Sunday, July 30, 2006
Risks of Epidural Analgesia for Labor
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Anesthesiology has a nice article which attempt to quantify some of the less common risks of having an epidural during labor: epidural hematoma, infection, and neurologic injury.
| Epidural hematoma |
1 in 168,000 |
6 per million |
| Deep epidural infection |
1 in 145,000 |
7 per million |
| Persistent neurologic injury |
1 in 240,000 |
4 per million |
Transient neurologic injury
[< 1 year] |
1 in 6,700 |
180 per million |
It contains an interesting tidbit others might find interesting, too. There are 4 million births in the United States each year and 2.4 million involve epidural analgesia. Wow. That's three fifth of all live birth get an epidural! (And some call nights, it seems every single one does...)
Tuesday, July 25, 2006
TIME: It was Heroism, Not Homicide, During Katrina
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From a critical care physicians stranded in a nearby hospital during Katrina:
"The major difference between comfort care and euthanasia or murder is intent. In a dying patient, giving sedatives and pain killers with the intent to cause death would be considered euthanasia or murder, while giving the same drugs in the same dosages with the intent to relieve suffering would be considered good, compassionate medicine, even if death were to be a consequence. In the wake of Katrina if a patient had died in a hospital without evidence of having received comfort care, I would question that treatment.
...[snip]...
"We don't know the whole story from all participants, including Dr. Pou and the nurses: what the conditions were like and what their intentions were. Until all the facts are known, it's wrong for the attorney general to act as if he's dealing with hardened criminals. He may very well be dealing with heroes."
My thoughts exactly...
[Time]
Sunday, July 23, 2006
Pennsylvania Showing Net Loss of Physicians Over Time
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The number of physicians in Pennsylvania has declined by approximately ten percent between 1999 and 2005. On its own that number may not sound like such a huge drop. Compare that number to the other 20 most populous states and it becomes obvious that the difference is very significant.
Almost all of have seen net increases of between 7% and 35% over the same period. I would find it very interesting to know how long the wait is for a new patient appointment in an internal medicine practice in Pennsylvania vs. these states that have seen an increase. A knee replacement? First visit to a Neurologist. Follow up visits? You get my drift. Pennsylvania has a population that is among the most aged. Medicare just announced plans for more cuts. New physicians are choosing not to practice in Pennsylvania and we've seen a net loss of 10% in our physicians with unique provider numbers over the last six years. Get the picture, Governor Rendel?
Data from State of Medicine in Pennsylvania--2005
Friday, July 21, 2006
NYT: Medical and Ethical Questions Raised on Deaths of Critically Ill Patients
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There's a very good article in the July 20 New York Times titled "Medical and Ethical Questions Raised on Deaths of Critically Ill Patients" that describes the ethical questions raised in the New Orleans case with some very good quotes:
"“I’m fundamentally unconvinced of the framing of the story,” said Dr. Steven Miles, a professor of medicine at the University of Minnesota and an expert on the care of dying patients. “I’m not inclined to believe this is a euthanasia scenario or a physician-assisted suicide scenario.”
One reason, Dr. Miles said, is that the drugs found in the dead patients — morphine and the sedative Versed — are not all that deadly and may not even have been what killed the patients. Many patients develop tolerances to the drugs and can handle high doses, he said. Barbiturates, readily available in a hospital, would be a far more efficient way to kill somebody if that was the intent, he added.
“The selection of drugs looks to me to be more typical of the drugs selected for providing palliative care rather than killing patients,” Dr. Miles said. Palliative care is treatment given strictly to keep a patient comfortable. "
Wednesday, July 19, 2006
Dr. Anna Pou Is Not a Murderer
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I just learned that a former colleague and friend has been charged with second degree murder in the death of four patients at a New Orleans hospital after Katrina. I worked with Dr. Anna Pou in the operating room when we were both in Galveston, Texas for three years in the late nineties. She worked as a head and neck surgeon specializing in cancer surgery and I provided anesthesia for many of her cases. After reading the story my only reaction is that this entire case is about an attorney general making a name for himself. Dr. Pou is a wonderful, caring, highly skilled surgeon. Her concern has always been for the comfort and well-being of her patients.
When I spoke to her by telephone several months ago to express my support, we were unfortunately not able to discuss the events leading up to the criminal charges filed Monday. I don't believe any of us can truly imagine the conditions at Memorial Medical Center in the days following the hurricane. The fact that she was there, taking care of patients rather than safely evacuated with her husband, reflects the deep committment she felt to her patients and is consistent with what I know about her.
In my mind, this case is all about whether or not the intent of administering morphine was to alleviate suffering or to cause death. If the purpose of administering morphine was to treat pain or aleviate suffering, then doing so is permissible even if respiratory depression and hastening of death is a forseable consequence. This ethical position is termed the 'Principle of Double Effect.'In normal practice a hospital ethics committee would be asked to help make these evaluations. Dr. Pou had no such resource available to her.
I'll be writing more about his case as information comes out.
Sunday, June 11, 2006
VA Physicians Data Apparently Also Lost
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A laptop containing names, social security numbers, and dates of birth on 26 million veterans was stolen from a VA employee's home on May third. Though extremely concerning, I had no reason to think my data was on that laptop. After all, I'm not a Veteran. A letter arrived yesterday informing me that "[a]s a result of this incident, information identifiable with you was potentially exposed to others." I've worked at the Veterans Administration providing anesthesia care. I can only assume that the laptop contained more than just data on 'veterans and some spouses' but some physicians as well.
I must say I'm surprised by this breach of security. In my experience with the VA, their IT security policies were among the most rigorous and thorough.
Friday, June 9, 2006
Two Google Firefox Extension: Browser Sync and Notebook
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Let's say you're like me use hospital computers a great deal. There are some neat tools you should know about to make hospital computers feel more like home. Here are my suggestions:
1. Use a USB thumb drive and install Portable Firefox.
Every hospital computer I've ever used has Internet Explorer as the default browser (sigh). Most don't allow you to install your own software. Having a USB thumb drive with your own lean, mean, pop-up blocking copy of Firefox gives you the browser preferred by nine out of ten dweebs. Any extensions you install are on the USB drive and travel with you. Lifehacker has a nice article on this. Speaking of extensions...
2. If you haven't already done so, get a Google account.
3. Install the Google Browser Sync Extension for Firefox.
I may get around when it comes to using lots of computers, but I do have a first love--my Apple MacBook. (The mooing sounds it makes are just so endearing). And that's where I spend most of my computer time and subsequently have the best organized set of bookmarks. The Browser Sync Extension synchronizes bookmarks, history, persistent cookies, and saved passwords between computers. For more on the security implications, see Lifehacker...
4. Install the Google Notebook Extension for Firefox.
I will occasionally find web content when I'm at the hospital that I want to look at when I get back home. The Notebook extension adds an additional contextual menu option to 'Note This...' which adds the page title, URL, and selected text to my Google Notebook where I can read it later.
5. Set up your Google Home Page and add the Body Mass Index and Allowable Blood Loss modules!
Sunday, June 4, 2006
NEJM CME: Body-Mass Index and Symptoms of Gastroesophageal Reflux in Women
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CME: Body-Mass Index and Symptoms of Gastroesophageal Reflux in Women
"Conclusions: BMI is associated with symptoms of gastroesophagealreflux disease in both normal-weight and overweight women. Even moderate weight gain among persons of normal weight may cause or exacerbate symptoms of reflux."
Thursday, May 25, 2006
Top 10 Causes of Death Worldwide
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Top 10 Causes of Death Worldwide:
"[F]or high-income countries:
1. Heart disease
2. Stroke
3. Lung cancer
4. Lower respiratory infections
5. Chronic obstructive pulmonary disease (COPD)
6. Colon and rectum cancers
7. Alzheimer's disease and other dementias
8. Type 2 diabetes
9. Breast cancer
10. Stomach cancer
Here is the list for low- and middle-income countries:
1. Heart disease
2. Stroke
3. Lower respiratory infections
4. HIV/AIDS
5. Fetus/newborn (perinatal) conditions
6. Chronic obstructive pulmonary disease (COPD)
7. Diarrhea
8. Tuberculosis
9. Malaria
10. Road traffic accidents "
[Via WebMD Health Headlines]
Wednesday, May 24, 2006
Pennsylvania's Health Care Crisis has NOT 'turned the corner'
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Our Governor is quoted as saying that Pennsylvania's health care crisis has turned a corner. It has not and as evidence I point you to the following article about a Cardiology group in Philadelphia that will no longer provide coverage at one health center there:
"Frankford Health Care System, which is already getting ready to discontinue maternity services at its Torresdale division, is losing another group of specialists at its Frankford campus in another departure tied in part to Pennsylvania's high medical malpractice insurance costs. --Philadelphia Business Journal"
Imagine you're, say, a plastic surgeon. There used to be fifteen of you on staff at a hospital so you took ER call only two days per months (as a precondition for maintaining staff privileges). Well, because of a malpractice crisis that has NOT turned the corner there are only three of you now. That's ten days of ER call each month. Kinda forces you to ponder whether maintaining staff privileges is worth is, doesn't it? And if you decide it's not, then patients loose access to yet another specialist at the hospital. See where this goes?
If it's not one virus, it's another
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Bird flu has been very much in the news, but now another type of virus is also threatening: chikungunya virus (named with a Swahili word meaning 'bent up').
"The chikungunya virus has infected around one-third of the population (about 250,000 people) on the French island of Réunion since early 2005. It has also hit the neighbouring islands of Mauritius, Seychelles, Madagascar and Mayotte, and reared its head in India."
With only a little over 200 deaths it's not near as big a killer as H5N1 might be, but it would wreak havoc nonetheless. Fevers over 102 and arthralgias. Yuck.
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Jun Oct
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