Excellent resource on screening for von Willebrand Disease
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"In light of the recent tragic death of a Florida teenager from a reported case of malignant hyperthermia, ASA recognizes the importance for patients to know the facts behind the occurrence of this rare genetic disorder...."
Incidence and Risk Factors for Perioperative Adverse Respiratory Events in Children Who Are Obese.
Aetna to Still Pay for Colonoscopy Drug
Effectiveness and Efficiency of Root Cause Analysis in Medicine
(Via JAMA current issue.)
I suspect that there is much more to Aetna's recent decision (pdf) to stop paying for Propofol for all (exceptions exist) colonoscopies than either Propofol or colonoscopies. At first glance it just look like they're trying to save themselves the additional cost the anesthetist or anesthesiologist that is needed if endoscopists want their patients to receive propofol adds. But I think there's more to it than that.
Let me state at the outset that my practice does not derive significant income from providing anesthesia for colonoscopies. The vast majority of colonoscopies done with propofol use RN's with anesthesia training (CRNA's) to provide the service. I point this out because it seems that having any financial involvement at all is cause for discounting ones opinion--it should not be, but it is.
Using propofol allows colonoscopies to be done without patient awareness of discomfort, true, but the real advantage is that patients recover from the drug fast. By way of example, if a colonoscopy is done the 'old fashioned way' using the sedative midazolam and the narcotic demerol or fentanyl, the patient will likely need to remain in the center for one to two hours before they meet discharge criteria (assuming they don't have any nausea). Propofol allows them to go home in about 30-45 minutes. Roughly twice as fast from completion of colonoscopy to discharge. That means they occupy a recovery bed for less time and that's the limiting step for many centers. Once all the recovery beds are full, you can't do any more procedures until one opens up. Being able to quickly discharge patients after their exam allows much greater throughput in terms of exams per day that can be done .
Here is where I think the policy change will have its real effect. Either endoscopy centers will continue to provide the option of propofol sedation but charge the patient for it (in which case the insurance company will pay less), will provide it as part of the facility fee as a way to compete more effectively for patients (in which case the insurance company will pay less), or centers will go back (and I do mean back) to using older drugs but sacrifice throughput (in which case the insurance company will pay less).
Is having a colonoscopy easier with propofol? Don't take my word for it. Ask any endoscopy nurse which way he or she would prefer having a colonoscopy done.
Aside from cost and cost savings there's the issue of who decides what appropriate care is. If insurance companies are allowed to dictate who can and cannot get a certain kind of anesthesia, what will they do next? Get rid of anesthesia payments for cataract surgery? How about for trigger finger releases and carpal tunnel surgery. Vasectomy? See where I'm going with this?
iPods and Pacemakers: "
Is there a consensus concerning the routine use of BIS monitoring during general anesthesia?
My uber-cool sister-in-law gave me the George Carlin Reads To You boxed set. George Carlin's "A Place For Your Stuff" exactly summarizes my dilemma about how to keep my computer 'stuff' handy. Thanks to Apple, 'there's all different ways of carrying your stuff.' Let me explain.
All my 'stuff' is on my 24" Core2Duo iMac. That stuff is automatically copied every hour to an external hard drive via Time Machine so my stuff is safe from a computer hard disk problem. My really important stuff is backed up online using dotMac. Every night at 2 in the morning. Really.
I want to take some of my stuff with me wherever I go. I use my 60 GB video iPod to carry stuff around on but I need to plug it in to another Mac to see my stuff and, let's face it, there aren't a lot of Macs around in the workplace. Right now I use my iPhone to carry important stuff, but there's lots of stuff I can't carry on my iPhone, like the article on how to use Google Reader that I'm working on, or the PDF files I'd like to read.
Going from my iMac to the outside world means I have to leave a lot of stuff behind.....until now. Thanks to the MacBook Air I can now take most of my important stuff with me and it will only weigh three pounds!