Friday, January 5, 2007

What Primary Care Physicians Really Do

From a recent JAMA section called A Piece of My Mind is an excerpt that gives a good summary of what primary care physicians spend a lot of time doing. The author describes what she will no longer be doing after moving to a new practice:

"No more primary care. No more forms to fill out for workers comp, disability, SSI, student loan forgiveness, longer-term-care insurance coverage, FMLA, or temporary suspension of billing for credit card or mortgage or rental furniture payments owing to customer illness.

No more forms for nebulizers, commodes, handrails, oxygen, home health nurses, adult diapers, wheelchairs, cock-up splints, lift chairs, physical therapy, or the dreaded power wheelchair/scooter doctoral dissertation.

No more forms to attest that someone can enter a nursing home, play soccer, work out at a gym, be in an assisted living facility, do chair exercise at the senior center, train to become a medical assistant, wrestle, teach school, or that he or she is, above all else, free from communicable diseases. "

The list of non-direct patient care tasks goes on for several more paragraphs, but you get the picture.


Thursday, January 4, 2007

Page Rank Gone Bad--Google and Vaccination Information

Medgadget brings up an important issue today. Using Google to search for information on vaccinations does tends to return anti-vaccination 'propaganda.'

"Google's search for 'vaccination' returns 10 results on its first page. Of them, two are from the CDC (Centers for Disease Control and Prevention). One result from Wikipedia that has some questionable statements , such as "...the overall effect might, in theory, be to cause more deaths than before the vaccination was introduced." The remaining seven results are from vaccination-haters and moonbats that accuse governments, pharmaceutical companies, the medical lobby, you name it, of untold millions of dead children. The second page of the vaccination search is even worse."

I didn't have any personal experience with families not immunizing their children until this year when I became a Cub Scout leader.


Sunday, November 26, 2006

A Cell Phone for the Elderly

I was looking for a cell phone for my in-laws last year but couldn't fine one I thought would ideal for older users--big buttons, simple menus, stuff like that. Samsung now has one out called the Jitterbug. The phone is not available for use with just any carrier. You have to order service from them too. See


Friday, November 24, 2006

Anesthesia is safer than ever (even in France)

Anesthesiology--Survey of Anesthesia-related Mortality in France.

" Conclusion: In comparison with data from a previous nationwide study (1978-1982), the anesthesia-related mortality rate in France seems to be reduced 10-fold in 1999. Much remains to be done to improve compliance of physicians to standard practice and to improve the anesthetic system process."

Thursday, November 23, 2006

On Negotiations With Hospitals, Insurers, and Physicians

Contract Negotiations Between Insurers, Hospitals Increasingly Acrimonious

" The AP/Arizona Daily Star on Monday examined how contract negotiations between insurers and hospitals increasingly have "taken an ugly turn" as both sides work to control rising costs. Insurers "are under pressure to lower premiums to win business," while hospitals believe that insurers are "skimping on payments to boost their earnings," the AP/Daily Star reports."

The exact same can be said for negotiations between hospitals and physician groups and insurance companies and physician groups. It all reminds me of that scene in Star Wars where the good guys are stuck in a trash compactor after their escape from the brig--all attempts to stop the walls from moving from the inside fail. (what, you were expecting a reference to Greek mythology?)

National Influenza Vaccination Week starts November 27th

National Influenza Vaccination Week -- November 27--December 3, 2006

[A]nnual influenza vaccination is recommended for the following groups:
Persons at high risk for influenza-related complications and severe disease, including:
  • children aged 6--59 months,
  • pregnant women,
  • persons aged >50 years,
  • persons of any age with certain chronic medical conditions


Persons who live with or care for persons at high risk, including:
  • household contacts who have frequent contact with persons at high risk and who can transmit influenza to those persons at high risk, and
  • health-care workers.

Bring Your Own

PortableApps Suite | - Portable software for USB drives

" PortableApps Suite™ is a collection of portable apps including a web browser, email client, office suite, calendar/scheduler, instant messaging client, antivirus, sudoku game, backup utility and integrated menu, all preconfigured to work portably. Just drop it on your portable device and you're ready to go."

Hospital computers tend to have Internet Explorer as the only web browser. It works (mostly), but it's not as secure, extensible, fast, standards-compliant as, say, Firefox. Besides that, I use Firefox at home and like to have the same bookmarks available. allows me to carry my own apps in on a USB thumb drive.

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 '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...)

January, 2007
Sun Mon Tue Wed Thu Fri Sat
  1 2 3 4 5 6
7 8 9 10 11 12 13
14 15 16 17 18 19 20
21 22 23 24 25 26 27
28 29 30 31  
Nov  Feb

Feeds and Categories

Blog Roll

Google Modules
   Body Mass Index
   Allowable Blood Loss

   The Ether Way
   Westmead Anaesthesia Blog
   Book of Joe
   i'm so sleepy

   Aggravated DocSurg
   Retired Doc
   Finger and Tubes
   Running A Hospital
   Chance To Cut
   DB's Medical Rants
   Palmdoc Chronicles
   The Well-Timed Period


Geeks Like Me
   Seth Dillingham
   Jonathan Greene