Going To Sleep Is Free, But

JAMA: Prevalence of HPV Infection Among Females in the United States

• Categories: Medical Articles
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Prevalence of HPV Infection Among Females in the United States [free full text]

Remember, prevalence is the proportion of cases that are present at a single point in time.

For a background primer on HPV infection, see the excellent JAMA Patient Page.

Even Malpractice Lawyers Need Doctors, Sometimes

• Categories: Medical Malpractice
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In An Eye For An Eye, Charity Doc describes a close encounter with a malpractice attorney who once sued him. I'm not sure I would have been as, um, gracious....

Lieberman on Iraq

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OpinionJournal - Featured Article

YouTube: Episure AutoDetect Syringe for Epidurals

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More YouTube instructional video goodness. This time demonstrating a special syringe to aid in identification of the epidural space--the Episure AutoDetect Syringe.

Looks like a very nice training tool.

I personally use the Australian Grip. I learned it from an Australian anesthesiologist (hence my naming of it). I place the Tuohy needle in the interspinous ligament and attach a saline-filed glass syringe. I then apply pressure with the palm of my dominant hand to the plunger only, not touching the hub or needle. On entry of the epidural space, pressure on the plunger causes saline to shoot out of the Tuohy needle opening and the needle stops. The one wet tap I've had with this technique has been in a patient who must have had a non-union of the ligamentum flavum.

[Indigo-Orb]

YouTube: Site-Rite Instructional Video

• Categories: Medical errors, Anesthesia resources, Anesthesia Tips, Instructional Videos
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The AHRQ published Making Health Care Safer: A Critical Analysis of Patient Safety Practices in 2001. Chapter 21 deals with Ultrasound Guidance of Central Vein Catheterization. I thought I'd include a link to a YouTube video that shows how this device is used:

Although the device has advance considerably since then (see below), the images it provides are still pretty much the same.

I will often use the device to locate and mark an internal jugular vein before draping the patient as I find the use of the needle guide extremely cumbersome.

[Site-Rite]

Are Alphanumeric Pagers Obsolete? That Depends.

• Categories: Technology
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Ever since I was an intern I've worn a pager while at the hospital--and at a lot of other times, too. They used to be as big as a pack of three by five cards, but now they're quite tiny (think matchbox). But it's still an item you have to remember to put on each day, an item that weighs on your waistline. Back when there were only pagers that wasn't a big deal. Wearing a pager was a status symbol.

But now that belt or waistline space is more crowded. There's probably a cell phone and a PDA. There may also be a Spectralink phone or two for in-hospital calls. If you're really important, you may have more than one or two pagers. It's enough to make your scrubs sag.

Someone explained to me once (and I don't have a reference for this) that FCC law prevents device manufacturers from integrating a digital pager into another electronic device such as a cell phone or pda and that this was done to protect the paging industry. Is that true? Does anyone know?

My group still carries pagers because we know they always work, no matter where we are. In a surgery center in the basement of a medical office building or far out of town, away from cell towers, the digital pager will let us know someone wants to talk to us.

As the Palmdoc Chronicles points out in his post titled Alternative to Paging, there are more options than there used to be: SMS/Texting, Push E-mail, IM, Push to talk. To the best of my knowledge, however, none of them offer the reliability of paging. If someone needs to be intubated, or needs an epidural, or is coding, 'Sorry, did you IM me? I didn't get it' isn't going to cut it.

The one upgrade I would love to have to our pagers is the ability to send text messages over them. For example, instead of getting paged to '3968', calling that number only to be asked to go do an epidural in labor room 8, I could just receive the message on the pager: 'Epidural labor 8.' See? Our pagers are hospital provided and the service I describe costs more. I have not been sufficiently persuasive in my appeals to get them to spring for the extra feature. When I offered to pay for the cost of the alphanumeric service over and above what regular digital paging service costs, I was told we can't do that either because they can't 'split out' a subgroup of the pagers.

Now, I realize I'm just an unfrozen caveman anesthesiologist, but if you know that 40 pagers are using a service that costs ten dollars more per month and I cut you a check for $400 each month, wouldn't that make us even?

Tesla Motors - Cut From A Different Cloth

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Tesla Motors - the Tesla blog

Seen Emoticons? How About Assicons!

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I received this in an e-mail today (if the word 'ass' offends you, don't continue reading):

NIDA: Drugs, Brains, and Behavior - The Science of Addiction

• Categories: Anesthesia resources, Medical Articles
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The National Institute on Drug Abuse just published a booklet intended to help patients understand drug addiction titled The Science of Addiction.

CRNA Independent Practice: Deciding Which Question to Answer

• Categories: Politics, Anesthesia practice
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In doing some more reading on the CRNA independent practice issue, I found what I thought was a curious quote in a Centers for Medicare and Medicaid Services press release from January 17, 2001. The press release is an announcement that Medicare will leave decisions on whether physician supervision of CRNA's is necessary to the States. Here's the quote from the second to the last paragraph:

I think asserting that there is no evidence that CRNA independent practice would cause adverse outcome is the wrong question to address. I think the question should be, 'is there evidence that CRNA independent practice would be as safe for patients as the present system?' (we're a six sigma specialty, remember).

The Safe Seniors Assurance Study Act of 1999 was to address the issue but it never made it out of committee:

Sounds like a good starting point for this discussion, however...

JAMA: Off-Pump vs On-Pump CABG and Cognitive Decline

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Five years after surgery, there is no difference in cognitive decline between on-pump and off-pump CABG.

Cognitive and Cardiac Outcomes 5 Years After Off-Pump vs On-Pump Coronary Artery Bypass Graft Surgery

(Another Reason Why) I Like Desflurane

• Categories: Technology, Anesthesia practice, Medical errors
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The Desflurane Tec 6 has a 'low agent' alarm and a 'no output' alarm, in addition to the ability to detect when it has been tipped (and therefore shouldn't be used). The other common agent, Sevoflurane, is delivered via a vaporizer that has none of these things. I am personally aware of two cases where no volatile anesthetic was delivered despite the vaporizer being 'open'. Two cases that would have been uneventful if desflurane and a Tec 6 vaporizer had been used. I'm going to ask the Society for Technology in Anesthesia listserv if there is any reason the Sevoflurane vaporizer couldn't have these features.

DaVinci Surgical Robots. A Hospital CEO Asks Advice.

• Categories: Health Care Finance, Policy, Technology
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Running a hospital: da Vinci Uncoded -- or, Surgical Robots Unite!

I just discovered this blog today via Medgadget and am already impressed. The large health system our group works in purchased a DaVinci last year. I don't know outcomes yet but it was apparent to me before the purchase that it was largely driven by regional competition in Central Pennsylvania. I think it's telling that many of the institutions which were the early adopters no longer use the systems.

I'm hoping to pick one up cheap in a couple of years so I can do labor epidurals from home. ;-p

Is CRNA Independent Practice Coming to Pennsylvania?

• Categories: Policy, Politics
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Governor Rendell's 2007 budget document includes a section titled Prescription for Pennsylvania on page A3.32. The first paragraph of that section states:

Sounds like independent practice to me. Rather than write a knee-jerk reaction right now, I'd like to take some time to educate myself and consider the ramifications...

Keeping Patients Warm Means Generating Heat

• Categories: Medical Articles, Anesthesia practice
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Once anesthetized with a general anesthetic, patients are largely defenseless. The anesthesiologist is responsible for protecting the patient from their environment--an environment that can be increasingly hostile. One key facet of that environment is temperature, but control of it has never been more contested in the operating room than it is today.

My perspective may be skewed because I do so much anesthesia for orthopedic surgery--a surgery in which the surgeon is physically working hard under an OR gown, gloves, and hot lights. Certainly in pediatric rooms no one ever complains during times when we make the room hot. That's not true, actually. They complain, but they know full well that we are all there to keep the pediatric patient safe and keeping them warm is part of that. They don't expect us to drop the room temperature until we have the child anesthetized and covered.

But why does room temperature matter? It matters because it can affect patient body temperature, and patient body temperature matters for the following reasons:

1. Mild hypothermia (1-3 deg. C) reduces resistance to surgical wound infection.
2. Mild hypothermia prolongs hospital stay.
3. Even mild hypothermia can cause shivering and be a very uncomfortable feeling after surgery.
4. Shivering increases stress on the heart. In patients with heart disease this may cause ischemia.

Under anesthesia, our normal mechanisms for keeping warm are limited. Anesthetics significantly impair our ability to control blood flow to the skin. Although there are five mechanisms of heat loss from the body in the operating room, 90 percent occurs through the skin via radiation and convection

For those wanting a detailed review article and that have a NEJM subscription, see: Mild Perioperative Hypothermia by Daniel Sessler, M.D. in the Department of Anesthesia at UCSF.

I'm sure patients would be gratified to know that it's not the person with the most knowledge and training in patient temperature management that decides in most cases, but the person that whines the most (or is the sneakiest).

For example, last year I was scheduled to provide anesthesia for a 16 year old athlete having an ACL reconstruction. This was not the first case in that room, so the room was already as cold as a meat locker--64 degrees. I reset the room thermostat to 72 degrees, and placed a sticky note saying 'Please Do Not Change,' printed my name, and went to go see the patient.

When I came back to the room several minutes later, the note was gone and thermostat reset to 64 degrees. I replaced the note and reset the thermostat two more times. Both times the note was gone and thermostat reset. The final time there was a note from the charge nurse asking me to come see her.

What did I do? I did what any self-respecting anesthesiologist would do--I told the OR nurses the case was on hold until the room temperature came up and went to get some coffee. Not long after that the charge nurse paged me to discuss the issue. (Nothing gets management's attention more than a case delay.)

Why had she reset it? Because, she claimed, biomedical engineering (some guy with a Bachelor's Degree) said that bringing surgical instruments into a 72 degree room would cause them to sweat and possibly impair sterility. I thought back to my years of doing anesthesia for burn surgery in 85 degree operating rooms and found this explanation novel and fascinating. 'So', I asked her, 'you're taking the advice of a four year college graduate over that of a board certified anesthesiologist?'

Well, you can guess how the conversation went after that. These days, if someone in the OR is feeling hot they either turn the thermostat down themselves or ask the circulating nurse to do it. If all this done without asking me when I'm in the room, I point out to them that they should have asked me before making that decision and ask instead that the room temperature be increased several degrees. If they do ask me if they can turn the room temperature down, provided the patient is reasonably warm and covered, I'll oblige and say 'Thank for asking me. The patient appreciates it. You may set the room temperature to whatever you like.'

In days past everyone acknowledged room temperature was the anesthesiologists choice. These days I have to fight to control it, as I do for every other shred of professional respect. What I'm working on is to get a ruling from the OR committee that states room temperature is my bailiwick. With impending pay for performance measures that will include patient temperature on arrival to the recovery room, this issue has been forced to a head.