Thursday, March 8, 2007

Send Addresses From Google Maps To Your BMW

well, in Germany anyway...

Why Are C-Section Rates Still Going Up?

csectionrate.gif

As an anesthesiologist I provide anesthesia for cesarean sections quite often. In fact, when I'm on overnight call it's what I spend most of my time doing. Usually, anesthesia for c-section consists of a spinal anesthetic, or using a pre-existing epidural catheter, or (more rarely and usually only in emergencies) a general anesthetic. I am therefore quite interested in the subject of cesarean section rates and what effects how often they are done. I learned some things from this article [free full text]:

Cesarean Delivery and The Risk-Benefit Calculus

1. Parturients are different--they are heavier and older.
2. The number of premature and low birth-weight babies has grown.
3. Vaginal breech deliveries are no longer recommended.
4. Operative deliveries (forceps or vacuum) are less common due to better data describing their risks.
5. More labors are induced (20% in 2003 vs 9.5% in 1990) and induced labors are more likely to result in C-section.
6. Changes in provider behavior

"At least one study found that physicians' malpractice premiums, the number of claims against physicians and hospitals, and the physician's preception of the risk fo being sued were all positively correlated with the likelihood of cesarean delivery. Many in the field defend the rising cesarean rates by citing concern about legal jeopardy, and indeed lawsuits often allege a failure to perform a timely cesarean delivery."

Look at John Edwards' list of law cases (thank you, Google). Notice the medical malpractice cases:

MEDICAL MALPRACTICE CASES
Another specialty Edwards developed was in medical malpractice cases involving problems during births of babies. According to the New York Times, after Edwards won a $6.5M verdict for a baby born with cerbral-palsy, he filed at least 20 similar lawsuits against doctors and hospitals in deliveries gone wrong, winning verdicts and settlements of more than $60M.
Case Summary of Facts Case Type Result
Griffin v. Teague, et al.
(Mecklenburg Co. Superior Ct., NC, 1997)		 Application of abdominal pressure and delay in performing c-section caused brain damage to infant and resulted in child having cerebral palsy and spastic quadriplegia. Verdict set record for malpractice award. Medical Malpractice $23.25M
verdict
Campbell v. Pitt County Memorial Hosp.

(Pitt County, NC, 1985)

 Infant born with cerebral palsy after breech birth via vaginal delivery, rather than cesarean. Established North Carolina precedent of physician and hospital liability for failing to determine if patient understood risks of particular procedure. Medical
Malpractice		 $5.75M
settlement
Wiggs v. Glover, et al. Plaintiff alleged infant's severe cerebral palsy was caused by negligent administration of pitocin, failure to use fetal monitor, or timely intervening in baby's fetal distress. Medical
Malpractice		 2.5M
settlement
Cooper v. Craven Regional Med. Ctr., et al. Infant suffered severe brain damage after obstetrician failed to moderate use of Picotin after baby displayed clear fetal distress. Medical
Malpractice		 $2.5M
settlement
Dixon v. Pitt County Memorial Hospital
(Pitt County, NC)		 Birth-related injuries including cerebral palsy and mental retardation allegedly caused by obstetrician's failure to diagnose fetal distress, including umbilical cord wrapped around baby's neck prior to delivery. Medical
Malpractice		 2.4M

settlement

Despite the increase in c-section rates nationwide, we have seen no reduction in the cerebral palsy rate...

Details On Why We Get Migraines

"A University of Iowa study may provide an explanation for why some people get migraine headaches while others do not. The researchers found that too much of a small protein called RAMP1 appears to "turn up the volume" of a nerve cell receptor's response to a neuropeptide thought to cause migraines.

"The neuropeptide is called CGRP (calcitonin gene-related peptide) and studies have shown that it plays a key role in migraine headaches. In particular, CGRP levels are elevated in the blood during migraine, and drugs that either reduce the levels of CGRP or block its action significantly reduce the pain of migraine headaches. Also, if CGRP is injected into people who are susceptible to migraines, they get a severe headache or a full migraine.

"We have shown that this RAMP protein is a key regulator for the action of CGRP," said Andrew Russo, Ph.D., UI professor of molecular physiology and biophysics. "Our study suggests that people who get migraines may have higher levels of RAMP1 than people who don't get migraines." "

The abstract is here.



Wednesday, March 7, 2007

Aspirin/NSAIDs For Colorectal Cancer Prevention Discouraged

"People who are at average risk for colorectal cancer, including those with a family history of the disease, should not take aspirin or non-steroidal anti-inflammatory drugs (NSAIDs) to try to prevent the disease, according to a new recommendation from the U.S. Preventive Services Task Force. The recommendation is published in the March 6 issue of the Annals of Internal Medicine."

"USPSTF assessment: Overall, the USPSTF concluded that harms outweigh the benefits of aspirin and NSAID use for the prevention of colorectal cancer."

[AHRQ]

Tesla Motors' Plan

The Tesla Motors Blog, this entry by marketing chief Darryl Siry, sums up their business plan:

"We have just announced that we will build an assembly facility in Albuquerque, N.M., to build our WhiteStar sports sedan in the future. We will establish company-owned sales and service centers where our customers can get their vehicles serviced. We have the plans, the management, and the access to capital to achieve our vision of being the leading designer and manufacturer of the most desirable electric vehicles in the world. We expect to grow into a multi-billion dollar company selling hundreds of thousands of vehicles. It might take some time but that is what we are going to do."

AFP: Preparation of the Cardiac Patient for Noncardiac Surgery

Excellent Lee Fleisher article in American Family Physician [free full text] for any primary care physician who is asked to do pre-op medical evaluations (note I didn't use the word 'clearance').

Medicare To Cut Physician Fees 9.9% in 2008

It's official (pdf). The Center for Medicare and Medicaid plans on cutting the physician fee schedule 9.9 percent as of January 2008. Five percent for 2007 (which cut was postponed due to a temporary one year patch), and 4.9% for 2008.



Tuesday, February 27, 2007

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

Prevalence of HPV Infection Among Females in the United States [free full text]

"Our study provides the first national estimate of prevalent HPV infection among females aged 14 to 59 years in the United States. Overall, HPV prevalence was high (26.8%), and prevalence was highest among females aged 20 to 24 years [ed. where it was 44%]. Our data indicate that the burden of prevalent HPV infection among women was higher than previous estimates. However, the prevalence of HPV vaccine types was relatively low."

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

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....

"Yeah, I'm a personal injury lawyer. I have no problems telling doctors that. I get better care that way, actually. Makes you guys more careful around me."

"Yes, I know you very well, Mr. Cochran. You were the plaintiff attorney accusing me of being a baby killer, remember?!"



Monday, February 26, 2007

Lieberman on Iraq

  • Categories: Politics
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OpinionJournal - Featured Article

"We are at a critical moment in Iraq--at the beginning of a key battle, in the midst of a war that is irretrievably bound up in an even bigger, global struggle against the totalitarian ideology of radical Islamism. However tired, however frustrated, however angry we may feel, we must remember that our forces in Iraq carry America's cause--the cause of freedom--which we abandon at our peril."



Sunday, February 25, 2007

YouTube: Episure AutoDetect Syringe for Epidurals

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


"(A)n automatic Loss of Resistance (LOR) syringe that provides an objective, visual confirmation that the Epidural Space has been identified. Whether you administer epidural anesthesia regularly or infrequently, we are confident that the Episure AutoDetect syringe will give you enhanced control and sensitivity."

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

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]



Friday, February 23, 2007

Are Alphanumeric Pagers Obsolete? That Depends.

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

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!

  • Categories: Humor
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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

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."


addiction.gif



Wednesday, February 21, 2007

CRNA Independent Practice: Deciding Which Question to Answer

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

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

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.

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?

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

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.

March, 2007
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