Wednesday, January 12, 2005
Triple Lumen Catheters Are Not Volume Lines
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...
Tuesday, January 11, 2005
Medical Weblogs Grand Rounds XVI
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.
Friday, January 7, 2005
Does Race-based Affirmative Action Help Professional Students?
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).
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"In the case of blacks, at least, the objective costs of preferential admissions appear to substantially outweigh the benefits. The basic theory driving many of these findings is known as the “academic mismatch” mechanism; attending an advanced school where one’s credentials are far below those of one’s peers has a variety of negative effects on learning, motivation, and goals that harm the beneficiary of the preference. Over the past several years, a wide range of scholars have documented the operation of the mismatch mechanism in a number of fields of higher education. "
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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.
Wednesday, December 29, 2004
NEJM: Ten Years After Gastric Bypass
Too bad it's not free full text, but the NEJM has published a study showing that bariatric surgery results can be good:
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"Two- and 10-year rates of recovery from diabetes, hypertriglyceridemia, low levels of high-density lipoprotein cholesterol, hypertension, and hyperuricemia were more favorable in the surgery group than in the control group, whereas recovery from hypercholesterolemia did not differ between the groups. The surgery group had lower 2- and 10-year incidence rates of diabetes, hypertriglyceridemia, and hyperuricemia than the control group; differences between the groups in the incidence of hypercholesterolemia and hypertension were undetectable."
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Here's a nice graph of the weight loss over the course of the ten year follow up:
The same issue contained another article on obesity in women as it relates to increased risk of death:
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"We estimate that excess weight (defined as a body-mass index of 25 or higher) and physical inactivity (less than 3.5 hours of exercise per week) together could account for 31 percent of all premature deaths, 59 percent of deaths from cardiovascular disease, and 21 percent of deaths from cancer among nonsmoking women."
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[Click for larger image]
It would be interesting to know if weight loss from bariatric surgery confers the same benefit.
New Genetic Test May Prevent Drug Interaction
New Genetic Test May Prevent Drug Interaction:
A new DNA microarray test called the AmpliChip Cytochrome P450 Genotyping Test analyzes abnormalities in the gene coding for Cytochrome P450, the liver enzyme involved in metabolizing many drugs. The hope is that testing for the abnormality will allow better use/selection of drugs in these patients. As the list of cytochrome P450-metabolized drugs is long and includes NSAID's, inhaled anesthetics. Are we looking at a standard pre-op test? Perhaps. Polymorphism at this gene may explain some of the bell-shaped curve we see in responses not only to anesthetics, but to many commonly prescribed drugs. What we need now are outcome studies...and to be patient.
More information about genotyping in general is here (thanks, Google).
[Via WebMD Health Headlines]
Lessons learned from troubles with COX-2 inhibitors - JAMA
JAMA: Arthritis Medicines and Cardiovascular Events—"House of Coxibs" (free full text)
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"In the wake of the high density of new data on coxibs, several important issues now need to be confronted. First, is there any continuing role for coxibs? Only rofecoxib has been shown to reduce gastrointestinal complications compared with naproxen, but valdecoxib and celecoxib have never been definitively confirmed to protect against gastrointestinal complications. While coxib superiority over NSAIDs for relief of arthritic pain has not been shown, many individual patients report pain relief with a coxib but not an NSAID. With the considerably higher cost, marginal efficacy, and known cardiovascular risks of the remaining agents on the market, valdecoxib and celecoxib, it would seem prudent, at the least, to avoid using these agents as first-line therapy. A contraindication is appropriate for patients with established coronary or cerebrovascular disease."
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and the final sentence
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"The combination of mass promotion of a medicine with an unknown and suspect safety profile cannot be tolerated in the future. An aggressive position going forward is necessary not only for ensuring the safety of prescription medicines but also to restore a solid foundation of public trust."
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[Via UK Medical News Today]
Donate to Doctors Without Borders
We've been talking about how best to donate to relief efforts after the tsunami. As I write this, the Doctors Without Borders web site is redirecting to a search page, but you can still reach the donation page directly.
Other choices for helping out are detailed here.
Sunday, December 26, 2004
Are Lawsuits Affecting Mammography Access in Florida?
Common Good points to the following article: Report: Lawsuits Limit Cancer Tests
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"In Florida, a governor-appointed task force reports that lawsuits are "discouraging radiologists from offering mammograms." Radiologists have good reason to be afraid. As many as 17 percent of tumors are "missed during at least one exam." And in 2002, a study of 25 insurance companies conducted by the Physicians Insurers Association of America found that "radiologists accounted for 33 percent of all claims and the most common allegation against radiologists was 'mammogram misread.'" Six seats are available in breast-imaging fellowship programs across the state of Florida, but none are filled. In fact, "a recent survey of 211 radiology residents showed that 63 percent of students wouldn't accept a fellowship in breast imaging." "Why would they jeopardize their lives and their careers if it's not absolutely necessary?" said Dr. Ada Patricia Romilly, a member of the Florida task force."
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I found the home page for the Workgroup on Mammogram Accessibility [thanks to Google] but see no final results. Those that are there indicate available data is inconclusive or invalid. So where does that leave us, exactly?
First cloned pet delivered by a US company
First cloned pet delivered by a US company:
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"The first cloned-to-order pet has been delivered by a US company, reigniting debate over the ethics of commercial cloning.
The 9-week-old kitten, named Little Nicky, was cloned for a woman in Texas, to replace a 17-year-old pet cat called Nicky, which died in 2003. She paid for $50,000 for her new pet. "
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Fifty thousand dollars for a cat? For a dog, I could see it, but a cat?
[Via Medical News Today]
Sales Rep Pleads Guilty in Federal Court To Bribing Physicians
Sales Rep Pleads Guilty in Federal Court To Bribing Physicians:
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"A former New York regional sales manager for Swiss biotechnology company Serono on Tuesday pleaded guilty to bribing doctors in New York City to write prescriptions for the company's AIDS-related drug Serostim, the Boston Globe reports."
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And what of the physicians he bribed?
[Via UK Medical News Today]
Charite Artificial Intervertebral Discs--ready for prime time?
DePuy Spine/J&J are marketing Charite artificial discs as an alternative to spinal fusion. A recent New York Times report, though pointing out that long term evidence is lacking, was basically positive and contained the following quote from a company representative:
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"Some of the anecdotal evidence for the Charité is impressive."
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Some of the anecdotal evidence? What? This device has been in use in Europe for two decades and that's the best they can do? The Charite web site with information for physicians has results but no references. None.
The one study I did find via PubMed concluded:
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"In this prospective randomized study, both surgical groups improved significantly. Complications of total disc replacement were similar to those encountered with anterior lumbar interbody fusion. Total disc replacement appears to be a viable alternative to fusion for the treatment of single-level symptomatic disc degeneration unresponsive to nonoperative management."
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It may be a 'viable alternative', but there's no data on long term results. Here's what I bet will happen. The FDA will approve the device and ask for long term followup, which is actually done by a company in fewer than half the cases where it is requested by the FDA. (I don't know J&J's record specifically, though.) Patients will read about it and find a surgeon that does the Charite procedure (even if it means going to someone who is not their normal orthopedic surgeon)...and resort to the legal system if their expectations are not met or their long term results are disappointing.
[Via Medgadget]
Radiologists Use iPod for Image Storage
Via Medgadget:
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Radiological Society of North America reports:
The iPod is not just for music any more. Radiologists from the University of California, Los Angeles (UCLA), and their colleagues at other institutions from as far away as Europe and Australia are now using iPod devices to store medical images.
'This is what we call using off the shelf, consumer market technology,' says Osman Ratib, M.D., Ph.D., professor and vice-chairman of radiologic services at UCLA. 'Technology coming from the consumer market is changing the way we do things in the radiology department.'
Dr. Ratib and Antoine Rosset, M.D., a radiologist in Geneva, Switzerland, recently developed OsiriX, Macintosh-based software for display and manipulation of complex medical image data.
Dr. Rosset set up the OsiriX software to automatically recognize and search for medical images on the iPod. When it detects the images, they automatically appear on the list of image data available - similar to the way music files are accessible by the iTune music application.
'It's easy to use and you don't have to worry about how to load and unload it from the iPod,' Dr. Ratib says. 'But the real beauty of it is that I can use the images directly on the iPod. I don't have to take the time to copy them to my computer. The iPod allows me to copy data from work to my laptop, but I don't have to do it if I don't want to.'
Dr. Ratib sees the iPod as a kind of giant memory stick, 'The performance is amazing.'
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Book Recommendation: Powerful Medicines
I began reading Jerry Avorn's 'Powerful Medicines: The benefits, risks, and costs of prescription drugs' before Vioxx and Celebrex made headlines for their possible effects on cardiac risk. Though I'm only a third of the way through the book, I want to pass along my recommendation. So far, I've gained real insights into how drugs are tested, 'approved' by the FDA, and marketed using examples such as Fen-phen, Premarin, Rezulin and others. I'm embarrassed to say that I didn't know a tenth of what actually goes/went on (and I'm a medical doctor!). You'll be amazed, too.
Friday, December 24, 2004
Online Posting of Med-Mal Payouts Is Seen as Chilling Settlements
Online Posting of Med-Mal Payouts Is Seen as Chilling Settlements:
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"Nearly five months after a [New Jersey] state government Web site began posting doctors' malpractice histories, the publicity may be having a chilling effect on settlements.
Lawyers on both sides of the aisle say that some doctors, faced with the reality that even a confidential settlement will end up on the Internet, are opting to take their chances in court.
They are exercising the right available under most medical malpractice policies to withhold their consent to settle, even when it goes against the wishes of their carriers and advice of counsel.
'Doctors do not want to settle at all now that it has to be reported to the databank for any payment whatsoever,' says defense lawyer Richard Amdur."
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[Via Point of Law]
Tuesday, December 21, 2004
New Web Resource: Consumer Reports Best Buy Drugs
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"The mission of the
Consumer Reports Best Buy Drugs project is to provide consumers and their doctors with information to help guide prescription drug choices–based on effectiveness, a drug's track record, safety and price.
The project aims to improve access to needed medicines for tens of millions of Americans—because they lack insurance coverage for prescription drugs, because the prices of many medicines today are so high, and because many consumers and physicians may not be aware of proven and affordable alternatives. "
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Washington Post: A Whole New Operation
A Whole New Operation (washingtonpost.com)
The following quote from the article gives a hint as to what may be going on behind the scenes in Pennsylvania's recent change in posture toward laparoscopic procedures in ASC's:
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"The one major health care player that's not pleased is your community hospital. Ellen Pryga, policy director of the American Hospital Association, said ASCs tend to draw away just the kinds of patients that financially pressed hospitals need to stay in business: people with relatively simple medical problems and the ability to pay. 'If the community looked to you to be the provider for all the safety net services,' she asked, 'and your ability to generate the revenues to support these services was disappearing left and right, wouldn't you be nervous?'"
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One thing to remember, though, is that many hospitals are investors in ASC's and so do share in the revenue they generate.
Which Surgeries Are Suited for Off-Site Centers? (washingtonpost.com)
Washington Post:Which Surgeries Are Suited for Off-Site Centers?
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"The Center for Medicare and Medicaid Services (CMS) authorizes reimbursement for some 2,500 procedures -- from cataract surgery to breast reduction -- at ASCs. Last month , it revised the list of approved procedures, adding 25, including knee arthroscopy, chin reconstruction and bladder repair, and deleting 105.
Among the items deleted as too risky: muscle and skin grafts, reconstructive cleft palate surgery, excision of the parotid gland, draining ovarian abscesses, repair of facial nerves and eardrum revision."
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The above references list of covered procedures was published at the Federal Register on November 26, 2004 (thank you, Google).
The WaPo article also makes reference to a paper by Fleisher titled: Inpatient Hospital Admission and Death After Outpatient Surgery in Elderly Patients. It concludes:
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"In multivariate models, more advanced age, prior inpatient hospital admission within 6 months, surgical performance at a physician's office or outpatient hospital, and invasiveness of surgery identified those patients who were at increased risk of inpatient hospital admission or death within 7 days of surgery at an outpatient facility."
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JCAHO Sentinel Event Alert: Patient controlled analgesia by proxy
Sentinel Event Alert Issue 33: Patient controlled analgesia by proxy
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"Patient controlled analgesia (PCA) is an effective and efficient method
of controlling pain, and when it is used as prescribed and intended, the
risk of oversedation is significantly reduced. However, serious adverse
events can result when family members, caregivers or clinicians who are
not authorized become involved in administering the analgesia for the
patient "by proxy." "
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I had this happen during my training. Healthy patient, uncomplicated anesthetic, uneventful recovery. Three hours after arriving on the floor she had a respiratory arrest. Despite numerous attempts from every quarter to blame my anesthetic (I had used Sufenta, a new synthetic narcotic at that time), it turned out to be the family pressing the PCA button.
Monday, December 20, 2004
I'll have some wine, fish, dark chocolate, fruits and vegetables, almonds, and garlic, please
The Polymeal: a more natural, safer, and probably tastier (than the Polypill) strategy to reduce cardiovascular disease by more than 75% -- Franco et al. 329 (7480): 1447 -- BMJ:
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What is already known on this topic
- Prevention of cardiovascular disease is limited by high costs and low compliance
- The concept of a combination pill (the Polypill) to reduce cardiovascular disease by more than 80% was introduced in 2003
- Pharmacological interventions are not the only option for preventing heart disease; a healthy diet and an active lifestyle reduce cardiovascular disease as well
What this study adds
- A combined meal of seven food components (the Polymeal) could reduce cardiovascular disease by more than 75%
- Chocolate, wine, fish, nuts, garlic, fruit, and vegetables are all known to have a positive effect on cardiovascular disease, and have been enjoyed by humankind for centuries
- Finding happiness in a frugal, active lifestyle can spare us a future of pills and hypochondria"
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More On PA Surgery Centers and Laparoscopic Procedures
A recent Pittsburgh Post-Gazette article contains a baffling statement from the spokesman for the PA Department of Health:
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"Surgery center operators say they have been performing laparoscopic procedures for years, but the state Department of Health became aware of the practice only this year, said spokesman Richard McGarvey."
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Laparoscopic surgery has been performed at surgery centers in Pennsylvania since 1985. Before a new center can open, it must be approved to perform certain procedures (such as laparoscopy). In their annual review if each center, the DOH inspects random charts, review lists of cases performed, looks at all event reports as well as QA minutes. In short, it is just not credible for the state to claim they did not 'become aware' until this year.
As far as I am aware, we have yet to see any evidence that laparoscopic surgery performed at a surgery center is any more risky to the patient. If I thought it was, I'd be the first to agree with the state's ruling. If patient safety were truly their motivation, the State would be looking at individual surgeons as risk factors, rather than the location of the procedure.
[Disclosure: I do not own a financial stake in any ASC, though my group does provide anesthesia for several. In other words, it's no loss to me because we provide anesthesia for the case either way.]
Sunday, December 19, 2004
Medicaid's fee-for-service drug expenditures increased 18% per annum
Medicaid’s Reimbursements to Pharmacies for Prescription Drugs (pdf)
This Congressional Budget Office report focuses on the markup paid to pharmacies by Medicaid for buying and dispensing drugs. For example, in 2002 medicaid reimbursed pharmacies an average of $46 per prescription. Of that amount, $14 was for purchase of the drug itself. The $32 difference constitutes the 'markup', which has been increasing at a rate of roughly 10% per year between 1997 and 2002.
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"Between fiscal years 1997 and 2002, Medicaid’s expenditures on prescription drugs in the fee-for-service part of the program increased from $10.2 billion to $23.4 billion. About one-quarter of those amounts went to wholesalers and pharmacies to compensate them for distributing and dispensing the drugs.
Prepared at the request of the House Committee on Energy and Commerce, this paper examines recent trends in that “markup”—or the difference between the total amount that state Medicaid agencies paid to pharmacies and the amount that pharmacies and wholesalers paid to purchase the drugs from manufacturers. In keeping with the Congressional Budget Office’s (CBO’s) mandate to provide objective, impartial analysis, the paper makes no recommendations. "
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and
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"Overall, the largest single factor contributing to the rapid increase in markups was the use of newer generic drugs, with their high markups. Another factor was the use of newer single-source brand-name drugs, which had somewhat higher average markups than did older brand-name drugs."
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Ambulatory Care, Procedures Requiring Surgical Site Marking
JCAHO: Ambulatory Care, Procedures Requiring Surgical Site Marking:
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"marking the site is required for procedures involving right/left distinction, multiple structures (such as fingers and toes), or levels (as in spinal procedures). Site marking is not required (nor is it prohibited) for other procedures."
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Saturday, December 18, 2004
100 Years Ago....
100 Years Ago....:
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"Maybe this will boggle your mind. I know it did mine! The year is 1904
...one hundred years ago. What a difference a century makes! Here are some of the US statistics for 1904:
The average life expectancy in the US was 47 years.
Only 14 percent of the homes in the US had a bathtub.
Only 8 percent of the homes had a telephone.
A three-minute call from Denver to New York City cost eleven dollars.
There were only 8,000 cars in the US, and only 144 miles of paved roads.
The maximum speed limit in most cities was 10 mph.
Alabama, Mississippi, Iowa, and Tennessee were each more heavily populated than California. With a mere 1.4 million residents, California was only the 21st most populous state in the Union.
The tallest structure in the world was the Eiffel Tower.
The average wage in the US was 22 cents an hour.
The average US worker made between $200 and $400 per year.
A competent accountant could expect to earn $2000 per year, a dentist
2,500 per year, a veterinarian between $1,500 and $4,000 per year, and a mechanical engineer about $5,000 per year.
More than 95 percent of all births in the US took place at home.
Ninety percent of all US physicians had no college education. Instead, they attended medical schools, many of which were condemned in the press and
by the government as 'substandard.'
Sugar cost four cents a pound. Eggs were fourteen cents a dozen. Coffee was fifteen cents a pound.
Most women only washed their hair once a month, and used borax or egg yolks for shampoo.
Canada passed a law prohibiting poor people from entering the country for any reason.
The five leading causes of death in the US were:
1. Pneumonia and influenza
2. Tuberculosis
3. Diarrhea
4. Heart disease
5. Stroke
The American flag had 45 stars. Arizona, Oklahoma, New Mexico, Hawaii, and Alaska hadn't been admitted to the Union yet.
The population of Las Vegas, Nevada, was 30!!!
Crossword puzzles, canned beer, and iced tea hadn't been invented.
There was no Mother's Day or Father's Day.
Two of 10 US adults couldn't read or write.
Only 6 percent of all Americans had graduated high school.
Marijuana, heroin, and morphine were all available over the counter at corner drugstores. According to one pharmacist, 'Heroin clears the complexion, gives buoyancy to the mind, regulates the stomach and bowels, and is, in fact, a perfect guardian of health.'
Eighteen percent of households in the U.S. had at least one full-time servant or domestic.
There were only about 230 reported murders in the entire U.S.
Where will we be in another 100 years? "
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[Via Aarmadillo]
Pennsylvania and Medical Courts
From Law.com: States Weigh Med-Mal Courts.
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"In Pennsylvania, a House bill was introduced in 2003 that would have created a Medical Professional Liability Court. The bill never made it out of committee.
"It was the source of a lot of discussions for the greater part of four or five months," said Mark Phenicie, the legislative counsel for the Pennsylvania Trial Lawyers Association. "But it hasn't happened ... .We have the additional impediment here that all of the judges are elected. If I'm a judge, I probably wouldn't want to have to run in a partisan statewide campaign just to be in a malpractice court." "
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Like other malpractice reform proposals, it never made it 'out of committee' because legislators from the Philadelphia area (who represent the trial lawyer lobby) prevented it from going to the floor for a vote.
[Via PointOfLaw Forum]
