Saturday, September 15, 2007
Tool of the Trade: Lidocaine
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Dr. Wes' post on the proper way to inject lidocaine got me to thinking about how I do it and I think I have some tips to share, too. I inject lidocaine in people's back while they're in labor, in their groins, necks, and arm pits when I do blocks, and of course in their hands and arms when I place IV's. (I inject it into their IV's, too, but there's no trick to that, really.)
When I have time, I like to add about a one fourth volume of bicarbonate to the lidocaine I'm injecting. (This doesn't work with bupivicaine as it will cause it to precipitate out.) I've testing this on myself, on nurses in labor, and in patients in labor and I am convinced this removes most of the burning sensation that comes with injecting lidocaine.
After having selected my injection site and cleaned it (with alcohol, betadine, chloraprep, duraprep, etc.) I wait for the prep to dry so that the prepping agent doesn't cause any stinging. I place a drop of lidocaine on the skin and insert the needle through the drop of lidocaine to make contact with the skin (after warning the patient, of course). This works, not because it numbs the skin under the drop (you need a eutectic mixture of local anesthetics for that) but because it caries some lidocaine in on the tip of the needle. I inject while inserting the needle intradermally. You should inject slowly, advance slowly, and see a skin wheal if it's truly an intradermal injection. This is easiest on horizontal surfaces but can also be done on a vertical surface like a back. In my opinion the wrong way to do inject lidocaine is the way tuberculin skin test are often placed: jab in the tiny needle (ouch!) inject the antigen quickly (ouch!).
When I watch trainees inject lidocaine I often see them stop to aspirate to make sure they're not in a blood vessel. This is unnecessary a) if you keep the tip of the needle moving and b) because the total dose of lidocaine in the 3cc syringe is not enough to cause toxicity even if injected intravascularly. We now return you to your regularly scheduled programming...
Sunday, September 9, 2007
Give Me $200 Off My NEXT iPhone
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People at the hospital gleefully point out to me that my iPhone is now $200 cheaper than when I bought it ten weeks ago. I'll tell you what I'd like more than a $100 rebate now: A $200 rebate on my next iPhone (you know, the one with 3G wireless).
Your History Can Haunt You
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A cardiologist in San Diego is accused of striking a patient during a heart cath:
Dr. Maurice Buchbinder, a prominent cardiologist, and Scripps Memorial in La Jolla are under federal investigation because he allegedly hit a patient several times during a procedure at the hospital, physicians and health officials have confirmed.
Having been called to the cath lab on several occasions to intubate his patients I can say that this report does not surprise me and is completely consistent with past behavior (though he never struck anyone in my presence). I'm quite sure he refrained from striking me only because of my size and ability to fight back.
Nothing can stand between me and my bluegrass
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On call at the hospital today. The work is done and we're getting ready to order Chinese food. Time for some computer work and bluegrass. But wait! The hospital has decided to block XM streams!
Thank you iTunes: Bluegrass Radio 128 kbps 100 Percent Pure Acoustic Bluegrass
Life is good (again).
Tuesday, July 31, 2007
Got Aperture, Want To Upload to Picasa? Think Ubermind.
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I just found a nice plugin for Aperture which automates uploading photos to Google's Picasa Web Album site--Aperture to Picasa Web Albums. My unfrozen caveman anesthesiologist review? Grrr. Upload easy. Good. Grrruh.
Sunday, July 29, 2007
Dr. Anna Poe of New Orleans Not To Be Charged
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Grand jury refuses to indict Anna Pou
"Closing one of the most sensational chapters in post-Katrina New Orleans, Dr. Anna Pou said Tuesday that she fell to her knees and thanked God when she learned that a grand jury had refused to charge her with murdering patients in dark, fetid Memorial Medical Center in the nightmarish days after the hurricane struck on Aug. 29, 2005."
Four civil suits are pending so her legal ordeal isn't over yet. As I understand it, the burden of proof in a civil suit requires only that the plaintifs version of the facts is 'more than likely' to be true (ref).
Wednesday, July 4, 2007
Safety Tip: Nerve Block Needle Disposal
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I most commonly use a 2 inch B-bevel insulated needle for nerve blocks. It is often not convenient to dispose of the block needle right away after completing the block, so I started placing it in the barrel of the empty syringe from the plunger side and holding it in place with by depressing the plunger. Like this:
Safer for myself and my assistant (when I have an assistant).
Dark Chocolate Proven Healthy, Again
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JAMA: Effects of Low Habitual Cocoa Intake on Blood Pressure and Bioactive Nitric Oxide
"Results: From baseline to 18 weeks, dark chocolate intake reduced mean (SD) systolic BP by –2.9 (1.6) mm Hg (P < .001) and diastolic BP by –1.9 (1.0) mm Hg (P < .001) without changes in body weight, plasma levels of lipids, glucose, and 8-isoprostane. Hypertension prevalence declined from 86% to 68%. The BP decrease was accompanied by a sustained increase of S-nitrosoglutathione by 0.23 (0.12) nmol/L (P < .001), and a dark chocolate dose resulted in the appearance of cocoa phenols in plasma. White chocolate intake caused no changes in BP or plasma biomarkers.
Conclusions: Data in this relatively small sample of otherwise healthy individuals with above-optimal BP indicate that inclusion of small amounts of polyphenol-rich dark chocolate as part of a usual diet efficiently reduced BP and improved formation of vasodilative nitric oxide."
With a change of roughly 3 systolic points and 2 diastolic points I'm not going to stop taking my Prinivil just yet.....
Tuesday, July 3, 2007
Muslim First, Doctors Second
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The news that several Muslim physicians were allegedly involved in the UK and Scotland bombing plots did not surprise me as much as it did some others. It made me think back to a conversation I had with a Muslim anesthesiology resident shortly after September 11th.
This resident physician was from Iraq, was a doctor in Saddam's army , surrendered to Canadian troops during Gulf War I and was granted political asylum in Canada. He was very well trained and was a wonderful resident to work with--good work ethic, felt responsible to his patient, a pleasure to teach, a natural in many respects. I'd like to think we became friends during those years. In fact, he gave my an anesthetic for my own appendectomy.
We'd had several conversations about Islam previously and I asked him what he would do if Grand Ayatollah al-Sistani instructed all Shia Muslims to kill Americans? Without even a pause he answered 'I would do it.' Muslim first, doctor second.
Sunday, July 1, 2007
Swapping 3G SIM Card Into Activated iPhone Fails
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Having settled on giving my wife the iPhone I wanted to see if I could insert her 3G SIM into the already activated iPhone so that her cellular number wouldn't change. No joy. I saw a brief message about it being the wrong SIM (even though the SIM cards appear identical on the outside). The device worked, but I had no cellular signal strength indicator or carrier name.
What I've done instead is set her original number to forward calls to her iPhone number when it's off.
The OTHER London Car Bomb
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Surveillance camera's in London have captured video of what looks to be another car bomb attempt near central London. This one used a Volkswagen rather than a Mercedes.
Saturday, June 30, 2007
iPhone + New User = Fascinating
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I did buy an iPhone even though I said I wouldn't (buy this first one). The line at our local ATT store was about 20 people long when I checked at 5:45 p.m. Friday on the way home from work so I waited and snagged a 4GB iPhone. It is as insanely great as the commercials make it out to be. Fast, responsive, intuitive, solid, revolutionary...all those things.
I think the real power of the iPhone is in how easily people who are not tech savvy can interact with it. If Apple is going to sell as many iPhones as they think they're going to sell it will have to be to people who are not gadget freaks. By that measure this device hit the bulls eye.
I gave the iPhone to my wife, showed her how to turn if on, and asked her to perform certain actions without telling her how. She made a call in less than 15 seconds (to me, I'm happy to say) and soon thereafter figured out how to use the contact list to call her sister. She next used Safari to go to her favorite site for weather radar images (what is it with women and weather radar?) and bookmarked it. She took my picture and added it to my card in the contacts. She then SMS's her sister, who chatted right back and she got to see that iChat-like conversation log. Next, out to the garden to take pictures of her flowers.
Every cell phone she has ever owned before this one has had these abilities (contact list, SMS, web browser, built-in camera) and they went unused in every case. Only recently did she start to watch John Stewart's Daily Show and local weather reports in Cingular Video on her V3xx. Not until she got an iPhone did she actually enjoy using all those features and even did so without prompting from me throughout the day.
Tomorrow I'm going to give it to my nine year old son and watch him interact with it. In the mean time I want to thank and congratulate Steve Jobs and everyone at Apple for this breakthrough product.
Friday, June 29, 2007
CDC: 2007 Influenza Vaccine Update
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The CDC has just released Prevention and Control of Influenza Recommendations of the Advisory Committee on Immunization Practices (ACIP), 2007
"The 2007 recommendations include new and updated information. Principal updates and changes include 1) reemphasizing the importance of administering 2 doses of vaccine to all children aged 6 months--8 years if they have not been vaccinated previously at any time with either live, attenuated influenza vaccine (doses separated by >6 weeks) or trivalent inactivated influenza vaccine (doses separated by >4 weeks), with single annual doses in subsequent years; 2) recommending that children aged 6 months--8 years who received only 1 dose in their first year of vaccination receive 2 doses the following year, with single annual doses in subsequent years; 3) highlighting a previous recommendation that all persons, including school-aged children, who want to reduce the risk of becoming ill with influenza or of transmitting influenza to others should be vaccinated; 4) emphasizing that immunization providers should offer influenza vaccine and schedule immunization clinics throughout the influenza season; 5) recommending that health-care facilities consider the level of vaccination coverage among HCP to be one measure of a patient safety quality program and implement policies to encourage HCP vaccination (e.g., obtaining signed statements from HCP who decline influenza vaccination); and 6) using the 2007-2008 trivalent vaccine virus strains A/Solomon Islands/3/2006 (H1N1)-like (new for this season), A/Wisconsin/67/2005 (H3N2)-like, and B/Malaysia/2506/2004-like antigens."
MedlinePlus Works Well on Small Device Browsers like N95
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My Nokia N95 runs the Symbian OS. Epocrates only runs on Palm and PocketPC devices. Epocrates online seems not to know what to do when a small device browser accesses it. I can log in, but the site is really unusable on a small screen (I've written to Epocrates to suggest they consider adding support for small devices/screen). So where do I get drug information? From the government!
I just discovered that the National Library of Medicine's Medline Plus
does play well with small screens/browsers. Below is a screenshot of the Medline Plus page on Opera for Handheld Devices:
Compare this to the page view on the N95's built-in browser:
Makes the $29 for Opera worth it, don't you think?
Thursday, June 28, 2007
Cingular Doesn't Play Nice With Midlets
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I have cell phone service with Cingular/ATT and have been quite happy with them. One reason is that I can move my SIM card between different phones and am not locked in to using only one cell phone. Another was that they didn't tend to hobble their devices the way Verizon did. For example, new Verizon phones would let you use bluetooth for wireless headsets, but not for syncing. Well, I just discovered one problem with Cingular...
My new Nokia N95 (which I had to purchase for full retail since Cingular doesn't offer any Symbian smart phones) is awesome. I was trying to get Widsets to work but failed. (Widsets are small web applications that can run on the phone much like the iPhone will supposedly use Web 2.0 technology to extend its application capability.) The reason? Cingular won't let most midlets have socket connections. Hmph.
I didn't make the Google Health Advisory Council :-(
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Well, I've checked my old e-mails to be sure I didn't miss something important. I didn't make the cut for the Google Health Advisory Council. (sigh)
Pennsylvania CRNA Scope of Practice Bills Withdrawn
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The two House bills dealing with CRNA scope of practice have been withdrawn by their sponsors due to 'lack of support' in the House Professional Licensure Committee. Good news for now but I'm sure we'll see these efforts again...
The Ether Way on the Preop Interview
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Right on, brother:
"Long ago, my preop interview became less pre-flight check-list and more gut-check and sniffing for smoke. (I'll write more about sniffing for smoke in another post) Paradoxically perhaps, the most important thing to me is to bond to the patient; it's the second part of that WCW observation. I might do eight or ten cases in a day; the consequence of treating my work as a technical exercise is the risk of inattention and the sort of boredom that drives the desperate discontent that I see in so many of my colleagues."
[The Ether Way]
Sermo: Finally a good online forum for physicians
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I just stumbled upon Sermo, a web community for physicians only:
"Here, physicians aggregate observations from their daily practice and then - rapidly and in large numbers - challenge or corroborate each others opinions, accelerating the emergence of trends and new insights on medications, devices and treatments. You can then apply the collective knowledge to achieve better outcomes for your patients."
Now, if they'd only have RSS feeds....
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Jul Oct
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