Tuesday, November 14, 2006

Ten Rules of Regional Anesthesia

From :

1. Anatomy. (anatomy, & anatomy)
2. Position. (position, & position)
3. Time is beverage.
4. Sedation is your best friend.(but also a willing accomplice: if it hurts too much you are probably not doing it right).
5. When in doubt: whip it out.
6. A 1:200,000 solution of epinephrine contains 5-mcg/ ml of epinephrine.
7. The patient is always right.
8. Life is hard enough already: empty your bladder & adjust the lights.
9. Know when 'it's time to numb the big ganglion'.
10. No one cares if you enjoy your job as much as you care.


11. "J, don't fill up on bread." (not really a rule of regional anesthesia, but something important I learned from my parents.)

Funny and true!

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.

Monday, July 31, 2006

Legal Defense Fund Information For Dr. Pou

A legal defense fund has been set up to help Anna Pou defend herself against criminal charges. Contributions may be sent to:

201 St. Charles Avenue
Suite 114-363
New Orleans, LA 70170

I'm sure any amount will be appreciated.

Sunday, July 30, 2006

Risks of Epidural Analgesia for Labor

Anesthesiology has a nice article which attempt to quantify some of the less common risks of having an epidural during labor: epidural hematoma, infection, and neurologic injury.

Epidural hematoma 1 in 168,000 6 per million
Deep epidural infection 1 in 145,000 7 per million
Persistent neurologic injury 1 in 240,000 4 per million
Transient neurologic injury
[< 1 year]
1 in 6,700 180 per million

It contains an interesting tidbit others might find interesting, too. There are 4 million births in the United States each year and 2.4 million involve epidural analgesia. Wow. That's three fifth of all live birth get an epidural! (And some call nights, it seems every single one does...)

Tuesday, July 25, 2006

TIME: It was Heroism, Not Homicide, During Katrina

From a critical care physicians stranded in a nearby hospital during Katrina:

"The major difference between comfort care and euthanasia or murder is intent. In a dying patient, giving sedatives and pain killers with the intent to cause death would be considered euthanasia or murder, while giving the same drugs in the same dosages with the intent to relieve suffering would be considered good, compassionate medicine, even if death were to be a consequence. In the wake of Katrina if a patient had died in a hospital without evidence of having received comfort care, I would question that treatment.


"We don't know the whole story from all participants, including Dr. Pou and the nurses: what the conditions were like and what their intentions were. Until all the facts are known, it's wrong for the attorney general to act as if he's dealing with hardened criminals. He may very well be dealing with heroes."

My thoughts exactly...


Sunday, July 23, 2006

Pennsylvania Showing Net Loss of Physicians Over Time

The number of physicians in Pennsylvania has declined by approximately ten percent between 1999 and 2005. On its own that number may not sound like such a huge drop. Compare that number to the other 20 most populous states and it becomes obvious that the difference is very significant.

Almost all of have seen net increases of between 7% and 35% over the same period. I would find it very interesting to know how long the wait is for a new patient appointment in an internal medicine practice in Pennsylvania vs. these states that have seen an increase. A knee replacement? First visit to a Neurologist. Follow up visits? You get my drift. Pennsylvania has a population that is among the most aged. Medicare just announced plans for more cuts. New physicians are choosing not to practice in Pennsylvania and we've seen a net loss of 10% in our physicians with unique provider numbers over the last six years. Get the picture, Governor Rendel?

Data from State of Medicine in Pennsylvania--2005

Friday, July 21, 2006

NYT: Medical and Ethical Questions Raised on Deaths of Critically Ill Patients

There's a very good article in the July 20 New York Times titled "Medical and Ethical Questions Raised on Deaths of Critically Ill Patients" that describes the ethical questions raised in the New Orleans case with some very good quotes:

"“I’m fundamentally unconvinced of the framing of the story,” said Dr. Steven Miles, a professor of medicine at the University of Minnesota and an expert on the care of dying patients. “I’m not inclined to believe this is a euthanasia scenario or a physician-assisted suicide scenario.”

One reason, Dr. Miles said, is that the drugs found in the dead patients — morphine and the sedative Versed — are not all that deadly and may not even have been what killed the patients. Many patients develop tolerances to the drugs and can handle high doses, he said. Barbiturates, readily available in a hospital, would be a far more efficient way to kill somebody if that was the intent, he added.

“The selection of drugs looks to me to be more typical of the drugs selected for providing palliative care rather than killing patients,” Dr. Miles said. Palliative care is treatment given strictly to keep a patient comfortable. "

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.

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