Friday, February 23, 2007
Are Alphanumeric Pagers Obsolete? That Depends.
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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 $400 each month, wouldn't that make us even?
"Ladies and gentlemen of the jury, I'm just a caveman. I fell on some ice and later got thawed out by some of your scientists. Your world frightens and confuses me! Sometimes the honking horns of your traffic make me want to get out of my BMW.. and run off into the hills, or wherever.. Sometimes when I get a message on my fax machine, I wonder: "Did little demons get inside and type it?" I don't know! My primitive mind can't grasp these concepts."
Tesla Motors - Cut From A Different Cloth
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Tesla Motors - the Tesla blog
"From the earliest days of our work developing the Tesla Roadster’s body, we realized we had several major challenges on our hands. We had to achieve a low level of aerodynamic drag to increase efficiency, and we had to keep our mass down in order to maintain a high power-to-weight ratio and achieve maximum acceleration. Equally important was our imperative to create a body style for the Tesla Roadster that made people desperately want the car - irrespective of its efficiency or level of performance."
I sincerely hope my next car will be a Tesla. Not the Roadster but the not-yet-in-production WhiteStar .
Seen Emoticons? How About Assicons!
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I received this in an e-mail today (if the word 'ass' offends you, don't continue reading):
"We all know those cute little computer symbols called "emoticons," where:
:) means a smile and :( is a frown.
Sometimes these are represented by :-) and :-(
Well, how about some "ASSICONS?"
Here goes:
(_!_) a regular ass
(__!__) a fat ass
(!) a tight ass
(_*_) a sore ass
{_!_} a swishy ass
(_o_) an ass that's been around
(_x_) kiss my ass
(_X_) leave my ass alone
(_zzz_) a tired ass
(_E=mc2_) a smart ass
(_$_) Money coming out of his ass
(_?_) Dumb ass
"
Thursday, February 22, 2007
NIDA: Drugs, Brains, and Behavior - The Science of Addiction
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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.
"As a result of scientific research, we know that addiction is a disease that affects both brain and behavior. We have identified many of the biological and environmental factors and are beginning to search for the genetic variations that contribute to the development and progression of the disease. Scientists use this knowledge to develop effective prevention and treatment approaches that reduce the toll drug abuse takes on individuals, families, and communities."
Wednesday, February 21, 2007
CRNA Independent Practice: Deciding Which Question to Answer
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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:
"There is no evidence that CRNA independent practice would cause adverse outcomes."
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:
"(1) The Secretary of Health and Human Services shall conduct a study of mortality and adverse outcome rates of medicare patients by providers of anesthesia services. In conducting the study, the Secretary shall analyze the impact of physician supervision of providers of anesthesia services, or lack thereof, on such mortality and adverse outcome rates.
(2) In conducting the study, the Secretary shall consult with appropriate national professional organizations with respect to the methodology of the study, and shall use medicare operating room anesthesia data, adjusted for patient acuity and other relevant scientific variables."
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
"Results After 5 years, 130 patients were alive in each group. Cognitive outcomes could be determined in 123 and 117 patients in the off-pump and on-pump groups, respectively. When using a standard definition of cognitive decline (20% decline in performance in 20% of the neuropsychological test variables), 62 (50.4%) of 123 in the off-pump group and 59 (50.4%) of 117 in the on-pump group had cognitive decline (absolute difference, 0%; 95% confidence interval [CI], –12.7% to 12.6%; P>.99). When a more conservative definition of cognitive decline was used, 41 (33.3%) in the off-pump group and 41 (35.0%) in the on-pump group had cognitive decline (absolute difference, –1.7%; 95% CI, –13.7% to 10.3%; P = .79). Thirty off-pump patients (21.1%) and 25 on-pump patients (18.0%) experienced a cardiovascular event (absolute difference, 3.1%; 95% CI, –6.1% to 12.4%; P = .55). No differences were observed in anginal status or quality of life.
Conclusion In low-risk patients undergoing CABG surgery, avoiding the use of cardiopulmonary bypass had no effect on 5-year cognitive or cardiac outcomes."
[free full text]
(Another Reason Why) I Like Desflurane
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I've
posted before on why I think the desflurane Tec 6 vaporizer is a good design (it doesn't need to be turned off to be refilled). I'd like to add another reason to the list: it has alarms.
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.
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Running a hospital: da Vinci Uncoded -- or, Surgical Robots Unite!
"Here you have it folks -- the problem facing every hospital, and especially every academic medical center. Do I spend over $1 million on a machine that has no proven incremental value for patients, so that our doctors can become adept at using it and stay up-to-date with the "state of the art", so that I can then spend more money marketing it, and so that I can protect profitable market share against similar moves by my competitors?"
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
Monday, February 19, 2007
Is CRNA Independent Practice Coming to Pennsylvania?
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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:
"Ensuring that all licensed health care providers – including nurses, advanced nurse practitioners, midwives, physician assistants, pharmacists and dental hygienists – can practice to the fullest extent of their training. Pennsylvania consistently lags behind other states in fully utilizing health care providers who are not physicians. Prescription for Pennsylvania will seek to eliminate the barriers in existing laws, regulations and insurance reimbursement policies that limit the ability of health care providers to practice to the fullest extent allowed by their training and education."
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...
Sunday, February 18, 2007
Keeping Patients Warm Means Generating Heat
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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:
- Mild hypothermia (1-3 deg. C) reduces resistance to surgical wound infection.
- Mild hypothermia prolongs hospital stay.
- Even mild hypothermia can cause shivering and be a very uncomfortable feeling after surgery.
- 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.
Wednesday, January 31, 2007
In West Virginia, Tort Reform Has Improved Physician Recruitment
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PointOfLaw Forum: Hospital chief: liability curbs rev up W.V. medicine
" The Charleston Daily Mail reports on the aftermath of West Virginia med-mal legislation: Charleston Area Medical Center is attributing its rise in new doctors to statewide medical malpractice reforms passed in 2003. Dr. Glenn Crotty Jr., chief operating officer, said the hospital has recruited around 30 doctors annually over the past few years, for a total of almost 100 new hires. Before the Legislature passed a comprehensive bill limiting the amount of payouts in medical malpractice lawsuits, the hospital would have been lucky to recruit one new doctor each year, Crotty said. "We were at almost zero before tort reform," Crotty said about the hospital's recruiting efforts. "And we had several doctors leaving.""
Senator Rendell, are you reading this?
Saturday, January 6, 2007
Vista Vs. OS X UI Comparison
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Review: Mac OS X Shines In Comparison With Windows Vista - News by InformationWeek
"I've yet to see anything in Vista that blows away the Mac OS, even a version of the Mac OS that's over a year old. Microsoft still can't manage to make something simple and easy to use. Vista reeks of committee and design by massive consensus, while OS X shines from an intense focus on doing things in a simple, clear fashion and design for the user, not the programmer."
Can't wait until Tuesday!
Friday, January 5, 2007
What Primary Care Physicians Really Do
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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.
[JAMA]
Thursday, January 4, 2007
Page Rank Gone Bad--Google and Vaccination Information
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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.
[Medgadget]
Sunday, November 26, 2006
A Cell Phone for the Elderly
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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 gojitterbug.com.
[PhoneScoop]
