Thursday, March 31, 2005
Malpractice Payouts in Pennsylvania Rose in 2004
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Malpractice Payouts in Pennsylvania Rose in 2004:
"In 2004, insurers reported paying out $448 million, a 13.5 percent jump from $394.5 million reported in 2003, according to the U.S. Health Resources & Services Administration. The 2004 figure broke the previous record, which had been set in 2001.
The increase in 2004 came after two years of decline. One researcher said he thinks payouts are climbing steadily, but that the steep increase in 2004 also was bumped up by delayed reporting of some payments made the previous year."
[Via Point of Law Forum]
Saturday, March 26, 2005
CMJ Review: Clostridium difficile-associated diarrhea in adults
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The Canadian Medical Journal: Clostridium difficile-associated diarrhea in adults (free full-text)
Thursday, March 24, 2005
CDC: Disinfectants and Their Properties
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The CDC published (as an appendix to another report) a guide on which disinfectant work for what organisms:
"All surfaces should be cleaned thoroughly before disinfection. For basic disinfection, a 1:100 dilution of household bleach (i.e., 2.5 tablespoons/gallon) or a 1:1,000 dilution of quaternary ammonium compounds (e.g., Roccal-D® or Zephiran®) may be used. This appendix includes instructions for disinfection when a particular organism has been identified. All compounds require a contact time of >10 minutes."
Wednesday, March 23, 2005
C. difficile Outbreaks, Anyone?
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Our hospital has pulled all 3M Avagard hand disinfectant from the operating rooms, preferring instead that surgeons go back to the old fashioned surgical hand scrub. At the same time, we are apparently seeing more nosocomial Clostridium difficile infections. C. diff. is not a reportable pathogen, and this was felt to contribute to the outbreak Canada experienced recently. Avagard does not inactivate C. diff. spores. Co-incidence? I don't think so.
The CDC page for healthcare providers on C. diff. provides an interesting nugget:
"If your institution experiences an outbreak, consider using only soap and water for hand hygiene when caring for patients with Clostridium difficile-associated disease; alcohol-based hand rubs may not be as effective against spore-forming bacteria."
Has anyone else seen this at their facilities?
Tuesday, March 22, 2005
NEJM: Two Articles On Schiavo Case
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The NEJM will publish two article on the Schiavo case in an upcoming issue. Both are online now and free without a subscription:
Perspective
Terri Schiavo — A Tragedy Compounded
T.E. Quill
Legal Issues in Medicine
"Culture of Life" Politics at the Bedside — The Case of Terri Schiavo
G.J. Annas
Sunday, March 20, 2005
Take Your Web Searching To The Next Level
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There's more to search than Google--especially for medical topics. I often need to go search eMedicine, Cochrane, Pubmed, specific journals (NEJM and Anesthesia & Analgesia are two I use often) or even a Google sub-site (plain, news, images, scholar, maps) . One way to do this is to go to each home page, find their search box and, well, search! Ah, but there's a better way and it's called iSeek (MacOS X only).
What you're really doing when you use a search box on a site is submitting a search request in their syntax. If you know the syntax, you can submit a search request without actually going to the site. If you look at the address bar after you submit a search on a site, you're looking at their search syntax. For example, if I do a search on Google Scholar for 'hyperthermia,' I see the following url in the address bar:
http://scholar.google.com/scholar?hl=en&lr=&safe=off&q=hyperthermia&btnG=Search
Now, it's a bit much for us to memorize that string of text, but computers are very good at that sort of thing...and that's where iSeek comes in. Here's what iSeek looks like in my menu bar (it's the text field with the magnifying lens):
And here's what the iSeek menu looks like with all my favorite search sites:
To search at one of the listed sites, I select the site (in this case eMedicine), enter the search term in the text field, and hit 'return.' iSeek takes my search term, slaps on the right prefix and suffix to put the search term in the right format, and submits it. The results appear in a new tab in my web browser.
If the thought of figuring out the right text strings bother you, fear not. The makers of iSeek have an extensive list of search engines you can add directly from their site.
Thursday, March 17, 2005
NEJM: The Serotonin Syndrome
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Boyer and Shannon's article in the NEJM The Serotonin Syndrome is an excellent review/introduction to a syndrome every anesthesiologist should be familiar with but that had not been defined when I was in training. Excess serotonergic agonism can be triggered not only by certain drug overdoses, but also by many drugs anesthesiologist give frequently (fentanyl!).
Why I'm Excited About Apple's 'Spotlight' Technology
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Rumor has it that Apple will release its next iteration of MacOS X, code named 'Tiger', in April. One component of it that is not a rumor is its new built-in search engine called Spotlight (tech preview pdf). The list of supported files types includes (but is not limited to):
- Plain text
- RTF
- PDF
- Mail
- Keynote presentations
- Microsoft Office Word documents
- Microsoft Office Excel spreadsheets
- Microsoft PowerPoint presentations
- iChat logs (if logging is enabled)
In other words, all the file formats in which clinical reference information might exist on my computer hard drive will be searchable
by content, not just by title.
How might this be useful to a clinician? For years now, I've been dropping files onto my hard drive because they contains information I want to have access to in the future. I have an entire textbook of anesthesiology as html files. Literally hundreds if not thousands of pdf files of articles I've saved from NEJM, Anesthesia & Analgesia, and other journals. Every lecture I've ever given. All the CME I've ever done (if available electronically).
I have tried mightily to keep it all organized. Seth Dillingham actually made some software for me to be able to use a local webserver to organize, index and serve all those files on my local machine. Extended to something we called the Reference Laptop Project, we endeavored to put everything an anesthesia resident could need during their training on a $1,000 20 GB Apple iBook, complete with automatic updating of reference materials via wireless LAN. I've installed Plone and learned some Python to be able to make a system that works for me. But now, finally, coming to OS X, is the core technology that will allow me to do what I want as a feature of the operating system itself, or perhaps even as a custom application.
Underneath it all, there's even an API that lets applications access Spotlight's power. Imagine a new application that imposes a structure on the information you already have or will add! As an example, imagine an outline of relevant topics in anesthesiology. For each topic, the application would use Spotlight to create Smart Folders for, say, information on malignant hyperthermia, and airway management, and peri-operative beta blockade. I have a great deal of information on each of these topics already on my hard drive. Some in the Documents folder, some under Sites. Some exists as HTML files, some as PDF, some as powerpoint. And as I add more information, the Smart 'Chapter' will automatically update. Perhaps the very capable makers of Delicious Library will explore creating 'Delicious Reference' just for me.
The future is here. It's just not evenly distributed yet. --William Gibson
Tuesday, March 15, 2005
Four Drug Rep Tricks Plus One Of My Own
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Polite Dissent is a blog I just discovered thanks to Grand Rounds. He/she has the same take on some of the techniques used by drug detail people as I do:
- False agreements
- Fake Thanks
- Bring the Boss
- Appeal to Authority
I'll just add my own to this very good list: use the people around you as billboards. It seems the people who make a paralytic called rocuronium have dropped off a thousand or so yellow operating room caps that say "Roc Solid" (Roc is our abbreviation for rocuronium, aka Zemuron). Many OR nurses and techs are now wearing these caps. My reaction? Even if I was planning on using rocuronium for the case, I'll draw up some tasty vecuronium or cis-atracurium instead. And besides, the vecuronium people gave me a nice nerve stimulator once...
Grand Rounds XXV: Respectful Insolence
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Grand Rounds XXV is up at Respectful Insolence. Just don't have a mouth full of coffee when you read it.
Monday, March 14, 2005
WHO warns of human bird flu mutation
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ABC News Online--WHO warns of human bird flu mutation.:
" The World Health Organisation (WHO) says the bird flu virus may be changing into a form that humans can pass on.
The WHO is worried that bird flu, which has killed 47 people in Asia, could mutate into an easily spread form that sparks the next influenza pandemic.
The organisation has identified a cluster of human bird flu cases among relatives and possibly health workers in Vietnam.
"Such cases can provide the first signal that the virus is altering its behaviour in human populations and thus alert authorities to the need to intervene quickly," the WHO said in a statement.
The main concern of the WHO was a series of cases of the deadly H5N1 bird flu virus in a family in the northern Vietnam province of Thai Binh and the possible infection of two nurses who cared for one of the patients.
The WHO also says it has received confirmation of an additional 10 cases of human infections from Vietnam's Health Ministry.
The new cases were detected in early March or through re-examination of older cases, some of which dated back to late January and three of which had been fatal, the WHO said. "
See the WHO web site for details.
Sunday, March 13, 2005
Pennsylvania Department of Health Reconsiders Laparoscopy Decision
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In a letter to ambulatory surgery centers dated March 7, 2005 and available on a DOH web site, the department has decided to place the issue under further study and to grant exceptions to the prior directive to allow some centers to resume certain laparoscopic procedures:
"Following its notification to providers that procedures such as laparoscopic cholecystectomies were not permitted in the ASF setting, some ASFs objected that some of these procedures were safe and should be allowed.
In response to these providers’ concerns, the DoH proceeded to meet on a number of occasions with the Pennsylvania Medical Society, the Federated Ambulatory Surgery Association and the Pennsylvania Ambulatory Surgery Association. We reviewed the applicable literature made available to us by provider organizations and through our own research. We worked with the Pennsylvania Health Care Cost Containment Council to collect available data into formats that would be helpful. We found that some ASFs were performing procedures that the DoH believes to be prohibited under its regulations. We also surveyed other states and found that Pennsylvania is more restrictive than other states, which tend to rely upon Medicare to control the types of procedures performed in ASFs.
The DoH agrees that providers have raised valid points and proposes to convene a group of stakeholders to review the current regulation and determine what changes are appropriate. This process, however, will take time and some providers that have been performing these procedures on a routine basis need more immediate relief. Therefore, the DoH has implemented the following two-pronged exceptions process.
In addition to the procedures allowed under the state regulations, the DoH has determined that ASFs should have the opportunity to perform procedures that are on the Medicare List since these procedures have been reviewed and approved by the federal government on a procedure-by-procedure basis for their safety in a freestanding ambulatory setting. This list is developed under § 1833(i)(1) of the Social Security Act, which requires CMS to specify surgical procedures that can be safely performed in a freestanding ambulatory surgical setting. The Medicare List is published in the Federal Register as an addendum to 42 CFR Part 416"
A PDF of the letter is uploaded here. On balance, I think this is a fair approach (for now), and a great improvement over the wholesale banning of all laparoscopic procedures at centers that provide a very high standard of care.
The Hipster PDA
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43 Folders has a wonderful post on a way to capture information on the go which they're calling the Hipster PDA. Now, I have tried to use all manner of PDA to keep track of info on the go at the hospital, starting with the Newton all the way up to my current Treo 610. Which one worked best? It was the system I used as an intern--3X5 index cards held together with a binder clip.
I have improved on it slightly over time, only because, as an anesthesiologist I have less stuff to remind myself about. My 'Palmster PDA' consists of the palm of my left hand on which I can conveniently write down who needs an epidural, which of my colleagues needs lunch or a break, or when I need to re-dose the antibiotic for my current patient.
Saturday, March 12, 2005
How To Use An iPod
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I've lectured on a variety of topics. I've been asked to give inservices to OR nurses and anesthesia techs alike. No topic is more frequently requested than how to use an iPod. Honest. iPods are becoming more commonplace in the operating room all the time. I've finally found a nice demo on the web of how to operate an iPod which allows self-paced learning:
Consequences of Physician Report Cards
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The Medical Informatics Weblog: Consequences of Physician Report Cards:
"Reporting quality information publicly can promote quality improvement. However, according to an article in the current issue of the JAMA, the Journal of the American Medical Association, the value of publicly reporting quality information is essentially undemonstrated and may have unintended and negative consequences on health care. These unintended consequences include causing physicians to avoid sick patients in an attempt to improve their quality ranking, encouraging physicians to achieve “target rates” for health care interventions even when it may be inappropriate among some patients, and discounting patient preferences and clinical judgment."
This is a very timely JAMA article as the Pennsylvania Health Care Cost Containment Council has just published its Guide to Coronary Bypass Graft Surgery 2003 in which it assigns higher than expected adjusted mortality mortality scores to three surgeons that I feel are head and shoulders above the rest in the list. In other words, it dinged the surgeons I think are the best. (as an aside, none practice an Pennsylvania any longer)
Obstetrical deaths in the UK--Anesthesia component
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Why Mothers Die 2000-2002 - Report on confidential enquiries into maternal deaths in the United Kingdom
Chapter 9--Anaesthesia
The anesthesia chapter concludes:
"The management of haemorrhage is a shared responsibility of midwifery, obstetric, anaesthetic and blood transfusion personnel. Anaesthetists should be ready to suggest that the obstetrician summons help in the face of major haemorrhage regardless of the obstetrician’s grade or experience. Good communication is vital and regular practice of emergency drills is crucial, particularly in units with a high turnover of staff."
I would like to think that many of the problems pointed out in this report would not happen in the United States, but that would be intellectually dishonest. If you provide anesthesia for obstetrical patients as I do, it's worth reading over this report for the lessons that are applicable in the US.
Medviews Weblog on Vaccine Controversies
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In a post titled Natural Danger Stuart Henochowicz takes on the issue of misinformation about vaccines that seems to be accumulating in the lay press.
" I have come across a truly appalling article on the supposed dangers of vaccines by a Dr. Sherri Tenpenny, who writes for Mothering Magazine. Under the guise of being nature's protector, this Osteopath writes some hideously inflammatory, misleading, and dangerous stuff. "
My wife has seen a number of families that have decided to withhold vaccinations from their children over mercury and other health concerns. As health professionals, we need to take this bull(shit) by the horns and make sure people know the facts. As Stuart points out, although herd immunity may give them a free pass, society will pay the price if the proportion of such unvaccinated individuals becomes too great.
U.S. Health Spending Projections U.S. Health Spending Projections For 2004–2014
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Health Affairs: U.S. Health Spending Projections For 2004–2014
"By 2014, total health spending is projected to constitute 18.7 percent of gross domestic product, from 15.3 percent in 2003."
Gulp.
Frist Indicates Willingness To Compromise With Democrats on Malpractice Legislation
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Kaisernetwork.org--Frist Indicates Willingness To Compromise With Democrats on Malpractice Legislation:
" Senate Majority Leader Bill Frist (R-Tenn.) on Thursday said he would again push for medical malpractice legislation this session and indicated that he would consider compromises with Democrats to examine the "elements of insurance reform" in addition to establishing caps on noneconomic damages awards, CongressDaily reports. Republicans have been unsuccessful in passing legislation that would impose a $250,000 cap on noneconomic damages because of Democratic filibusters. Democrats maintain that rising medical malpractice insurance premiums stem from problems within the insurance industry. Frist suggested that he might be willing to reconsider the $250,000 limit but added, "There absolutely should be a cap." According to Frist, medical malpractice reform will be considered in the Senate after bankruptcy and other tort reform legislation, including changes to the asbestos litigation system, are addressed (Heil, CongressDaily, 3/10). "
Senate Committee Approves Bill To Establish Medical Error Reporting Database
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Kaisernetwork.org--Capitol Hill Watch | Senate Committee Approves Bill To Establish Medical Error Reporting Database - :
" The Senate Health, Education, Labor and Pension Committee on Wednesday approved by voice vote a bill (S 544) that would create a database to allow care providers to report medical errors, CQ Today reports. The database would be used to track medical errors, examine trends and prevent reoccurring mistakes, CQ Today reports. Information included in the database would not be used in medical malpractice lawsuits, according to CQ Today. Before the full Senate considers the measure, committee Chair Michael Enzi (R-Wyo.) and Sen. Edward Kennedy (D-Mass.) are expected to insert language to clarify that the bill would not affect information already available to attorneys for use in malpractice suits. The committee last year approved similar legislation, which was unanimously approved by the Senate. The House approved a separate version of the legislation, but the issue died after conference committee members were not appointed. The new bill is expected to pass the Senate. The House Energy and Commerce Committee has not yet scheduled a review of the bill (Schuler, CQ Today, 3/9). "
Wednesday, March 9, 2005
"If you're wrong, I'll sue you."
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That's what the patient was overheard to say after I finished a discussion with her about why she would not need prophylactic antibiotics before a nasal procedure. Her medical history was significant only for a 'heart murmur' (which I could not auscultate). No workup or echocardiogram had been done to rule in a structural cardiac abnormality. The patient denied signs or symptoms of valvular heart disease including mitral valve prolapse, and had a very good exercise tolerance. I quoted the AHA Recommendations which, it turns out, admit that....
"There are currently no randomized and carefully controlled human trials in patients with underlying structural heart disease to definitively establish that antibiotic prophylaxis provides protection against development of endocarditis during bacteremia-inducing procedures. Further, most cases of endocarditis are not attributable to an invasive procedure. "
"If you're wrong, I'll sue you" was reportedly spoken by the patient after I had left the bedside. As I saw it, I had three choices:
- Tell her I would not provide her an anesthetic for this elective surgery as she had revealed herself to be a litigious patient.
- Reschedule her surgery after an echocardiogram had been performed to elucidate the origin of the murmur.
- Give her the antibiotic and get on with things.
Part of why I had such a strong emotional reaction upon hearing this was almost certainly because I have been in practice over eight nearly nine years and have yet to be named in a suit (the average physician is sued once every eight years). And because some very talented surgeons have left Pennsylvania because of the malpractice environment (and have been replaced by considerably less talented surgeons).
After I talked it over with the surgeon (who asked me to proceed so as not to put him in a difficult position) I gave her the antibiotic and got on with things...but not until after I had listed for her every possible complication of both the antibiotic dose and the anesthetic she was about to receive, including brain damage and death.
Now, all the informed consent in the world isn't going to stop a patient from suing regardless of outcome if they want to sue. I decided to save my charm, humor, and best bedside manner for patients that have the good sense not to talk about bombs while they're waiting in line at airport security.
Monday, March 7, 2005
'Good guys' show just how easy it is to steal ID
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'Good guys' show just how easy it is to steal ID:
" Teams of hackers surfed the Web at Seattle University yesterday, harvesting Social Security and credit card numbers like a farmer cutting wheat. In less than an hour, they found millions of names, birth dates and numbers -- cyberburglar tools for the crime of identity theft -- using just one, familiar Internet search engine: Google. "
The problem is not Google. The problem is the sites that allowed these documents to be indexed. I wonder how successful we would be finding protected health information?
[Via HIPAA Blog]
Tuesday, March 1, 2005
Discovery Health: Anesthesia (Reporting) Nightmares
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I watched 'Anesthesia Nightmares' on the Discovery Health channel last night (listing). As an anesthesiologist, the awareness and recall of surgery are of grave concern to me, so I tuned in for what I hoped would be an informative, informed, hour of Discovery Health television. What I saw amounted to fearmongering.
Let me state at the outset that I do not doubt the ordeals described by the victims interviewed in the show. Awareness and recall under anesthesia happen. How often they happen has recently been answered by an article titled The incidence of awareness during anesthesia: a multicenter United States study. The study was funded by the company that makes depth of anesthesia monitors (Aspect), but I can't find fault with their data:
" Assuming that approximately 20 million anesthetics are administered in the United States annually, we can expect approximately 26,000 cases to occur each year. "
Before I point out some of the specific information I disagree with, let me make a few general points.
I. Not every occurrence of awareness is the kind of 'anesthesia nightmare' described in the show. This should have been pointed out during the report. From the article referenced above:
Summary of Awareness Descriptions (n = 25)
Variable
|
n
|
%
|
| Auditory perceptions |
12 |
48 |
| Unable to move or breathe |
12 |
48 |
| Anxiety/stress |
9 |
36 |
| Pain |
7 |
28 |
| Sensation of endotracheal tube |
6 |
24 |
| Feeling surgery without pain |
2 |
8 |
|
| More than one description may occur per case. |
|
II. We know the risk of awareness is higher in certain kinds of operations (trauma resuscitations, open heart surgery, and emergency cesarean sections are three that come to mind) and in certain kinds of patients (patient with significant coexisting medical conditions such as heart disease or renal failure). In those cases there is a trade-off between depth of anesthesia and patient well-being. There can also be awareness during an unanticipated difficult airway (the first dose of injected anesthetic begins to wear off before the inhaled anesthetic is started.
III. We sometimes are asked to do anesthetics which would not be our first choice. Certain orthopedic spine procedures require special monitoring which is in turn affected by anesthetic levels. We have to modify our preferred anesthetic to take into account this new requirement--and the risk of awareness is higher if we can't use inhaled agents, for example.
Let me now give some quotes from the show that I think are misleading and explain why I think so:
Narrator: "The gas was not working, but like all surgical patients, Joe had also been given a paralytic drug"
This is false. Most surgical patients do not receive a paralytic drug. Intra-abdominal, intrathoracic, intracranial cases do because the surgery could not be done without them, but that's not a majority of cases. We try to avoid giving paralytics unless they're clearly indicated.
Dr. Frank Sweeny: "There are a variety of theories about what anesthesia is, but really I can summarize it in three words: We Don't Know"
This is simply a poor choice of words on Dr. Sweeny's part or Discovery Health taking it his quote out of context. Although it is true we do not precisely understand the mechanisms of some anesthetics, we do know a great deal about how these drugs work as evidenced by the safe and uneventful conduct of the vast majority of anesthetics given each day.
Narrator: "Anesthesiologists have to find a delicate balance between three types of drugs: paralytics to prevent movement, analgesics to dull pain, and narcotics to induce unconsciousness"
Well, not quite. Anesthesiologist seek a balance between drugs that cause unconsciousness, amnesia, anxiolysis, attenuation of the stress response, and muscle relaxation (for a history, see this article). Narcotics are used to block pain and therefore attenuate the stress response (but so do drugs like beta blockers). Narcotics do not induce unconsciousness (very well). We use inhaled anesthetics (such successors to ether) and intravenous anesthetics (such as successors to sodium pentothal) for that. It is this line that makes me think that the creators of this show did not allow an anesthesiologist to screen the final product for accuracy.
Narrator: "What no one in the operating room realized is that the canisters of anesthetic gas were empty"
This can happen, but if the pre-anesthetic checklist is used properly, it won't. Checking anesthetic levels is on the checklist. In addition, one of our inhaled anesthetics (Desflurane) has a vaporizer with a built-in alarm for when the anesthetic level gets low that can then be refilled without having to turn the vaporizer off (thus eliminating the risk of forgetting to turn the vaporizer back on).
Narrator: "A muscle relaxant is used to keep the body still during surgery"
A muscle relaxant is used to relax (paralyze) the muscles. We keep the patient still by making sure they are sufficiently anesthetized. Reflexly giving more paralytic if a patient moves is the wrong response. First insure lack of awareness, lack of pain, adequate anesthetic levels, then consider re-dosing the muscle relaxant.
Narrator: "Studies have shown that mistakes happen in 3% of all operations."
That may be true, but it's far too vague to have any bearing here. Mistakes by whom? Of what magnitude? Did harm actually come to the patient?
Finally the show introduces the brain monitor called Bis (for Bispectral Index), and the person introducing it is a Dr. Don Mathews. What the series does not indicate is that Dr. Mathews is on the speakers buereau for Aspect medical, maker of the Bis monitor. Dr. Mathews narrates a case where the patient actually requires less anesthesia than he thought--and that's exactly my experience with the Bis monitor. After using it for several years, I have never deepened someone's anesthetic because of what the monitor showed, only lightened it. The Bis monitor, and others like it, is being studies intensely in the literature, but I don't think there's a consensus yet. Bis measures level of hypnosis. Not depth of anesthesia. Using Bis makes no difference in the incidence of painful awareness.
It's late and I want to get this posted, but reserve the right to add a Part II should the urge arise.
For more information, see the JCAHO Sentinel Event Alert on "Preventing, and managing the impact of, anesthesia awareness" published in October 2004.
