).

This combination is typically infused via the epidural catheter at a rate of 10 to 15 cc/hr. If necessary (i.e. if the patient continues to have pain) we give additional volumes of epidural drug to try to get them comfortable. How much? I've given up to 26 cc in an hour.

What's going on with this patient? I can think of two possibilities: Either the 'paralysis' described is from the large amount of local anesthetic she received (in which case it will resolve) or the large volume of anesthetic compromised blood flow to the spinal cord (in which case it may or may not resolve).

But I have other questions as well. Medical errors rarely happen in isolation. There are usually several events that together contribute to the error.

  • What time of day was the epidural initiated?
  • How busy was the OB floor?
  • Was the physician familiar with the equipment? Was it new?
The popular press will never give me these answers, of course. There will surely be a law suit and no one will want to talk about it since it's the subject of a legal action. I do feel certain of one thing: no one feels worse than the anesthesiologist involved.

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