Sunday, May 6, 2007
I'm a Better Anesthesiologist Today Than A Year Ago
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At the end of this busy week I began to reflect on how this week was different than an average week would have been even a year ago. It was different both for me and for a significant number of my patients. Hopefully, it was as good for patients as it was for me.
For the first ten years after I finished my training I did not believe nerve blocks for extremity surgery were worth doing. Surgeons didn't want to wait for me to do them or for the blocks to 'set up.' Blocks failed a certain amount of the time. There were complications that just didn't happen when 'numbing the big nerve.'
My thoughts on all this changed, not because of a journal article or discussions with a colleague, but because of an article in Wired magazine. The Painful Truth was an article on the use of regional anesthesia to improve medical care to our wounded soldiers in Iraq and Afghanistan:
Now Buckenmaier is leading a group of army doctors and nurses determined, as he puts it, "to drag the military kicking and screaming into the 21st century." His team believes the future of wartime pain control is a new form of anesthesia called a continuous peripheral nerve block, which takes a more targeted approach by switching off only the pain signals coming from the injured limb, leaving patients' vital signs and cortical functions unimpaired.
The applicability to civilian anesthesia was obvious. In my hospital, when someone gets a knee replaced, the surgeon usually blindly injects a large amount of local anesthetic in the general vicinity of the femoral nerve and we dope them up with morphine. Patients are in the hospital for three days largely for pain control issues, all the while at risk for nausea, vomiting, respiratory depression, etc.
I took a second look at regional anesthesia and decided to use it in my practice again. This week two elderly ladies had total shoulder replacements after having interscalene blocks. They were pain free for the rest of that day. Six of my patients had knee replacements after femoral and sciatic blocks. They had no pain until the next morning.
With catheter techniques, these pain-free intervals will be measured in days instead of hours. The surgeons are giving us the time to do these techniques because they are hearing about how good they are for patients at their own national meetings. My colleagues who 'didn't do blocks' have learned to do simple femoral nerve blocks and want to learn others.
It was a good week for me because I love seeing patients do well. It was a good week for my patients (whether they knew it or not) because they trusted me enough to let me poke them with a needle once or twice to make their recovery that much easier. By next year I hope to be placing catheters and doing infusions. Thanks, Trip Buckenmaier.
Friday, April 27, 2007
Pennsylvania Malpractice Numbers Ignored?
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I composed a polite letter to the editor of our local paper, the Patriot-News. It went something like this (exactly like this, actually):
"Title: Is Pennsylvania's Malpractice Crisis Solved? Maybe for trial lawyers.
Dear Editor,
Data just published by the non-profit, non-partisan Kaiser Family Foundation at http://www.statehealthfacts.org/ provides facts to consider in our discussion of health care reform in Pennsylvania.
Based on data from the National Practitioner Databank, Pennsylvania ranks third in the nation in the number of paid malpractice claims per thousand physicians (http://tinyurl.com/22mppw). Pennsylvania ranks second only to New York in total payments for claims made during 2006--over $300,000,000 (http://tinyurl.com/26hh9p).
Please consider passing these facts on to your readers so that they may form their own conclusions about the state of Pennsylvania's malpractice system. I submit that being ranked second and third in the nation in two objective measures of malpractice payouts does not support those who contend that our malpractice crisis is 'over.'"
Was it published? Nope. Oh, well.
It WAS published on Sunday, April 29th, 2007,
Wednesday, April 18, 2007
PA Ranks Second in Total Dollars Paid in Malpractice Claims
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At the same website mentioned in the preceding post one can find information on total dollars paid in malpractice cases in 2006. Pennsylvania ranked second with $308,781,000 paid (second only to New York). See for yourself.
Vermont looks pretty good to me right now...
PA Ranks Third in Paid Malpractice Claims
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The Kaiser Family Foundation maintains StateHealthFacts.org, a site "designed to provide free, up-to-date, and easy-to-use health data on all 50 states". The site just published Number of Paid Medical Malpractice Claims, 2006. Pennsylvania ranks third among all states in number of malpractice claims paid per thousand physicians. See for yourself.
Tuesday, April 17, 2007
Acoustic Respiratory Monitoring: What Is It?
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An intriguing press release last week from Masimo (known for their motion artifact-resistant pulse oximeters) begins as follows:
"Masimo, the inventor of Pulse CO-Oximetry and Read-Through Motion and Low Perfusion pulse oximetry, reported that three new independent studies, including one presented the recent International Anesthesiology Research Society (IARS) Clinical & Scientific Congress in Orlando, concluded that Masimo Acoustic Respiratory Monitoring technology (ARM) is "at least as accurate as capnometry" and "significantly more reliable" for monitoring respiration in spontaneously breathing patients."
The release then refers to "an adhesive bioacoustic sensor applied to the patient's neck and connected to a breathing frequency monitor prototype" which in turn accurately monitors respiratory rate.
If this device does what I think it does, it will become the standard of care for post-surgical patients very rapidly. We've been looking for a way to reliably monitor respiratory rate on the floors, once patients are discharge from the recovery room. For example, a patient may receive pain medications from multiple sources, with unpredictable onsets. How do we know their maximum respiratory depression won't happen after they've been delivered to their hospital room?
A patient can receive oxycontin and celebrex orally from a surgeon before their knee replacement surgery, then more fentanyl, morphine, and versed from us (anesthesia). The surgeon may then inject bupivicaine and morphine into the joint at the conclusion of surgery (without necessarily telling the anesthesiologist). I might also do a femoral nerve block to further reduce post-op pain. All of us are trying to do right by the patient but, given the right set of circumstances, are setting them up for significant respiratory depression post-op. The ability to reliably monitor respiratory rate with this new Masimo monitor would be a huge patient safety advance.
The Society for Technology in Anesthesia abstract is here.
Monday, April 2, 2007
Skim for OS X
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A new application called Skim has been released for Mac OS X and I mention it here for readers who stuff their hard disks with pdf files of articles they have heretofore been unable to annotate electronically:
"Skim is a PDF Reader and note-taker for OS X. Skim is designed to help you read and annotate scientific papers in PDF."
[Michael McCracken]
Do Specialty Hospitals Call 911 to Save Their Patients, or Transport Them?
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The New York Times has an article titled Some Hospitals Call 911 to Save Their Patients which details two cases of patients having surgery at a specialty surgical hospital, experiencing complications, and then being transferred to a medical center (where they ultimately died). The whole article is written, and certainly the title was chosen, to suggest that 911 emergency services were called in order to treat a deteriorating patient as no physicians routinely stay in-house overnight.
Although I am not familiar with the particulars of the two cases mentioned in the New York Times article, it should be known that 911 would be called for any intra-facility transfer and does not necessarily imply they were called to render care in an emergency or that care was unavailable from other professionals already there.
Isn't it interesting, though, that a patient who is has no objection to getting their care from a CRNA, nurse practitioner, physician's assistant, or other 'health care provider' (after all, it's cheaper, right?) suddenly deems it essential to have a doctor there when things start to go south? Of course they do. I would, too!
If you're flying a commercial flight and the landing gear won't deploy, you feel better knowing the pilot is a former military pilot with years of experience in 'heavies.' If your child's safety is threatened by a stranger, you feel better knowing that highly trained and qualified officers are there to protect you. If you're having surgery and things start to go bad, you want an anesthesiologist, a physician, a smart, independent thinker who doesn't get flustered or do whatever the surgeon says to do. You want me. Not someone who is cheaper, less highly trained, less experienced, someone who will do in 99% of cases.
Friday, March 30, 2007
P4P: Are Vested Interests Pushing the Agenda?
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New Data, More Doubts About Pay-for-Performance (P4P)
"Again, as we have noted before, developing performance measures that will truly benefit patients will require detailed understanding of the clinical context, keen skeptical analysis of the available relevant research data, and careful balancing of benefits, harms and costs. All this would be very hard under the best of circumstances. But the continual attempts by those with vested ideological and financial interests to influence performance measures to advance their own interests make it unlikely that the whole P4P movement will have any good effects on patients.
The first improvement needed in the P4P movement is clear, detailed disclosure of all conflicts of interest affecting those involved in the movement at any stage.
At this point, patients and physicians should be very skeptical about who is likely to benefit from any new performance measure, particularly measures that are lavishly promoted."
This nicely sums up my suspicions about P4P beyond just the fact that it rewards task completion over the exercise of medical judgement...
[Health Care Renewal]
March 30, 1842: The First Ether Anesthetic
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Wikipedia
"Although William T.G. Morton is well-known for performing his historic anesthesia on October 18, 1846 in Boston, Massachusetts, C.W. Long is now known to be the first to have used an ether-based anesthesia.
After observing the same effects with ether that were already described by Humphry Davy in 1800 with nitrous oxide, C.W. Long used ether the first time on March 30, 1842 to remove a tumor from the neck of his patient, Mr. James M. Venable. Long subsequently removed a second tumor from Venable and used ether anesthesia in amputations and childbirth. The results of these trials were published several years later (in 1849) after Morton's publication. "
Counterinsurgency in Congress
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Professor Arthur Herman
"I think in some ways here, what you are really seeing is that we’ve got a general who finally understands and gets it about the counterinsurgency in Iraq. What we need is an administration that’s going to deal with the counterinsurgency at home, which is taking root in the Democratic Congress."
[Hugh Hewitt]
Thursday, March 29, 2007
Which is more important? Iraq or Afghanistan?
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Charles Krauthammer: The wars against radical Islamic insurgents
"Thought experiment: Bring in a completely neutral observer -- a Martian -- and point out to him that the United States is involved in two hot wars against radical Islamic insurgents. One is in Afghanistan, a geographically marginal backwater with no resources, no industrial and no technological infrastructure. The other is in Iraq, one of the three principal Arab states, with untold oil wealth, an educated population, an advanced military and technological infrastructure which, though suffering decay in the later Saddam years, could easily be revived if it falls into the right (i.e. wrong) hands. Add to that the fact that its strategic location would give its rulers inordinate influence over the entire Persian Gulf region, including Saudi Arabia, Kuwait and the Gulf states. Then ask your Martian: Which is the more important battle? He would not even understand why you are asking the question. "
Resolved: C. diff enterocolitis should be a reportable disease
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The CDC just published their Summary of Notifiable Diseases --- United States, 2005
I wonder why C. diff enterocolitis isn't on the list? I've seen this illness cause more morbidity and mortality in the United States than the big long list they do track...
MMWR: Percentage of Children with Selected Allergies
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"During 2003--2005, the percentage of children with hay fever increased with age; children aged 10--17 years were nearly three times as likely to have hay fever than children aged 0--4 years. In contrast, the percentage of children with skin allergies decreased with age, and the percentage of children with food allergies did not vary with age."
Tuesday, March 27, 2007
New Study on Malpractice Costs
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Pacific Research Institute:
JACKPOT JUSTICE: The True Cost of America's Tort System
Processing....
Thursday, March 15, 2007
CDC: Insurance Affects New Patient Acceptance
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Percentage of Office-Based Primary-Care Physicians Who Did Not Accept New Patients, by Expected Payment Source --- National Ambulatory Medical Care Survey, United States, 2003--2004
"Although 94.2% of primary-care physicians reported in 2003--2004 that they were accepting new patients, acceptance varied by the patient's expected payment source. Among the physicians, 43.0% did not accept new charity cases, 29.3% did not accept new Medicaid patients, and 20.3% did not accept new Medicare patients. Only 7.0% did not accept new patients who self-paid."
Monday, March 12, 2007
CDC: Quadrivalent Human Papillomavirus Vaccine
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Recommendations of the Advisory Committee on Immunization Practices (ACIP)
"Routine Vaccination of Females Aged 11--12 Years
ACIP recommends routine vaccination of females aged 11--12 years with 3 doses of quadrivalent HPV vaccine. The vaccination series can be started as young as age 9 years.
Catch-Up Vaccination of Females Aged 13--26 Years
Vaccination also is recommended for females aged 13--26 years who have not been previously vaccinated or who have not completed the full series. Ideally, vaccine should be administered before potential exposure to HPV through sexual contact; however, females who might have already been exposed to HPV should be vaccinated. Sexually active females who have not been infected with any of the HPV vaccine types would receive full benefit from vaccination. Vaccination would provide less benefit to females if they have already been infected with one or more of the four vaccine HPV types. However, it is not possible for a clinician to assess the extent to which sexually active persons would benefit from vaccination, and the risk for HPV infection might continue as long as persons are sexually active. Pap testing and screening for HPV DNA or HPV antibody are not needed before vaccination at any age. "
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Apr Jun
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