Friday, October 31, 2014

All About That Bass? What About All That Diabetes And Cardiac Disease?

Yeah, my mama she told me don't worry about your size
She says, "Boys like a little more booty to hold at night."
"All About That Bass" by Meghan Trainor

From the Centers for Disease Control:

The Ebola Hysteria. Where Is The Next Ryan White?

The New York Times reports that the medical staff at Bellevue hospital who are treating Dr. Craig Spencer, the physician who contracted the Ebola virus while working in Africa for Doctors Without Borders, have been shunned and discriminated against throughout the city, even within their own hospital. Businesses have asked them to leave when they find out they are employees of Bellevue. Some nurses who moonlight at other facilities have been told their services would no longer be needed.

Unfortunately, this panic among the general population, and even within the medical community, has been promulgated by the clumsy handling of the issue by the government and specifically the Centers for Disease Control. On their very own website, the CDC states the Ebola virus can only be spread by direct contact. It is transmitted through body fluids or a needle puncture with a contaminated needle. It is NOT spread through the air, by water, or with handling of food. Yet this important information has not been aggressively emphasized as the government has pursued people all over the country who may have flown on a plane that on a previous flight had carried an Ebola positive patient with a very low grade fever. Their mandatory 21 day quarantine also reenforces in people's minds that Ebola is so easily transmittable and so deadly that even people who have tested negative for the virus need to be isolated even though they show no evidence of being infected.

If all of this sounds familiar, then you are right. Back in the early 1980's, America was caught up in another viral disease panic. Its name was HIV. Like Ebola, HIV is not spread through the air or drinking out of the same water fountain. It is now well known that HIV is only transmitted by body fluids or contaminated needles. But at that time, the government's mishandling of the situation led to massive discrimination against HIV patients.

HIV remained in the public conscious as a disease of the damned: the homosexuals, IV drug abusers, and the prostitutes. It was not until a young Ryan White from Indiana came along that put a personal face on the disease. Ryan was a boy with hemophilia. He caught the virus through a blood transfusion at a time when blood wasn't tested for HIV. He faced horrible and ignorant intolerance from children and adults alike. He was banned from attending school. Their family car was vandalized. Store clerks would throw change at his mother to avoid coming in contact with her hands.

Back then, HIV was much more prevalent than Ebola is now. People were familiar with the images of skeletonized HIV patients. There were hundreds of HIV patients in the big cities, making them easy fodder for the major TV news operations of the country. Yet it took the courage of one young man to finally make the country understand that a person who has contracted a disease should be treated with compassion, not as a pariah. With the help of the medical community and the government, people got educated on how HIV is really spread, not just basing their fears and rumors and hearsay.

Ebola is currently in that same early stage of awareness as HIV where people are more fearful of the unknown than the reality. Heaven forbid Ebola will one day reach the same prevalence as HIV. But if it does, we will at least have experienced a similar teaching moment to fall back on and not make the same mistakes all over again.

Thursday, October 30, 2014

Why Nurses Have Bigger Cojones Than Doctors

Physicians can be such wimps. You would think that a group of people as smart as doctors would be natural leaders in society when it comes to making medical decisions. Yet we are pushed around by lawyers and politicians with nary a complaint even though we furtively grouse about our predicaments behind the closed doors of doctors lounges. Meanwhile, when nurses feel they have been wronged, they let everybody know about it.

The latest example is Kaci Hickox, the nurse in Maine who had just returned from Sierra Leone after taking care of Ebola infected patients. The state wants her under "voluntary" quarantine for three weeks even though she has tested negative for the virus and exhibits no fever or other signs associated with the disease. Like a good New England rebel, she has defiantly resisted this rule, even riding her bicycle out in public. She claims it is unconstitutional for the state to keep her locked up in her home out of fear and without any evidence.

This follows the defiance of nurses at Brigham and Women's hospital in Boston (must be something about New England that breeds dissenters) who are suing the hospital over forced flu vaccinations. The hospital has called for termination of their jobs if they don't get the shot. The hospital is demanding the vaccinations despite the fact that there is little evidence the vaccine actually prevents the flu or that it is necessary for healthy young people. Besides the lack of efficacy, the vaccine has real potential complications that can lead to a lifetime of disability, like Guillain Barre.

Meanwhile doctors just complain to each other about how difficult our professional lives have become because our decisions are being made by others, usually not even in the medical field.  Instead of doing something about it, we, and our professional societies, continue to kowtow to sharper legal and political minds as we trudge through our daily grind.

Doctors should be leading the charge against mandatory quarantines where there is no evidence of illness. Physicians should be educating the public about why the flu vaccine may not actually prevent the flu and can lead to crippling illnesses. But we don't. How pathetic is that?

What Are The Most Common Anesthesia Complications?

Pardon the profusion of lists on this post but there are some really fascinating data here that every anesthesiologist should read. The Doctors Company, a national medical malpractice insurer, compiled a list of anesthesia claims between 2007 to 2012. A total of 607 cases were identified. Their most common anesthesia complications leading to claims were:

1. Teeth damage-20.8%
2. Death-18.3%
3. Nerve damage-13.5%
4. Organ damage-12.7%
5. Pain-10.9%
6. Cardiac arrest-10.7%

The most common allegations of malpractice against anesthesiologists were:

1. Improper performance of anesthesia procedure-25%
2. Tooth damage related to intubation and extubation-24%
3. Improper management of patient under anesthesia-19%
4. Failure to monitor patient's physiologic status-3%
5. Positioning-related-3%

And what are the improper performance of anesthesia procedures that people are suing for?

1. Injection of anesthesia into the spinal canal-37%
2. Intubation of respiratory tract-35%
3. Injection of anesthesia-peripheral nerve-20%
4. Injection of anesthesia-sympathetic nerve-3%
5. Nasopharyngeal intubation-2%

The average payout for anesthesia related complications was $309,066. That compares poorly with the average for all other physicians, which was only $291,000. However anesthesiologists are right in the middle of the pack in a list of other specialties. Pediatrics had the highest indemnity with well over $1 million while ENT had the least with under $200,000.

There is a lot more information from The Doctors Company study than is presented here.

Our Hospital's First Ebola (Computer) Virus Scare

Our hospital recorded its first ebola scare today. A woman came in for a routine outpatient procedure. She has been coming to us regularly for months so nobody was especially on guard about any potential health hazard with this lady.

When we opened her electronic medical record, a stunning display popped out. Right at the top of the page, in bold red background lettering, the computer had declared she was positive for the ebola virus. A minor panic nearly ensued as everybody started scrambling for protective gear and wondering how we would all get along as roommates for the next 21 days in quarantine.

Then cooler heads prevailed. A quick call to the IT department confirmed that this was an error. In fact, if we had looked up every patient that was in the hospital at the moment, they all had the same ebola warning. The department was inserting new programming into the system for the diagnosis of ebola, which didn't exist before. Somehow it had crossed over into the live system and infected every patient's chart (pun intended).

After that we all gave a big sigh of relief and laughed at the stupidity of IT. Now we can go back to ignoring the big bold warnings about our patients with MRSA, VRE, MDRO, etc...

Wednesday, October 29, 2014

Anesthesiologists Need To Work Out These Muscles

You know that tired feeling you get after a long day of intubating patients? That sore aching sensation in your lanryngoscope lifting arm that has you popping Advils by the mouthful by the afternoon? Well now somebody has gone ahead and determined which muscles are causing you so much grief.

A study in the British Journal of Anaesthesia has determined which muscle groups an anesthesiologist uses the most rigorously during intubations. They used a surface electormyograph to compare the muscle activity of ten anesthesiologists as they intubated a mannequin using either a Glidescope or a regular Macintosh blade.

Glidescope 
They found that the Glidescope allowed for less muscle exertion compared to a Macintosh overall. But it was most significant in the anterior deltoid, posterior deltoid, upper trapezius, and brachioradialis.

So before the next time you start having tender and aching left sided upper body pain, you may want to ask your department to invest in a video intubation system. Or risk having an anesthesiologist file a disability claim against the group for not providing adequate equipment to do his job. Or maybe you just need to hit the gym more often you girlie man. Yah.

GI Doctors Want To Make Their Patients Less Safe During Procedures

This is pretty freaking unbelievable. Despite the fiasco of the death of Joan Rivers during a routine endoscopic procedure under sedation, some gastroenterologists want to provide even less monitoring of their patients. Some GI doctors are resentful of ASA guidelines to improve patient safety during a procedure. The ASA has declared that all patients under sedation, even "only" moderate sedation, must have their end tidal CO2 monitored.

Apparently even this minor inconvenience is too burdensome for some GI to take. A paper was presented recently at the American College of Gastroenterology Scientific Meeting that tries to refute the necessity of capnography for ASA 1 or 2 patients under moderate sedation for colonoscopy. The study claims that there is no benefit to capnography for this patient population.

According to Dr. Paresh Mehta, the author of the study, the ASA has "mandated something without any evidence of benefit with moderate sedation. Yet capnography increases the cost of colonoscopy because all endoscopy centers have to purchase these devices and specialized nasal cannulas. You have to train your staff how to use the device because not everybody is familiar with looking at wave forms and making decisions off that."

You can practically hear the derision of the ASA from the statement. But Dr. Mehta's so called evidence based practice is so short sighted it's almost malpractice. Anybody with any experience with oximetry and capnography knows that the two instruments work best when done in tandem. Pulse oxes are great for detecting hypoxia before the patient becomes cyanotic. But they also have a lag in their reading. Depending on a patient's pulmonary status, a patient can be apneic anywhere from 30 seconds to two minutes before the pulse ox starts trending downward. Once the numbers start dropping and resuscitation is begun, there is a very scary period where the numbers continue to drop as the pulse ox lag starts to catch up with the real oxygen saturation. It is during this frantic hypoxic episode that a patient can suffer a cardiac arrest or stroke. If capnography is present, a patient's apnea can be detected and corrected immediately. Isn't preventing these potential complications alone worth the price of having a another monitor in an endoscopy center?

GI docs may also be lulled into thinking ASA 1 and 2 patients are chip shots to sedate. Anesthesiologists know that any patient can have respiratory distress regardless of ASA status. Maybe the patient has an undiagnosed sleep apnea. Perhaps they are taking medications at home that make them more susceptible to sedatives but they didn't disclose that information to the doctor. Just because somebody is an ASA 1 doesn't make them immune from an anesthetic catastrophe.

Finally it doesn't seem right that not all patients are getting the same level of care when it comes to safety precautions. The endoscopy center already owns capnography monitors for their other procedures. Why not use them on all patients getting sedation? Why discriminate one group of patients from another? Imagine how a GI will respond to a malpractice lawyer asking him why a patient died from respiratory distress because the patient went apneic for too long before being detected and capnography was available but not used, "But I read a study that said capnography is not necessary during a colonoscopy." Better whip out that checkbook right then and there.

Obviously the main reason GI doesn't want to use capnography is mentioned in Dr. Mehta's statement; they don't want to spend the money. They don't want to have to buy the equipment. They don't want to have to train people on how to use it (though today's equipment is as simple hooking it up to the patient and turning it on. Not rocket science). Surgery centers are all about cash flow and profits. That's why they don't want any anesthesiologists or their pesky safety equipment to keep them from their assembly line of endoscopic examinations.

The AGA should be ashamed of presenting a study like this that advocates expediency and profits over patient safety.