Tuesday, February 7, 2006
Smoking Cessation Before Surgery Encouraged
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"According to a new comprehensive review of existing studies in the February issue of Anesthesiology, surgical patients who are nonsmokers, or who stop smoking prior to surgery, tend to fare better in the recovery period than smokers. This is in addition to the benefit seen during the actual surgery, when anesthesia is safer and more predictable in nonsmokers due to better functioning of the heart, blood vessels, lungs and nervous system.
Add to all of this another bonus: smokers who have quit around the time of surgery may have fewer problems with nicotine withdrawal after the operation than they would have if they had tried to quit at other times. This may be due to medications and therapies commonly used during surgery and recovery, which may suppress nicotine withdrawal symptoms. Even if patients do have problems with nicotine withdrawal after surgery, they can safely receive help such as nicotine patches."
I think this is noteworthy because, in terms of complications, we used to think that one would need to quit smoking for at least six weeks before surgery for there to be any benefit. Though that may still be true, this review seems to indicate that if someone were to quit around time of surgery, their chances of success are better.
[via Newswise]
Sunday, February 5, 2006
Pennsylvania Doctor's Advocate
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An organization called Doctor's Advocate is announcing it's first successful effort to stop a 'frivolous' lawsuit in Pennsylvania: Doctor's Advocate Terminates First Frivolous Medical Malpractice Lawsuit; Case Against OB-GYN Dropped in Seven Weeks:
"Dr. Coslett-Charlton's case stemmed from an incident earlier in 2004, when she met with a woman late in pregnancy for the first and only time. After an examination revealed drastic complications, she sent the patient directly to the hospital. The doctors at the hospital took over treatment of the patient. The patient later sued several doctors including Dr. Coslett-Charlton."
Here's the background on the organization: "Doctor's Advocate works to reverse the medical malpractice crisis and keep doctors in Pennsylvania by raising public awareness, lobbying for legislation to produce tort reform, and combating frivolous lawsuits with an inexpensive legal service."
Looks like being a member costs $1200 per year.
Are Lower Back Tattoos A Contraindication To Labor Epidurals?
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My Google News section on 'epidurals' came up with an interesting hit: Lower-back tattoos are popular with women, but do they make having epidurals during childbirth more dangerous?. It's a very good question because, at least in my practice, lower back tattoos are extremely common in laboring women. So common, in fact, that Saturday Night Live has a commercial parody for a product called Turlington's Lower Back Tattoo Remover (quicktime | windows media).
I was taught to avoid putting an epidural needle through tattooed skin and have gone to great lengths to do so. For example, one patient had a very large tattoo of what appeared to be the face of the devil on her lower back. On closer inspection, I noticed that the devil's right nares (which was free of tattoo ink) was right over her L3-4 interspace. I wished I'd taken a picture of that epidural catheter snaking out of the devil's nose.
I can't seem to find much science on the subject save for one abstract which makes a very reasonable suggestion to avoid coring out tattooed skin by making a small incision, if necessary. This may sound like a lot of trouble, but all it takes is a 16 gauge (or similarly large) hypodermic needle inserted into the skin first, then the epidural needle through that 'incision'.
High Tech Noise Canceling Stethoscope
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Also via A Chance To Cut is a Chance to Cure, a pointer to a new stethoscope: 3M Littmann Electronic Stethoscope Model 3000
Listening to a patient's heart and lungs before anesthesia is something I don't do nearly enough. This may just be the gadget that makes it fun again...
Music Not To Play in the OR
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A Chance To Cut is a Chance to Cure points to a cartoon or music that may not be right for the operating room.
It reminded me of a post at my first blog (which I'm reposting below):
A colleague pointed out to me that there are certain songs one should probably not play, or at least not while the patient is awake. What follows is his list of songs not to play while the patient is awake (with iTunes Music Store links where possible):
- Don't Fear The Reaper
- American Pie
- Stairway to Heaven
- Hurts So Good
- Knocking On Heaven's Door
- First Cut Is The Deepest
- Paralyzed
- Everybody Hurts
- Like A Surgeon
- Maxwell's Hammer
Wednesday, February 1, 2006
Pandora's Box Of Music
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It looks to me like this would solve the OR's music problems. Staff could pre-program their favorite station and just log in from an operating room computer...as long as that wouldn't interfere with online shopping...
Sunday, January 29, 2006
Influenza Map--through Jan. 14, 2006
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Tuesday, January 24, 2006
No Trasylol For Me or My Patients, Please
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Trasylol (Aprotinin) is a very expensive drug used during many kinds of cardiac surgery to reduce blood loss. In today's print edition of the NEJM (but not online yet) is a very important article by Dennis Mangano (very, very smart anesthesiologist) which shows an "association between aprotinin and serious end-organ damage" including doubling the risk of renal failure requiring dialysis, a 55% increase in the risk of MI or heart failure, and a near doubling of the risk of stroke or encephalopathy. The good news is that there are alternative drugs which cost one tenth as much and are also very good at reducing the need for blood transfusion. More soon....
Saturday, January 21, 2006
In advocating for patient safety, be forceful but not 'disruptive'
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Is whistleblowing worth it?
"What would you do if you discovered that conditions at your hospital posed a threat to patient safety? Let's say you reported the problem to your supervisor, and got no response. Would you then go to the hospital's administrator or CEO? Say you do, but he also refuses to deal with the problem. Then what? Would you file a formal report, or contact state or federal health officials?
If you do decide to blow the whistle, chances are you won't be rewarded for your efforts. In fact, you're more likely to be labeled a troublemaker or "disruptive physician." And if you persist in pursuing your cause, you could risk losing your staff privileges or your job. "
Can damage caps influence premium growth and physician supply?
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The Impact of Caps on Damages: How are Markets for Medical Liability Insurance and Medical Services Affected?
"[This report] provides a summary of research on the impact of caps including those on punitive and total damages in addition to those that apply only to non-economic damages. Our focus is on those papers that employ statistical techniques to control for potentially competing explanations of changes that are observed when simple descriptive statistics are used."
and concludes
"the body of research on the impacts of tort reform shows that caps have resulted in lower growth in medical liability losses in states that passed caps than in states that did not. The more recent literature on premium effects has found that caps result in lower premium growth. And, two very recent papers based on sufficiently many years of the AMAâs Masterfile data have found that non-economic caps and direct tort reforms more generally have a positive effect on the number of physicians per capita in a state."
Insurance Profits Don't Explain Malpractice Crisis
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The American Medical Association has released a new article which takes to task the so-called 'Angoff Report' which claimed that the medical liability insurance crisis is caused by insurance companies booming profits, overcharging physicians for coverage, and ballooning surpluses. It refers to two subsequent analyses which point up the flaws in the approach used by Angoff. Revised analysis shows the growth rate of insurance company surpluses was only 3.9% per year, and they were profitable in only one year (2004) when they made 5%
Thursday, January 19, 2006
Or Their Designee...
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If you read your consent for surgery, you'll see those words right after your surgeon's name. Maybe you've noticed them. Probably you haven't.
Ghost surgery is defined as "substitution of an authorized surgeon by an unauthorized surgeon or the allowance of unauthorized surgical trainees to operate without adequate supervision". Now, that definition is sufficiently vague to allow all manner of stuff to go on, but I would wager that if you asked the patient wether they were under the impression their surgeon would do the entire surgery, that they would say 'yes.' If I ask surgeon W to do my surgery, I'd like surgeon W to sew the skin closed, too. Residents can practice closing just fine in partial-task simulators.
Wednesday, January 18, 2006
Anesthesia Blood Loss
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Anesthesia-related blood loss almost never exceeds surgical blood loss...but it can. I recently had a case where the IV tubing became disconnected from the IV hub during a case. The blood pressure cuff was on the same arm, and the intermittent tourniquet effect of the cuff cycling served to increase venous pressure sufficiently to cause blood to flow backward and out the now disconnected IV.
But wait, there's more. The patient was receiving the medication that kept her asleep through her IV and the disconnect put her at very real risk of waking up or having awareness in the middle of her surgery. This apparently did not happen in this case based on my interview of the patient in the recovery room, but it surely could have.
This misadventure would have been entirely avoided by the use of IV tubing with a locking hub (often called a Leur-Lock connector) connecting the IV tubing to the IV hub. In our case, someone decided the locking connectors were not worth the extra cost and our connections were just slip fit (no lock). How many times should this happen before the equipment is changed?
This has happened many times to my colleagues and I (though usually not with such blood loss), each time we complained, were told it was being looked in to, but kept getting the same connectors. I took the above rather striking photograph to some clinical managers, who agreed we needed to change, and said that they had already ordered the new tubing. Until it arrives, I'm starting IV's myself so that I can use locking connectors.
Wednesday, January 11, 2006
Medpundit Looks At His Financials
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Ugh: I just spent the better part of the afternoon...:
"Ugh: I just spent the better part of the afternoon doing my least favorite task - reveiwing the financials of my practice. It doesn't look pretty. With Congress electing to decrease my pay by 4%, and my malpractice premium set to increase by 30% you can see it's not going to be a good year. The cost of supplies has been steadily going up, too, as have the cost of services. My medical waste haulers upped their fees by 20% in the past six months due to rising gas prices.
The Medicare cut may not sound like much, but it translates into a loss of about $2-3 per patient visit. And it isn't just limited to Medicare patients. Insurance companies base their rate of reimbursement as a percentage of Medicare fees. They might, say, pay 110% of whatever the fee Medicare pays. A practice that sees 25-30 patients a day will make $50-$90 less a day in 2006. That adds up quickly. Assuming a five-day work week, that adds up to $13,000 to $23,000 less over the course of the year. And despite what you might read in the newspapers, the majority of patients who pass through a doctor's office have health insurance - so the cut goes across the board.
How does that translate into day to day life? It means that my staff didn't get a cost of living raise this year. It means that I'll have to drop their health insurance if the premiums increase. And it means that I'm working harder - double booking patients when I can and adding an extra half day to my work week. Hopefully, I'll break even and avoid a decline in my own wages."
Wednesday, January 4, 2006
Antibiotic Resistance In Terms I Can Understand
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Penicillin and Amoxicillin's days are numbered
"Researchers from the University of Rochester started with the analysis of data from 11,426 children who has suffered a common throat infection.
They found that 25 per cent of children given penicillin, along with 18 per cent given amoxicillin treatment needed further treatment within weeks.
The data, taken from 47 studies from the past 35 years looked at the effectiveness of various drugs on treating strep throat in children.
Additional results revealed that of those given older-generation cephalosporin antibiotics, 14 per cent had to return for more treatment, while just 7 per cent prescribed newer versions like cefpodoxime and cefdinir, given for just four or five days, had to go back to the doctor. "
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