Going To Sleep Is Free, But

A Momentous Day

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The Fox News headline sums it up rather well: "A New Dawn of Democracy".

Iraq, our thoughts and prayers are with you--especially today. Let Freedom Ring!

BehindTheMedspeak: Pediatric MRIs will never be the same - thank God almighty!

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My fellow blogging anesthesiologist Book Of Joe posted BehindTheMedspeak: Pediatric MRIs will never be the same - thank God almighty! and points to new motion-correction software available for MRI's.

I agree whole heartedly.

Palm Anesthesiology

• Categories: Software
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PalmSource maintains an excellent resource for anesthesiologists (thanks to Donald M. Voltz, M.D.) at Palm Anesthesiology which includes:

Software

• Medical Calculators
• Drug References
• Case-Tracking Software
• Educational Software
• Medical Billing Software
• Quality Assurance Software
• Clinical Information

Included is some billing software I'm going to have to review...

Unusual Venue for a Tribute: iTunes Music Store

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I ran across an unusual, but moving, tribute from a son to his mother. I say 'unusual' mainly because of where I found it--on the iTunes Music Store. I'll post it below for you to consider:

For those of you with iTunes, you can see the iMix.

RSS for PubMed Searches

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Orac Knows points to a really nifty use of rss for those of us that use PubMed for literature searches called HubMed and use RSS. HubMed offers 'RSS feeds of literature queries - updated daily'. For example, I can enter a search string like 'liver transplant anesthesia' and get a nice list of hits on a web page. Encoded in the html of the page is the url for the rss feed of this search. Handing the html page url to your news reader/aggregator allows it to 'discover' the rss url for you. After that, your news reader will highlight any new references the search turns up.

'X' Marks the Spot. Or Does It?

• Categories: Medical errors
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Newsday.com has details of a recently announced jury verdict in a case of wrong side surgery:

Does an 'X' mean 'operate on this one' or does it mean 'do not operate on this one--operate on the other one'? I've seen a few patients write 'No!' on the non-operative side. We all got a chuckle out of it, but it worked! Rather than an 'X', the mark should be placed on and refer to the correct side--either 'R' or 'L'.

The rest of the article points out that the OR was also set up for the wrong side. Just another example of multiple failures being needed for a medical misadventure to occur. I'm sure there was no end of the 'blame game' going on for this one.

Why I Like Being An Anesthesiologist

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I've tried to explain to people why I like being an anesthesiologist so much--with difficulty (unfettered access to narcotics, starting my work day at 07:30, having patients ask me if I'm a real doctor, oodels of respect from surgeons and nurses alike are the reasons that usually come to mind). I just ran across something on the web that really helps me understand why. Getting Back To Work: A Personal Productivity Toolkit at kuro5hin.org is an article about procrastination. Now, my favorite motto is 'hard work pays off after a time, but laziness pays off now,' so I was naturally drawn to this article.

The article describes the ideal work experience as being in a state of 'flow' and goes on to outline the kinds of tasks that make it more likely you'll be able to attain it:

Bingo! That's why I like being an anesthesiologist in private practice!

That's also why I like using Conversant to build web sites. When I'm working on a Conversant site, I often reach a state of 'flow.'

[Via 43 Folders]

Google--Preventing comment spam

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Google--Preventing comment spam:

Read the rest for details of how to implement this tag

JAMA -- Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac Arrest, January 19, 2005, Wik et al. 293 (3): 299

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JAMA -- Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac Arrest, January 19, 2005, Wik et al. 293 (3): 299 (free article)

Bottom line--it's hard to do it right. I have given chest compressions in the operating room with an arterial line in place so I can see what effect my compressions are having in terms of generating a pressure. Depressing the chest 4 to 5 cm is a lot, but that's the guideline, and that's what it takes to keep blood pumping to the brain. If you're going to the OR and know you're going to have a cardiac arrest, ask for me.

2004 Best Medical Weblogs Announced

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Echo Journal has the Best Medical Weblogs of 2004 results.

Grand Rounds XVII

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Welcome to Medical Weblog Grand Rounds XVII with a theme of medical errors. One week is not a great deal of notice to make a topic-specific post (note that I didn't make one myself), but a 'thank you' goes out to those of you who did post on the topic. Near the end, I've included a 'roundup' of other posts.

If I missed your post, please accept my apologies...and forward it to A Chance to Cut is a Chance to Cure.

This document is an outline. Any underlined headline can be collapsed (or re-expanded) with a single click. You can manipulate the entire outline as follows:

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(try it!)

Where available, I've attached the syndication link to the icon. This should make it easier to add blogs you don't already follow to your aggregator.

1. DB's Medical Rants: More on resident work hours
   1. DB's Medical Rants: More on resident work hours
   2. "Resident work hours seems a simple problem to those observing from the outside, but the solutions may well have unintended and undesirable consequences. The ACGME violated a fundamental principle of change - carefully examing the results of a change on the educational process. They acted unilaterally, against the wishes of residents and programs."
2. The Cheerful Oncologist: Listening to Mini-Me
   1. The Cheerful Oncologist: Listening to Mini-Me
   2. If I had to choose a new favorite medical weblog I discovered in preparing Grand Rounds, it would be this one. From it, I learned:
   3. Three Things to Avoid
      1. Making a Decision in Anger
      2. Making An Assumption
      3. Relying on Other Doctors to Do Your Work
   4. What a medical oncologist really does.
3. Mental Notes: Family therapy for medical errors
   1. Mental Notes: Family therapy for medical errors
   2. "It's sort of like the approach that a family therapist takes. When a family presents for treatment, someone is always identified to the therapist as the bad family member. It's either a child with behavior problems or a dad who is drinking, or the like. But family therapists know that the "identified patient" is just showing that there is a problem in the family system. To stop the bad behavior or the drinking, you have to treat the larger problem.
      
      Likewise, doctors need to understand that the goal should be to identify the problem within the "hospital family" that leads to medical errors, instead of having an identified bad-doctor in the hospital family."
4. GruntDoc: Emergency Department Errors: No Help Here
   1. GruntDoc: Emergency Department Errors--No Help Here
   2. "The ED is going to be the hardest place to exorcise all errors. It's a chaotic environment with no set pattern, the entire panoply of presentations and problems, from day zero to the last of life. It takes teamwork and compulsiveness to prevent errors. We're trying."
5. Chronicles of a Medical Madhouse: Doctoring and Medical Errors
   1. Chronicles of a Medical Madhouse: Doctoring and Medical 'Errors'
   2. "Did we act as doctors then? Is this a medical 'error'? We have failed the patient but satisfied the guidline. No official error committed. How about unofficially?"
6. Shrinkette: Iatrogenosis
   1. Shrinkette: Iatrogenosis
   2. "A 79 year old woman has hip replacement surgery. Post-op, she is given patient-controlled analgesia (PCA) with a 2 mg morphine loading dose, and 1 mg every 10 minutes prn (maximum dose 6 mg every hour). After 48 hours, she is agitated and hallucinating, seeing insects and dogs. A psych consult is called."
7. Blogborygmi: Swan Song
   1. Blogborygmi: Swan Song
   2. Fellow: "What's the #1 complication due to Swans?"
      ...[snip]...
      Fellow: "It's actually misinterpretation of the data. Overwedging, or mistaking PAP for LVEDP. It leads to errors in fluid management."
8. CodeBlog: Pay No Attention To Those Voices Over There
   1. CodeBlog: Pay No Attention To Those Voices Over There
   2. "What are staffing ratios? It's different for each area of the hospital. ICU's are to have only one-two patients per nurse. Medical/Surgical floors are supposed to have only 6 patients per nurse. (I've worked on med/surg floors and have had nine patients.) The staffing ratios were supposed to be put into effect over the course of several years. This means that as of yesterday, January 1, 2005, med/surg nurses were supposed to be assigned only 5 patients apiece."
9. The Write Wing: Medical Errors
   1. The Write Wing: Medical Errors
   2. "In the fast pace of the emergency room environment, there are very common mistakes involving medication orders. When orders are spoken, you need a nurse who will 'call back' your orders to you to confirm, and MOST ESPECIALLY when she is in doubt about the dosage or the route of a medication! It is NOT an affront to your ego, a statement of your competence as an MD, it is the job of any good nurse to do so. This is how a TEAM operates."
10. Parallel Universes: Refusing to Release a Dead Patients Medical Records
    1. Parallel Universes: Refusing to Release a Dead Patients Medical Records
    2. "A mother giving birth by cesarean section last December was given blood transfusion with the wrong blood type, and eventually died. Patient's relatives demanded the medical abstract from the hospital staff but they refused to give it allegedly for fear of crminally incriminating themselves. What is wrong here?"
11. WakingUpCosts: Anatomy of a Near Miss
    1. WakingUpCosts: Anatomy of a Near Miss
    2. "Medical errors are insidious. Many, many errors occur that do not lead to a bad outcome, but they are errors nonetheless. Given a different patient or set of circumstances, those same errors could result in injury, death, or at the very least less than optimal care. The following example serves to reinforce this point."
12. The Examining Room of Dr. Charles: Livelihood of a Drummer
    1. The Examining Room of Dr. Charles: Livelihood of a Drummer
    2. "I then asked him about jazz.
       
       His eyes brightened, and his posture loosened. A satisfied but unspoken calm descended upon him as his mind sifted through the various circuits of memory stretching between the left and right sides of his brain. He told me of the best musicians he had ever played with, and it was like listening to a man recount the loves of his life. It was neither lustful nor corporeal, but rather experiential and otherworldly."
13. Orac Knows: Battling quackery in "conventional medicine"
    1. Orac Knows: Battling quackery in "conventional medicine"
    2. "I was utterly flabbergasted that a company could use such false and/or misleading statements this on a large AM station in order to sell a test whose validity had not yet been established for that purpose and that insurance companies didn't pay for. Concerned about the false information being promulgated several times an hour on his station, I politely wrote the program director and expressed to him my concerns that this ad was deceptive in exaggerating the shortcomings of mammography and the usefulness of breast MRI as known at the time."
14. Hospice Blog: Why people like hospice
    1. Hospice Blog: Why people like hospice
    2. "So, why do people with a past hospice experience have a positive view of hospice? The answer, in my mind, is somewhat simple. When people stop me on the street tell me how wonderful hospice is and how much we helped one of their family members or friends, I usually say, “We’re the experts at the one thing that nobody wants to be an expert at.” I believe that simple statement is why hospice is so well received."
15. Kevin, MD: I have pain in my arms
    1. Kevin, MD: "I have pain in my arms"
    2. "A 72-year old female comes into the clinic with arm pain. This occurred when she was shoveling snow on her porch, and was brought in by her family. The pain is described as dull and aching, worse when she was shoveling the snow, somewhat resolved on rest. She denies chest pain, shortness of breath, nausea, vomiting, fevers or chills."
16. Different River: Medicare for All=None
    1. Different River: Medicare for All=None
    2. "The dirty little secret behind Medicare is that it works only because it does not cover every American. Part of the reason for this is that Medicare’s payment structure is designed to pay doctors and hospitals in such a way as to limit total spending, rather than to ensure they can break even. Clearly, they have to do better than break even to stay in business, and the people running Medicare know that. Medicare depends on the fact that there are lots of non-Medicare patients out there who (through their private insurance) can pay enough to keep the doctors and hospitals in business. This is called “cost shifting.”"
17. Medviews: Dry Cleaning
    1. Medviews: Dry Cleaning
    2. " [We] should not be attempting to become like the corner dry cleaners, but instead strive to be like Starbucks."
18. The Well-Timed Period: Skip Period Regimens
    1. The Well-Timed Period: Skip Period Regimens
    2. "Skip a period, or skipping your period on Yasmin, tricyclics, and NuvaRing are among the most common terms used by the people who find my site via search engines. So, to help these visitors, as well as my regular readers, I've decided to do a post on the regimens used to skip a [fake] menstrual period. This way, you'll have all the information in one place."
19. Catallarchy: You Know What Happens When You Assume
    1. Catallarchy: You Know What Happens When You Assume
    2. "I think we should be afraid whenever we see people all thinking the same way and coming to the same conclusions. When you see this, you can be sure the exact same assumption are being made. And these assumptions are often unspoken. And when unspoken assumptions are made, a lot of interesting questions are never asked nor addressed."
    3. And be sure to read to comments...
20. Chance To Cure: Bariatric Surgery Follies
    1. Chance To Cure: Bariatric Surgery Follies
    2. "Another great tradition, itinerant surgery. Bariatric surgery can save lives, when done properly, saves many lives, unfortunately many put financial gain before patent safety, both long and short-term."
21. Next Week
    1. Grand rounds are hosted by my surgical colleague at A Chance to Cut is a Chance to Cure.
22. Credits
    1. Thanks to Seth Dillingham and Macrobyte Resources for weblog hosting and the super duper outlining javascript.
    2. Also thanks to Nick from Blogborygmi for coordinating.

Triple Lumen Catheters Are Not Volume Lines

• Categories: Anesthesia Tips
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I brought a patient to the operating room recently who had a Type A ascending thoracic aneurysm dissection. She was bleeding into her pericardium and was in tamponade on arrival. She had a radial arterial line that wasn't (in an artery), and two triple lumen central lines--one in a femoral vein and one in an internal jugular vein.

I immediately thought back to my medical school days when I would see patients in the ICU with a GI bleed being transfused with cold, undiluted packed red blood cells through a triple lumen central line....and they were on vasoactive drips for 'hypotension.'

What's my point? Triple lumen catheters are long and narrow (especially compared to Cordis introducer sheaths or products like them made by other manufacturers such as Arrow). Remember the Poiseuille-Hagen equation shows that flow rate is directly proportional to the fourth power of the radius, to the viscosity of the fluid being transfused, and to the pressure gradient established and inversely proportional to the length of the tube. A 9 French introducer sheath can infuse fluid at about 1000 cc/min. Compare that to about 250 cc/min for the 14 gauge lumen of a triple lumen catheter. So it follows, then, that if you need to give someone fluid (like blood) fast, you infuse it through a fat catheter that is short, reduce the viscosity by diluting it and warming it (in the case of packed red blood cells), and apply some pressure by elevating it well above the patient or putting a pressure bag on it. Got it? Good! This might come in handy when you next see a hypovolemic patient...

Medical Weblogs Grand Rounds XVI

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At Medical Madhouse today.

Next week, I'm hosting Grand Rounds right here on WakingUpCosts and I'd like to focus the submissions on the subject of medical errors. Other posts are welcome, of course, but if you've been thinking about medical errors (as I have), why not blog about that this week and submit it? Please add your suggestions as a comment to this thread or send an e-mail.

Does Race-based Affirmative Action Help Professional Students?

• Categories: Policy
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An article is about to be published in the Stanford Law Review that is already creating a great deal of buzz in the law community. UCLA Law School professor Rick Sanders has written "Systematic Analysis of Affirmative Action in American Law Schools" which argues that African American students have been materially and tangibly harmed by law school affirmative action policies (a summary is here).

Based on my experience as a medical student and then as a member of medical school admissions committees, these finding resonate with me. I hope that a similar analysis can be done for medical school admissions. More importantly, I hope we can have an open discussion focussed on what's best for the individual students.