Download of the Day: Gmail Manager (Firefox) - Lifehacker
A must-have for a Firefox Gmail user
well, in Germany anyway...
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
Look at John Edwards' list of law cases (thank you, Google). Notice the medical malpractice cases:
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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. |
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| 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 |
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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 |
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| 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 |
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| 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 |
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| 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 |
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Despite the increase in c-section rates nationwide, we have seen no reduction in the cerebral palsy rate...
The abstract is here.
[AHRQ]
The Tesla Motors Blog, this entry by marketing chief Darryl Siry, sums up their business plan:
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').
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.
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.
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....
OpinionJournal - Featured Article
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]
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]
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 $400 each month, wouldn't that make us even?
Tesla Motors - the Tesla blog
I received this in an e-mail today (if the word 'ass' offends you, don't continue reading):
(_!_) a regular ass"
(__!__) a fat ass
(!) a tight ass
(_*_) a sore ass
{_!_} a swishy ass
(_o_) an ass that's been around
(_x_) kiss my ass
(_X_) leave my ass alone
(_zzz_) a tired ass
(_E=mc2_) a smart ass
(_$_) Money coming out of his ass
(_?_) Dumb ass
The National Institute on Drug Abuse just published a booklet intended to help patients understand drug addiction titled The Science of Addiction.
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...
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
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.
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
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...
