Saturday, December 31, 2005

America's "Bottom 10"?

There's an interesting challenge that has been issued by Alexandra at All Things Beautiful -- it seems that British historians have put together a list of the ten worst Britons in the last 1000 years, one for each Century, for the BBC History Magazine. Since one good list deserves another, Alexandra decided to issue A Challenge To The Blogosphere: 'The Ten Worst Americans' List:

It is very interesting how a few names are emerging as a constant. On everyone's lips and the number one favorite is Benedict Arnold, very closely followed by Jimmy Carter, Joseph McCarthy, Richard Nixon, George Soros, Aaron Burr, Julius and Ethel Rosenberg (no particular order). Jane Fonda has appeared on quite a few lists, and so has George Bush, J. E. Hoover, John Kerry, Lyndon Johnson and Alger Hiss.
Given my lack of proper attention to anything meaningful in my decadent youth, I defer the nomination of historical figures to, well, those bloggers who read something other than science fiction in high school (I'm trying to catch up; at least I read Atlas Shrugged when I was 15!.). It's kind of fun to peruse the thoughts of bloggers coming up with names -- sometimes of folks I would not have necessarily thought of as among the "worst." The lovely Atlas, for example, listed Robert E Lee ("His military genius actually prolonged the agony of the Civil War") and John Sherman ("author of the >Sherman Anti-Trust Act, 15 U.S.C. Crucial turning point in the descent of the American economy was the passing of anti-trust laws").

From a purely contemporary standpoint, I nominate Arthur O. Sulzberger, Jr., publisher and chairman of the New York Times. Since the time I was old enough to read the paper, the "Gray Lady" has steadily been given over to the mad rantings of the far left in this country. A sane man would have long ago sent MoDo and Krugman packing, to follow Howell Raines into obscurity. By extension, I would have to state that the majority of these folks should be nominated to round out my "bottom 10," especially Gail Collins, the editorial page editor. The shrill, anti-American, anti-anything-positive-about-Bush/GOP, heavily Democratic Party-biased nature of the editorials have led many to follow the advice of a friend of mine: "I read the NY Times editorial page just to find out how far left the Democratic party will lean this week."

On the other hand, I'd like to name Will Shortz, the crossword puzzle editor at the NY Times, as a personal fave --- I can't get through the week without a challenging Sunday Times crossword.

UPDATE: Perhaps even the NY Times' public editor might agree with me (just a little bit). Hugh Hewitt may as well:
Perhaps by January 2, 2007 the New York Times will have gotten around to admitting that its reputation as a reliable reporter of facts was lost long before Jason Blair and has never been recovered, that Maureen Dowd and Paul Krugman are jokes among most center-right Americans and a good portion of the left as well, that Valerie Plame has always been a non-story, that leaking of top secret surveillance programs of al Qaeda conducting surveillance on it sagents in America etc etc etc was the problem, not the rise of a new information network.

Friday, December 30, 2005

'Coaching' in labor makes little difference, UT Southwestern researchers say

Does this mean that expectant dads should go back to smoking cigars in the waiting room?

Tuesday, December 27, 2005

80 hour week Redux

This month's American Journal of Surgery contains an interesting article from the Dept. of Surgery at Baylor in Houston entitled Impact of the 80-hour work week on resident emergency operative experience. As I have written previously, I am not convinced the 80 hour work restrictions will deal an even hand to surgeons in training, or their future patients.

The current study is a retrospective comparison of the emergent operative experiences of PGY-4 and PGY-5 residents before (group 1) and after (group 2) imposition of work hour restrictions. Similar to a previous study published in JACS (reviewed extensively by Dr. Bard Parker), overall operative numbers were essentially unchanged between the two groups. However, the residents' "numbers" were preserved by increasing performance of less complex, less emergent procedures that were previously performed by more junior residents:

The mean total of procedures per resident as primary surgeon was similar between the groups. However, a qualitative analysis of the level of technical complexity of laparotomies showed an obvious shift from advanced to basic procedures: a resident in group 2 (after work hour restrictions) performed, on average, 40% fewer advanced laparotomies compared with those in group 1. In addition, there was a concomitant 44% increase in the mean number of basic laparotomies done by residents in group 2.

(in the comments section) In other words, senior residents are now preserving their "numbers" by encroaching on the operative experience of their juniors. The long-term consequences of this phenomenon are obvious and must be addressed.
Additionally, there was a dramatic drop in the residents' experience acting as first assistant or as teaching assistant in major emergent operative procedures:
An 82% reduction in the opportunity to participate as a learning first assistant in a major abdominal trauma procedure means that a senior resident will often be called upon to do a major trauma case without ever having had the opportunity to see one. Similarly, fewer cases done as teaching assistant translate into less opportunity to develop operative independence and technical self-confidence. Surgical training is thus evolving into a "read one, do one" situation.
While some may not feel that decreased operative experience is necessarily a bad thing (I don't share that view), what was more striking was the change in continuity of care.
The total number of cases that required a return to the operating room for another procedure during the same hospital stay remained the same throughout the study period. However, in group 1, 60% of reoperations were performed by the same resident who did the original procedure. This percentage dropped to 26% in group 2.
I have always felt that continuity of care is one of the most important hallmarks of general surgery; basically, the surgeon shoulders the responsibility to see his or her patient through the perioperative period, and be the one responsible for returning the patient to the OR in the case of an adverse event if at all possible. In fact, the surgeon's ability to deal with postoperative complications is perhaps his/her most important asset. If residents are only taking their own patients back to the OR a quarter of the time, they are missing out on what I would consider a critical part of their education. From the article's abstract:
Conclusions: The ACGME regulatory environment is adversely affecting the emergency operative experience of surgical residents. Our findings underscore the need to develop alternative methods to augment the residents' operative experience.
For another perspective, Dr. Parker has had other interesting posts about this subject -- here, here, and here.
Experience is the worst teacher; it gives the test before presenting the lesson.
Experience teaches only the teachable.
—Vernon Law

Grand Rounds -- The Last of '05

Matthew Holt is hosting the last Grand Rounds session of 2005 at The Health Care Blog; it's a good roundup of this year's medical blogging.

This is a special edition as it’s the last of 2005 and so I’ve asked my fellow bloggers for their best posts of 2005. For some of them, like any great soccer player whose best goal is their last, their best post is their most recent. But for many we’ve gone back into the archives. There’s some great stuff, and some great series of posts too. So let me act like the consultant I am and put it into sections, and act like the blogger that I also am, and give you some not so unbiased commentary. Oh, and it’s pretty long with some nearly 60 posts mentioned. But you weren’t doing anything else this week, were you? So settle in and enjoy.
It's worth the time to read, as there are a lot of great posts to be seen!

Saturday, December 24, 2005

Glass Half Full

Some time ago, I wrote a post about the Porkbusters effort that has been supported by a number of folks across the blogosphere. I feel it is high time that our congressional representatives take a stance against the astounding degree of wasteful "pork" spending that gets tacked on to otherwise needed legislation. The best analogy I can come up with is this:

Imagine you are a new father, with bills to pay, a baby to feed, and diapers to buy. Your wife sends you out to the grocery store to pick up those few items that you [a] need and [b] can afford. If you act like a US Senator, you promptly call 99 of your drunk frat brothers to join you, who then load the grocery cart with every last item that they desire....because they are not paying for it. Beer, chips, soda, guacamole dip, a big screen TV, etc., all of the great things you could have if you had an unlimited budget; and all on your tab, sometimes without the money left over to buy the things you truly needed.
Now, imagine the hell you'd catch when you got home with an empty wallet and with your buddies taking home the goodies to their houses! I can tell you SWIMBO would be so mad it would be hot tongue and cold shoulder for dinner that night, and every night for a good year. It is amazing to me that the US taxpayers don't respond in the same manner, and that we accept the idea that "pork" in legislation is simply a fact of life. It. Does. Not. Have. To. Be!

I wrote my two Senators, asking them to support the Fiscal Watch Team Offset Package --- which basically says that we need to cut out the extras in order to pay for true national needs, such as Katrina relief. One has finally responded, and although he did not specifically endorse the Porkbusters effort, he did state (emphasis mine):
"In short, I will be open to any and all proposals that will effect greater discipline. If we must change Senate rules, current law, or even amend the Constitution to instill fiscal discipline in this process so be it."
Ok. The glass is half full. Perhaps we may be able to get Congress to change its rules so that last minute spending does not get tacked on to, for example, a highway bill. Perhaps pigs will fly too, but one can hope. In this era of easy communication with your congressional representatives (believe me, you and your internet savvy friends can send a lot of emails), it's time to put the pressure on those folks, and keep them out of your grocery basket.

Tuesday, December 20, 2005

The Death Star of American Medicine

I wish I had written this (JCAHO Unplugged; registration required), because it gives voice to the feelings that I (and probably 99% of the physicians in this country) have about the Death Star of American medicine -- JCAHO. A few excerpts (emphasis is mine):

That is why it really upsets me to watch the JCAHO people walk through my hospital like they were navigating a toxic waste dump. What upsets me even more is the utter paralysis of normal activity that occurs months before their visit and the huge sums of money spent on mock drills and consultants to prepare for the JCAHO invasion. JCAHO (the Joint Commission on Accreditation of Healthcare Organization) arouses more fear in hospitals than MRSA gone wild, and their "visit" has a greater institutional paralytic effect than circulating a neuromuscular depolarizing agent through the ventilation system.

A few unsigned verbal orders, or an anesthesiologist carrying a syringe of Anectine in his or her scrubs, or not locking up I.V. bottles of normal saline will result in conditional or provisional approval, and failure to take remedial action within 30 days may result in the death penalty, which for the hospital means bad PR, and more significantly, loss of all federal money. That's right, you can get the chair for parking tickets in the JCAHO world.

It doesn't matter that the hospital admits 50,000 patients a year, saves countless lives and performs daily miracles. Write q.i.d. twice and you can get your liver transplant someplace else.
A response by Russell Massaro, MD, FACP, Executive Vice President Accreditation and Certification Operations, JCAHO, follows Dr. Cossman's screed. The only thing I can say about it is that he makes clear that unannounced surveys will be forthcoming in 2006. Oh, joy!

A lot of the press in the past few days has been discussing issues such as oversight, accountability, and clearly expressed legal authority. JCAHO operates without any real semblence of these niceties, and does so with all the subtlety of a bureaucracy run by Darth Vader. Watching hospital administrators lose bowel and bladder control the minute a JCAHO inspection is brought up has always reminded me of Vader's underlings wilting in his presence --- and for good reason. Without the JCAHO seal of approval, they cannot operate an otherwise well-run, caring facility. The organization, as it was originally intended, was designed to ensure a basic level of safety for all hospitals. It has now become yet another "certifying" agency which must come up with new "critical" problems to fix in order to ensure its ongoing existence (those of you who have gone through the most recent mental masturbatory experience of banning QD and QID in orders know what I mean). What is most galling to me, however, is that hospitals must fork over a hefty sum for these frequent torture sessions, and the inspections are done not by practicing physicians or nurses, but by folks who long ago gave up the difficulties of actually caring for patients for the safety of a clipboard to hide behind.

Maybe I have my metaphors mixed up --- JCAHO comes in like the Death Star, but leaves no room for different institutions to solve problems in their own way. The JCAHO mantra can really be translated as "Resistance is futile. You will be assimilated!" As a result, I suppose JCAHO is really The Borg.

Grand Rounds

Medpundit is hosting Grand Rounds this week --- take a stroll over to her place and check out this week's best medical blogging!

Thursday, December 15, 2005

Purple Celebration


This photo is a cause for celebration, in Iraq, in the US, and anywhere people love freedom. (Tip of the hat to Lifelike Pundits)

Another Criminal Charge for a Colorado Health Care Provider

As noted in a previous post, manslaughter charges have been brought against a Colorado physician who removed a tracheostomy tube in a patient who subsequently suffered respiratory arrest and anoxic brain injury. While unusual, this incident was soon followed by another manslaughter charge -- this one against a nurse in Colorado:

A former nurse at the Denver veterans hospital is accused of killing an elderly World War II vet in 2003 when she disabled a machine monitoring the oxygen level in his blood. Carol Elkins was treating William Thomas Leslie when she disconnected a pulse oximeter, which resulted in his death, according to a federal indictment unsealed Tuesday.

Federal involuntary manslaughter charges were brought because this incident occurred at a VA facility, where federal authorities have jurisdiction. According to the article, federal authorities will be notifying state regulatory authorities.

Why does removal of this monitoring device matter, and what does it involve? Basically, a pulse oximeter measures how well a patient is receiving oxygen, and how well he is delivering that oxygen to his tissues. In the event of respiratory compromise or cardiovascular failure, the pulse oximeter will alarm to allow potential intervention. If the unit is disconnected, the patient may become hypoxic without anyone knowing. Pulse oximeters are used throughout the hospital in a variety of situations, and the newspaper reports don't specify why this patient needed one. As for its removal, the indictment does not state why the nurse would have disabled the unit; a "mercy killing" is not suspected.
The government contends that Elkins was bothered by noise from the monitor.
Interestingly, this incident was apparently not reported to the state health department, which is required by law. It was also not an issue with this nurse obtaining another job two years ago; a routine pre-employment check turned up nothing of substance:
Elkins was suspended Tuesday from her job in an adult medical unit at the Medical Center of Aurora, where she had worked for about two years, according to spokeswoman Beverly Husted-Petry.....She said there was no report of any alleged incident at the veterans' hospital.
Despite the lack of a report to the state health department, the family was able to press for, and receive, a civil settlement from the Dept. of Veterans Affairs. To make their case, prosecutors will need to have plenty of witnesses who will be able to back up their charge of "wanton and reckless disregard for human life;" or, as in the case of Dr. Hogle in my previous post, this may be a case of an error in judgement that led to a very bad outcome. Or, given the financial settlement from the VA, this could also have resulted from a "system issue," rather than the erroneous, or criminally negligent, actions of a single nurse. And if I was an ICU nurse caring for critically sick patients, I'd worry about the potential for criminal charges in the event of an unexpected death.

Tuesday, December 13, 2005

Grand Rounds

Grand Rounds are being held this week by Derek Lowe at In the Pipeline. Take a gander at the best of the medical blogs this week!

Not all slippery slopes in Colorado are at the ski resorts

Something interesting occurred in Denver, Colorado the other day -- a physician was arrested and charged with manslaughter. This is not a typical case of jealousy, financial problems, an auto accident, etc. He was arrested for something he did in the care of a patient. Obviously, all of the facts of the case are not well known, but there has been some new information come to light since the original charges were filed and noted in the news.

The physician, Dr. Greg Hogle, is a 56-year-old Denver ENT specialist. He was referred a patient with a tracheostomy tube in place, and saw her on April 8, 2005.

(another physician) referred the case to Hogle after concluding the patient likely needed surgery to repair blockage, court records show. She sent images of the blockage with the medical records. But Hogle told investigators that the patient was accompanied by a woman who had trouble translating from Russian to English. The doctor decided based on his examination to remove the tracheostomy tube, records show.
The patient, Khusni Yusupova, age 46, developed swelling at the tracheostomy site and therefore difficulty breathing after she left Dr. Hogle's office. She was taken to the hospital, but suffered significant anoxic brain injury before a new tracheostomy tube could be placed. She was taken off life support and died two days later.

So, what happened? Without the records, it's difficult to speculate; it does seem, however, that this patient had upper airway obstruction and was not able to breathe without a tracheostomy.
According to the Denver Medical Examiner report, the only way she could have breathed at the time of her death is through her neck.
It also appears that the treating physician did not adequately review the patient's history and records; the history was likely difficult to obtain due to translation issues.
Denver Police say Dr. Hogle admitted he removed the tube without reviewing Yusupova's medical records, which she had brought to the appointment.
So, based upon his examination, Dr. Hogle decided that it was safe to remove the tube -- this presumably involved an examination of the upper airway with a determination that it was patent enough to allow breathing through the mouth and nose, with no obstruction to air flow. He was wrong, and admits he made an error in judgement:
Hogle admitted to police, "I made a serious mistake." He went on to tell police, "she did need the tube for her airway...because she had an obstructed airway, it means she did need the tube and I made a mistake."
Criminal charges might seem to be unthinkable in delivery of medical care, but actually occur -- including relatively recently in Colorado.
In a highly publicized case, a Denver anesthesiologist was charged with manslaughter after prosecutors alleged he fell asleep during a routine surgery in 1993 at St. Joseph Hospital. The patient, an 8-year-old boy, died during the operation. After two manslaughter trials, the doctor, Joseph Verbrugge, was ultimately convicted of a misdemeanor, but that conviction was later thrown out on appeal. He was stripped of his medical license.
But there are other wrinkles to this case. To muddy the waters further, the coroner ruled the death a suicide. Why? Be cause this relatively young lady had a tracheostomy and an obstructed upper airway as a result of an attempt to take her own life.
The report doesn't dispute that Dr. Hogle's decision played a role in the death. However,the report reveals that the reason Yusupova had the tracheostomy tube in the first place was because she had " ... Ingest(ed) ... A caustic liquid (concentrated acetic acid) in a suicide attempt months earlier." Therefore, the coroner ruled "the manner of death is suicide."
What is interesting to me is the apparent lack of involvement by the Board of Medical Examiners, with criminal charges being filed before the BME has made even preliminary recommendations public. Under most circumstances, cases that appear to be egregious failures of judgement and care are rapidly dealt with by the Board. That process allows a complete review of the medical issues and facts, so that an appropriate action can be taken (see the case above where despite the anesthesiologist not being convicted, he was stripped of his license).

While I do not have at my disposal all of the case data, the fact that criminal charges have been filed, for an error in judgement in the delivery of medical care, is worrisome to me. All physicians make errors, just like the remainder of humanity. What about this case rises to the level of criminality? And as we stand atop that slippery slope, that is the crux of the issue. When I or one of my colleagues makes an error in judgement that results in death, will we too be criminally charged?

UPDATE: Colorado Medical Society President Dr. Rick May issued this statement about the charges against Dr. Hogle:
"In medical practice, bad things can happen to good people, and good doctors can and do make mistakes. These are not purposeful assaults. They are errors, however rare, that we all work very diligently to prevent. Medical mistakes are not criminal, clear and simple, and should never be dumped in the criminal justice system. Colorado's civil justice system allows our patients broad rights to seek redress through the courts, and the State Medical Board has full legal authority to discipline an errant physician, including license revocation."

Sunday, December 11, 2005

Reheating the Leftovers

I always appreciate nicely designed, well-executed studies that address a common problem in a sensible manner. Such is the case with a report in this month's Journal of the American College of Surgeons (subscription required, but abstract available). It comes from Turkey (hardly a major contributor to American surgical literature), and is the lead article this month --- "Use of Resterilized Polypropylene Mesh in Inguinal Hernia Repair: A Prospective, Randomized Study," by Asim Cingi, M.D., et al.

The article addresses the resterilization of polypropylene mesh, such as when only a portion of a larger sheet of mesh needs to be used for a given operation. The authors initially evaluated mesh that was manually manipulated, divided into smaller pieces, and resterilized. Sort of like reheating leftovers.Subsequent cultures proved to be negative, and tensile strength was only minimally altered. They then embarked on a double-blinded, randomized study, placing either "virgin" or divided and resterilized polypropylene mesh in patients undergoing first-time inguinal hernia repair. No differences were noted in either group (total 184 patients) with a median follow-up of two years.

OK, so what's the big deal? Actually, we're talking about a significant amount of cash, particularly in poor countries. Inguinal hernias are extremely common, and it has been very well-established that the recurrence rate for non-mesh repairs is unacceptably high (in adults), leading to lost work and productivity.....an even bigger problem in poor countries. If larger sheets of mesh can be "tailored" to be used in several operations, the costs to the health system in developing countries will be significantly lower. This might allow increased mesh use in those regions, lowering recurrence rates to about 2%. As my daughter would say, "cool beans."

What about here in the good old USA? Actually, this was done routinely back in the dark ages (when I was but a wee intern), but was subsequently abandoned, primarily over theoretical concerns with HIV infection. I would love to see a much larger similar study done here, with standardization of how the mesh is handled and sterilized, potentially to include resterilization of large sheets that are cut to size on the "back table." The specter of prion disease is also one that would have to be dealt with. I suspect the results would be similar; I also suspect that study will never be done here, due to potential liability issues (can you imagine the consent form that your local IRB would come up with?).

Disclaimer : I'm not just the president of The Mesh Club For Men; I'm also a client! I got my mesh in 2004!

Sunday Ear Candy

It's been a long weekend, and it ain't over yet! Oh, well, at least I got to sleep last night; tonight may very well be a different story. After two emergency laparotomies today, rounds, and spending time in medical records so the hospital will hopefully let me continue to practice here, the past hour has been spent on....paperwork! I am having fun, however, as I have a new 'puter, with great speakers, and I have loaded more than a few CDs onto iTunes. so, the drudgery of paperwork has been eased by the company of Yes, Van Morrison, The Kinks, Jeff Beck, John Wesley Harding, Elvis Costello, and the lovely lady Diana:



























At least I have a little ear candy to get me through the day. Even as someone who cannot carry a tune with a forklift, I have always loved music; fortunately, the surglings have inherited SWIMBO's talents, and can all play (quite well, if I may brag). I, on the other hand, can play the stereo with grace and accomplishment!

Thursday, December 08, 2005

CPOE Difficulties

Dr. Andy reviews a very interesting study about computer physician order entry, which has been found to be a bit troubling at one pediatric hospital. A cautionary tale, to be sure, but worth being aware of.

Wednesday, December 07, 2005

Tuesday, December 06, 2005

Catching up with Grand Rounds and the Medical Weblog Awards

I've been remiss lately in pointing anyone interested towards Grand Rounds. This week's edition has been put together by the always entertaining Dr. Charles --- well worth the time to read!

Additionally, Medgadget is taking stock of the medical blogosphere in a different way, asking for nominations for the 2005 Medical Weblog Awards. A very nice person was kind enough to nominate me --- why, given my recent lack of posting, I have no idea --- which is quite flattering!

Monday, December 05, 2005

Pandora and the NHS

I haven't much felt like blogging lately -- I blame it on a combination of excess turkey intake, too much work, and good old fashioned procrastination. While there are certainly a few posts percolating around the few remaining sulci in my frontal lobes, nothing has sprung forth in a frenzy of keystrokes (yet).

I did find something interesting recently while perusing the news, however. It is the kind of governmental decision that generates all sorts of interesting dilemmas, all under the guise of saving money and "doing what's right for patients." It will also generate rather intense debate, I suspect. Fortunately for those of us on the western side of the great Atlantic pond, this debate will be taking place in Great Britain. It seems that the National Health Service has issued a "guidance" to physicians permitting them to refuse to treat a patient if they judge that an illness is self-inflicted. It also appears that this directive has already been an undeclared policy for some NHS physicians:

The guidelines will be introduced as a poll shows that one in five doctors admits that he or she has already denied patients treatment because they drink heavily, smoke or are obese.
Wow. It seems that Pandora's box has been nicely untied and opened, not by the lovely Pandora herself, but by bureaucratic fiat!
Just as Pandora loosed a torrent of ills for humanity upon opening that crate, the potential ramifications of this decision may be quite far-reaching (and beyond the expectations of those who crafted it). To be sure, the obvious self-inflicted diseases can be, and frequently are, listed by any second grader:
  1. Smoking, with the potential sequelae of lung, oropharyngeal, and bladder cancer; COPD/emphysema; coronary artery disease; peripheral artery disease....
  2. Alcohol abuse, which may result in cirrhosis and liver failure; pancreatitis (acute or chronic....and eventual diabetes); alcohol-related accidents and injuries; withdrawal; depression.....
  3. Drug abuse, a culprit in hepatitis and liver failure; endocarditis; renal failure; severe dental problems (seen particularly in meth abusers)....
  4. Obesity, which can lead to diabetes; sleep apnea; heart disease; degenerative joint disease; depression; steatohepatitis;....
That's a laundry list of potential medical problems that some physicians may not feel bound to treat unless the patient chooses a different lifestyle. No one can argue that it is imperative for patients with these issues to take charge of their own health, quit smoking, stop drinking, lose weight, etc. It appears, however, that the real reason behind this decision is a bit less idealistic, and a bit more pecuniary in nature:
This weekend Sir Michael Rawlins, chairman of the National Institute for Health and Clinical Excellence (Nice) said the guidelines would ensure that the limited National Health Service budget was well spent.... He singled out alcoholics by saying the institute├é’s new social value judgments will make it clear that if patients continue to drink they will not be given a liver transplant....The Nice guidelines state that care cannot be denied simply on the grounds that a condition is self-inflicted. However, according to a draft of the code to be debated next week, the treatment can be withheld if the patient├é’s lifestyle affects the success or cost effectiveness of the operation.

I know that Sir Michael Rawlins must be in a difficult position, trying to help a nationalized health system be both a deliverer of good medical care and be fiscally responsible. Make no mistake, however --- this is health care rationing (which has always gone on in the British system), but it is doing so while singling out certain types of behavior which clearly cost the system a lot of cash.

One could easily argue that we in the US do this all the time --- the morbidly obese patient may be told to lose weight before having a total knee replacement, the smoker may be told to quit before the distal bypass can be done --- but it is hardly an official policy of our "system" as a whole. There is certainly no unanimity among American physicians about which patients should and should not receive certain types of therapies. Nor, I suspect, will there ever be.

Perhaps before the British (or we) embark on such a policy, it might be a good idea to expand the above laundry list, and look at a wider array of diseases that have a hefty self-inflicted component:

  1. Sexually transmitted disease from promiscuity -- including HIV, with all of its financial ramifications; HPV infection resulting in cervical cancer; STD induced infertility...
  2. Sporting activities --- leading to orthopedic injuries, head injuries, and later development of arthritic conditions requiring expensive joint replacement surgeries
  3. Tattoos and piercings --- associated with a higher risk of hepatitis
  4. Sun-worshippers and tanning salon users --- obviously risk development of skin cancers
  5. Loud music --- those who like to listen to "head banger heaven" on MTV are at a huge risk for hearing deficits in the future
  6. Political junkies --- risk mental illness and ulcer disease when their party leaders make boneheaded statements, and may get lund disease while inhaling the orations of political windbags

Yes, the last one was (a bit of) a joke. In the long run, it will be difficult to make such blanket decisions that affect only one type of self-inflicted disease. Those of you who are familiar with the legend of Pandora (ok, ok, I had to look it up!) will remember that she opened the box a second time, and released Hope. I would hope for a more market-based approach --- if patients are a bit more responsible for the financial costs of their health care, they may be more incentivized to change their behavior.

A few British reactions can be read at The Scotsman and at this pro-smokers' rights site.

Wednesday, November 30, 2005

Worth Every Penny

Slogging away at administrative duties -- meetings (ugh!; with administrators -- double ugh!!), phone calls, software problems, etc. -- have left me little time between surgeries to do any blogging. In the car, however, I have been able to listen to one of the finest series of lectures I have ever heard. My 20 minute drive to and from work these past several weeks has been enhanced by the fascinating Professor J. Rufus Fears. Prof. Fears is "David Ross Boyd Professor of Classics at the University of Oklahoma, where he holds the G.T. and Libby Blankenship Chair in the History of Liberty." That's all well and good, but for me he is quite simply an outstanding speaker and teacher. I have had the good fortune to have a friend who has purchased several of the "Great Courses" offered by The Teaching Company, and loaned me Prof. Fears' "The History of Freedom." I cannot recommend it highly enough, and plan to purchase my own copy for the surglings to watch before they run off to get their minds polluted at college.

Thursday, November 17, 2005

Birthday Kudos for Bill Buckley

National Review Online has a nice collection of plaudits for William F. Buckley, who will be turning 80 next week. A brilliant mind, coupled with the charm and wit to present the conservative view with ease, made Mr. Buckley instrumental in the development of the modern conservative movement. Take a look at what these NRO contributors have to say.

Way Cool

I just love stuff like this -- when smart people can take a new technology and make it into something really useful:

By coating the surfaces of tiny carbon nanotubes with monoclonal antibodies, biochemists and engineers at Jefferson Medical College and the University of Delaware have teamed up to detect cancer cells in a tiny drop of water. The work is aimed at developing nanotube-based biosensors that can spot cancer cells circulating in the blood from a treated tumor that has returned or from a new cancer......
The group took advantage of a surge in electrical current in nanotube-antibody networks when cancer cells bind to the antibodies. They placed microscopic carbon nanotubes between electrodes, and then covered them with monoclonal antibodies -– so-called guided protein missiles that home in on target protein "antigens" on the surface of cancer cells. The antibodies were specific for insulin-like growth factor 1 receptor (IGF1R), which is commonly found at high levels on cancer cells. They then measured the changes in electrical current through the antibody-nanotube combinations when two different types of breast cancer cells were applied to the devices......
"The breast cancer cells don't give a spike if there is a non-specific antibody on the nanotube," he says, "and cells without that target don't cause a current jump whatever antibody is on the nanotubes.
"This method could be used for detection and it could be used for recurring circulating tumor cells or micrometastases remaining from the originally treated tumor," Dr. Wickstrom explains.

This is only one example of the really great work medical researchers are doing with nanotechnology. The next steps will involve directly targeting tumor cells with "chemotherapy-armed" nanoparticles. Sort of reminds me of Fantastic Voyage, only without Raquel Welch's cleavage.

Tuesday, November 15, 2005

Grand Rounds

Doc Shazam at Mr. Hassle's Long Underpants is hosting Grand Rounds this week (that still has to be the best title for a medical blog). Surf on over and have a look at the best of the medical blogosphere this week.

Sunday, November 13, 2005

Baseballs and Dr. Pepper

I visited a grave yesterday. The sky was clear, blue, untroubled. The wind sent the last remaining leaves scurrying to and fro, forming little eddies around memorials large and small.

I had never met the young man buried there. He died a year ago, and his death, like most involving teenagers, had a profound effect on many in our community. He was the older brother of my middle child's close friend, and he died in a manner so sadly common today, one more blip on the DUI statistics chart.

As we drove through the cemetery, quietly searching for the tombstone, I could not but think about his parents. Good people, easy to talk to, folks I know only enough to share a few words with. Twelve months is scarcely time enough to let the pain slide into only profound sadness. I have many times this past year felt an emptiness in myself, inadequate to the simple task of expressing condolences. Not knowing the young man, I cannot feel his loss; I can't not feel for his family. But how does one tell the most casual of acquaintances that you grieve for them?

We had arrived after the office closed and had no map to guide our way. And yet my daughter somehow spied the marker, one among thousands. The gravesite was bedecked with flowers from those who had come to remember this young man, by all accounts a great kid. There must have been some who knew him well, leaving a few baseballs and bottles of Dr. Pepper at the base of the stone. When my only son asked what those mementos meant, I had no ready answer. They were an expression of love and regret, of the sorrow that only is felt in missing a friend who can never return, that touched me in a way the flowers did not. I could only hold his little 11 year old body close and pray that he would have the chance to grow old enough to understand.

About 18 hours before we took that quiet trip, I cared for a young man who drove his car into an immobile object at about 90 mph. ETOH level was a good 300, no seatbelt, fixed and dilated on arrival. The head CT showed enough swelling that the brain had a uniform flatness, with no discernible contours. After the tornado of activity in the trauma room subsided, it was clear to all, with the simplest of tests confirming it, that he was brain dead. Yet there was no one to call, no family known, no donor card signed. Nada. Zilch.

The next day, I stood in the wind hugging my kids in the cold bright daylight. I could not help wondering who will leave this new statistic flowers, hockey pucks, or bottles of pop in remembrance? And what other set of parents will awaken each day now so much older, with someone missing in their lives?

Buckle up. Teach your kids to buckle up. And take the time to remind them that drunk driving death statistics are made up of real people, including teenagers. If they don't quite get it, or just aren't listening, your friendly neighborhood ED is a good place for them to volunteer on a Friday night.

Tuesday, November 08, 2005

Grand Rounds No. 2, Vol. 7

Grand Rounds with a Star Trek theme is being hosted at the MSSP Nexus Blog -- go where many men have gone before to see the best of the medical blogs this week!

Monday, November 07, 2005

Doctors for Medical Liability Reform

As many physician bloggers will attest, there is a real struggle going on for the hearts and minds of Americans being waged over the issue of medical lawsuits. Up until the past few years, this fight was being engaged publicly primarily by trial lawyers. I certainly do not need to educate readers of this blog about my feelings regarding lawsuit abuse, "CYA" defensive medicine, the inequities involved in the current medical malpractice legal climate, etc. Let's just say that I'm not on the attorney's side here.

So, I was very excited when I received an e-mail about two months ago announcing the "Protect Patients Now" effort:

Protect Patients Now is a project of Doctors for Medical Liability Reform (DMLR), a coalition of 230,000 practicing medical specialists who are committed to protecting patients' access to healthcare by supporting federal legislation that will reform our nation's broken medical liability system.
The e-mail came from Tom Russell, M.D., the executive director of the American College of Surgeons; the chairman of Doctors for Medical Liability Reform is Stuart L. Weinstein, M.D., an orthopedic surgeon at the University of Iowa. I think the DMLR site is worth a visit for those wishing to see an admittedly one-sided view of this issue.

In my mind, this type of organized effort is welcome, albeit a bit tardy. Unfortunately, it also appears to be a little amateurish; the animations, which can be seen with IE but not Firefox, succeed only in demonizing trial lawyers. As much as some might feel that's appropriate, what is really needed is education, so that the public understands the personal costs of our current liability system. Actually, a coordinated effort that extends across multiple types of businesses would be the ultimate solution, with TV and radio ads expressing how children can no longer use certain types of playground equipment, why the ED physician orders a chest CT when his suspicion for a pulmonary embolus is essentially zero, why Starbucks has to have a written warning on each of its cups stating "Warning: the beverage you are about to consume is extremely hot," why there are so few vaccine manufacturers left in the US, why (you fill in the blank).....

Nobody is perfect 100% of the time, whether that person is a physician, policeman, butcher, or even attorney. Americans need to move beyond the "culture of blame," or we will continue to cannibalize our society. So, even with its shortcomings, I give a thumbs up to the DMLR freshman effort.

Sunday, November 06, 2005

The Sights and Sounds of Sausage Making

This item from Wednesday received little fanfare while being thrown out into the great media mixing bowl this week, but it is not without impact. Medicare is planning to reduce fees to physicians by 4.4% in 2006, while increasing payments to hospitals by at least 3.7%. This has been in the works for some time, and reflects a long trend of decreasing pay to physicians caring for Medicare beneficiaries; I have related posts here and here.

I was waiting over the past few days for some sort of response from the American College of Surgeons and from Congress -- I subscribe to both the ACS's weekly "ACS NewsScope" e-mails and Senate Majority leader Bill Frist's "Weekly Health Report." The ACS gave it's standard line:

The College continues to urge Congress to pass legislation before the end of the year to stop the 4.4 percent cut from becoming effective. If Congress does act on this issue, it will most likely be tied to pay for performance. Fellows are strongly urged to contact their Representatives and Senators regarding this issue.
Interestingly, Senator Frist's e-mail missive said absolutely nothing that was not already included in the CMS press release (emphasis mine):
Wednesday, the Centers for Medicare and Medicaid Services announced a final payment rule for physicians and hospital outpatient departments. The final rule specifies that, based on the yearly update formula, payment rates per service for physicians’ services will be reduced by 4.4 percent for 2006 unless Congress acts. A provision to address the cut was included in the Senate Budget Reconciliation Bill. The rule also includes other policies affecting Medicare Part B services such as extending the glaucoma screening benefit and providing supplemental payments to federally qualified health centers (FQHCs) that contract with Medicare Advantage (MA) plans.

“The existing law calls for a decrease in payment rates for physicians in response to continued rapid increases in use of services and spending growth, and Medicare does not have the authority to change this,” said CMS Administrator Mark B. McClellan, M.D., Ph.D. “The current system is not sustainable, and the payment reduction offers further proof that we must move to a payment system that ensures adequate payments to physicians, but also supports high quality and efficient health care services. We want to continue to work with Congress toward a payment system that is more sustainable. In this rule, we continue to refine payment rates to reflect current medical practice, while doing all we can under current law to support physicians’ efforts to provide greater quality and efficiency of care for Medicare beneficiaries.”
It appears that the Senate did indeed pass the budget reconciliation bill (S 1932) late Thursday, but given the tortured process involved with getting bills through, I have been unable to determine if the above-mentioned provision was left intact --- a series of proposed amendments were voted down. Most of the attention given to this bill in the press has been centered around its provision to allow drilling in ANWR and its intended $35 billion deficit reduction. We may need to wait for a few days to determine if we will truly see a significant reduction in Medicare payments to physicians. Payment reduction will significantly impact the ability of Medicare recipients in many areas (mine included) to access primary care physicians....driving them to the ED for care....driving up health care costs.

Hopefully, someone with inside knowledge can read the tea leaves and let the rest of us know what is in the final bill.

Tuesday, November 01, 2005

Grand Rounds -- In Session

Grand Rounds is being hosted this week at Kidney Notes -- it's always worth perusing the best of the medical blogs!

Monday, October 31, 2005

Porkbusters -- A Worthwhile Blogger-Supported Effort

I support the Fiscal Watch Team Offset Package.

The idea of getting rid of the "pork" extras in upcoming Senate appropriations bills is gathering steam....and, quite frankly, is light years overdue. It has always been accepted political dogma that "pork" projects get thrown into otherwise needed bills, and there is little that can be done about it. Until now. This is neither a Republican nor Democratic, liberal or conservative issue; it is simply fiscally appropriate. Many bloggers have written in support of the efforts of Senator Coburn, and are calling on all of us to jump on the Porkbusters bandwagon; it makes good sense to get trade the money spent on pork barrel projects for use in hurricane Katrina relief.
I support the Fiscal Watch Team Offset Package, and I urge you to as well. Visit NZ Bear for more information on Sen. Coburn's new effort, and visit the Porkbusters tracking page to see if your Senator is getting behind this effort -- if not, let him or her know why they should. (Image blatantly stolen from Instapundit, but for a good cause).

Friday, October 28, 2005

Enjoying the Sunrise

Having a week off with nothing scheduled to do (except tend to the surglings while SWIMBO is away) is very therapeutic. I have been able to read, sleep, take leisurely walks with DogSurg, and enjoy an adult beverage or two in the evenings. The hardest part has been getting up in the morning (when there is no need to go to work) -- two of the surglings leave the house for school at 6:15, and it's DARK! As a consolation, however, I have been treated to spectacular sunrises this week.
Oh, well, back to the salt mines on Monday!

Thursday, October 27, 2005

GERD Therapy Option Recalled

Traditionally, options for the treatment of gastroesophageal reflux disease (GERD) have been acid-blocking medication (for the vast majority of patients) or surgery (fundoplication, for a few patients). For the sake of brevity, I won't go over the pros and cons of each; in general, patients would prefer a non-operative treatment (which as a surgeon I just can't understand!).

GERD is a very common problem....and as a result, lots of $$ are at stake for those who can come up with a good treatment. How many ads do you see or hear about "the purple pill?" The battle between pharmaceutical companies for GERD therapy market share is intense. In the past few years, two alternative endoscopic therapies have been developed: the Stretta procedure and the Enteryx procedure. One is no longer an option.

The Stretta procedure involves application of radiofrequency energy to the gastroesophageal junction, basically causing tissue thickening in an attempt to augment lower esophageal sphincter tone, thereby decreasing the tendency of the patient to reflux. It is reasonably effective, although not the "silver bullet" many had initially hoped for (it is not, for example, efficacious in the patient with a large hiatal hernia). It has been found to be fairly safe as well.

A competing therapy aimed at creating the same process via a different method is the Enteryx procedure. The procedure consists of injection of a polymer into the lower esophageal sphincter, once again generating thickening of the tissues to augment LES function and prevent reflux. It was developed by Enteric Medical Technologies, which was later bought out by Boston Scientific. FDA approval was granted in 2003, and positive study results were reported at this year's Digestive Disease Week:

"These clinical trial results demonstrate the safety and efficacy of the ENTERYX Procedure at controlling GERD symptoms, and show that the ENTERYX Procedure contributes to high levels of patient satisfaction as compared to daily proton pump inhibitor (PPI) treatments," said Glen Lehman, M.D., Professor of Medicine and Radiology, Associate Director of Clinical Affairs, Department of Medicine, Indiana University Medical Center. "“The growing body of clinical data suggests that the ENTERYX Procedure has a place in the treatment algorithm for chronic GERD sufferers."”
That endorsement now seems a bit premature. Last week (10/14), the FDA reversed field and ordered a recall of the Enteryx kits, citing complications from injection of the polymer throught the entire wall of the esophagus, leading to (emphasis mine):
chest pain, flu-like symptoms, pneumonia, atelectasis, reactive pneumonitis, mediastinitis, pneumo-mediastinum, reactive pleuritis, pleural effusion, pericardial effusion, syncopal episodes, and flank pain. Some cases of transmural injection were not recognized at the time of the procedure or during immediate follow-up; these occurred even though fluoroscopy was used throughout the procedure. Three weeks was the longest period that we know of in which a transmural injection went unrecognized by a physician.

At this time, it is not possible to provide accurate estimates of the number of adverse events associated with transmural injection of ENTERYX®, or to describe all of the possible outcomes. Reports received thus far suggest ENTERYX® has been injected into various sites outside the esophagus including the mediastinum, pleural space and the aorta. When injected into the aorta, ENTERYX® may migrate to and occlude blood vessels which supply other organs including the kidneys. One reported death was due to injection of the ENTERYX® into the wall of the aorta, which resulted in an aorto-enteric fistula. Another patient experienced a partial reduction in renal function due to partial embolization. It is not known at this point whether ENTERYX® injected outside the esophagus can be removed.
Boston Scientific apparently initiated its recall on September 23rd, stating on their web site
The Company has been collecting and analyzing a growing body of data that indicates procedural injection technique is critical to achieving clinically acceptable results. There have been a limited number of injections through the wall of the esophagus (transmural) that were undetected at the time of the procedure and resulted in adverse events. Boston Scientific considers the possibility of an undetected transmural injection an unacceptable risk and has elected to recall these products.
I'm not a gastroenterologist, and don't know how much acceptance the Enteryx procedure had gained; none of the GI docs I routinely work with have used it (or the Stretta, for that matter). However, as a surgeon who has always had an interest in foregut surgery, I have had a natural disinclination towards these two procedures, and was concerned that transmural injection was a real, but likely rare, possiblity. It appears that it was not that rare, and that the FDA acted pretty quickly to do the right thing.

Late Aspen Leaves

Kitty has been photoblogging the progress (or lack thereof) of the changing of the leaves in here neck of New York. We have had a longer run than usual of great colors in the city (long gone in the mountains), but I have not had much of a chance to take any pictures until today. While the remaining scrub oak leaves are the color of dried mud, there are still some Aspens with yellow around. So, DogSurg and I took a great hike today in search of a few good leaves, but even the nearby hills have lost their color ---- these photos are from around the house:
DogSurg, as you can see, is none too pleased to be done with his hike -- he prefers the 3-4 hour ones that leave me aching for a hot tub and a stiff martini.
By the look he's giving me here, I'd better share the martini.

New Agent for Postop Nausea?

One of my patients' biggest fears is postoperative nausea and vomiting (PONV) -- often times, a bigger concern than postoperative pain. This is rarely a worry of patients who have never had surgery, but is seen in some who have had prior postop PONV issues. It is also a problem for surgeons; I particularly do not want a patient to start to wretch after a fundoplication or major laparotomy. A large number of medications, solo or in combinations, have been used through the years to try to prevent this problem --- a better approach than trying to treat it once it has been established. At the most recent American Society of Anesthesiologists meeting in Atlanta, yet another class of medications was presented as a potential remedy, NK-1 receptor antagonists. The study came from the Duke University Dept. of Anesthesiology, and found that:

Compared to existing drugs, the NK-1 receptor antagonist blocks at a different site the cascade of biological signals leading to nausea and vomiting. Specifically, 95 percent of patients taking the NK-1 receptor antagonist before surgery did not experience vomiting 24 hours after surgery, compared to 74 percent for the most commonly used drug, ondansetron. The results were similar 48 hours after surgery, 93 percent vs. 67 percent.
NK-1 is also known as Substance P. The trial was funded by Merck Research Laboratories, the developer of NK-1 receptor antagonist known generically as aprepitant; it is not actually new, and has been available for treatment of chemotherapy-related nausea for a while.

I hope that this newer drug is shown to be useful in more trials, as I have been terribly unimpressed with the effectiveness of the most commonly used agent, Zofran (which I have found to be poor in the postoperative setting). In fact, over the past few years I have become more convinced that cheap, good old dexamethasone, in combination with lower doses of more commonly used antiemetics, is more effective at prevention of PONV than higher doses of those newer agents alone.

Tuesday, October 25, 2005

Grand Rounds Is Up!

Grand Rounds, Vo. 2, No. 5, is being held this week at Hospital Impact. It's worth a look!

Thursday, October 20, 2005

Dead Meat

Browsing the blogs while on call tonight, and came across an interesting post at small dead animals (a Canadian blogger). The post delineates ongoing problems with the Canadian health care system --- remember, that's the one that Teddy Kennedy and Howie Dean think we should have. The post points readers towards a recently published Fraser Institute study entitled "Waiting Your Turn: Hospital Waiting Lists in Canada, 15th Edition, " which reveals that although small improvements have been made,

Total waiting time between referral from a general practitioner and treatment, averaged across all 12 specialties and 10 provinces surveyed, fell from 17.9 weeks in 2004 back to the 17.7 weeks last seen in 2003. This small nationwide improvement in access reflects waiting time decreases in 5 provinces, while concealing increases in waiting time in Manitoba, Ontario, New Brunswick, Nova Scotia, and Newfoundland.

Among the provinces, Ontario achieved the shortest total wait in 2005, 16.3 weeks, with Manitoba (16.6 weeks), and Alberta (16.8 weeks) next shortest. Saskatchewan, despite a dramatic 7.8 week reduction in the total wait time, exhibited the longest total wait, 25.5 weeks; the next longest waits were found in New Brunswick (24.5 Weeks) and Newfoundland (22.3 weeks).
A companion news release is here.

Reading through the small dead animal comments, I found a reference to a new short film entitled Dead Meat, a critical look at the Canadian system which is worth viewing (high speed connection a must). After watching the film, it's worth asking if we really want to emulate a system that even the Canadian Supreme Court has ruled causes delays resulting in morbidity and mortality? Or the slightly better British system? One of the most absurd things I found in the film was the fact that purchasing health insurance for animals is quite legal (and they get prompt treatment), but purchasing private health insurance is illegal in Canada. I suspect this film won't make the short list for the Oscars or the Sundance film festival (they are much more interested in whatever Michael Moore has to say), but I hope it gets reasonable exposure in the US.

Update -- a reference to this film was also posted at Symtym.

Ode to the Astrodome

This is something I put together for a talk a few years ago --- I thought I'd resurrect it and add a few hyperlinks now that the Astros are actually in the World Series!

It was the Taj Mahal of sports, the 8th Wonder of the world, called the “Can-Do Cathedral” in response to those who said it could never be built. This vast structure was large enough to comfortably house an 18 story building. It was here that Ali danced, Elvis sang, Billy Graham preached, Evel Knievel jumped over cars on his motorcycle, and Elvin Hayes met Lew Alcindor in an epic college basketball contest. It has hosted polo matches, soccer and ice hockey games, bullfights, auto races, rodeos, conventions, boat shows, and even a little tennis match between a woman and a self-described male chauvinist pig. Robert Altman even made a movie here. It was an unmatched engineering marvel, though not necessarily a beautiful structure; Larry McMurtry once called it “the working end of the world’s largest deodorant stick.”

Under its circular roof lay a beauty parlor, chapel, children’s library and playground, 5 restaurants, a barber shop, a bowling alley, a movie theater, and even a presidential suite appointed with Louis XIVth furniture. Bob hope once said that "if it had a maternity ward and a cemetery, you’d never have to leave.”

Men named Nolan and Earl put opposing players on their behinds here, one with a blistering fastball and the other with a withering stiff-arm that felt like a bolt of lightning. But somehow, no matter who was the star of the event, the building itself was often the top attraction. In its heyday, this structure was unquestionably the most ambitious and forward-thinking project of its kind in the world, described at its opening as “a tribute to the boundless imagination of man” by the Rev. Billy Graham. It was such a phenomenon that within a year of it’s completion, it was the third most visited man-made tourist attraction in the US, trailing only Mt. Rushmore and the Golden Gate Bridge.

But oh, how times have changed. Now, a mere 40 years after it debuted, it is considered a relic, as outdated and useless as a cheap polyester leisure suit, reduced to hosting high school football games and the occasional monster truck show. "It" is the Astrodome, a once proud product of a city with a true can-do spirit, now being replaced by more modern, single-use facilities. While it has been the site of a number of spectacular events, the story of the Astrodome has never been merely one of games and entertainers; it is the story of a remarkable building, and how a self-described huckster born in Beaumont, Texas was able to build it.
Roy was a gifted motivator and speaker even as a young man, and soon made a name for himself in Houston where his family moved in the 1920s. By age 14, he was booking and promoting dance and live music events on his own, driving around town in a garishly decorated Model A to advertise them. Offered a scholarship at the University of Texas at age 16, he chose to stay home and attend Rice Institute due to the untimely death of his father; at the time, Rice offered free tuition to all who were accepted for enrollment. At 18, Roy was awarded the first scholarship ever given by the Houston Law School for his “speaking abilities and other possibilities.” He briefly practiced law, but politics beckoned, however, and Roy became the youngest man elected to the Texas state legislature at age 22. He was flashy and flamboyant, a gifted speaker, a PT Barnum of politics. Here he began cultivating a group of powerful friends in the Democrat party who would become lifelong admirers and supporters – people like John Connally and a young man named Lyndon Baines Johnson. Within 2 years he was elected the youngest county judge in the nation, and the man described as the “Boy Orator” and the “Bayou Buffalo” would be known simply as “The Judge” for the remainder of his life.

A rising star in the Democrat party, he was the campaign manager for his friend LBJ’s ill fated 1941 senate run. However, with the Judge it was hard to tell where politics ended and business began over the next several years; he was skillful at doling out political favors and getting involved with local real estate and other business ventures. He left office at 32 to start a string of radio stations with the aid of wealthy benefactors, and by 37 was a bona fide millionaire. While often described as arrogant and ruthless, even his detractors felt he was very forward thinking, particularly in regards to new business opportunities and promotion ideas. The Judge jumped back into politics in 1952, being elected mayor of Houston with the help of close aides Jack Valenti and eventual Watergate prosecutor Leon Jaworski. By this time the Judge was used to getting his way, and frequently butted heads with the City Council. He eventually was impeached and lost a special election midway through his second term. By this time, however, he was firmly entrenched in local business, and expanded his empire to include a television station and extensive real estate holdings with the aid of wealthy partner Bob Smith.

By 1960, the Judge was enough of a fixture in Houston political and business dealings that almost anybody with a significant proposal ran it by him first. And so it came to pass that two Houston businessmen, George Kirksey and Craig Cullinan, pitched their idea for a bringing Houston a major league baseball team to Judge Roy. Not only was he interested, he dove in feet first and took control of the idea. Soon the Houston Sports Authority was formed, and eventually the Judge and Bob Smith became essentially the only meaningful partners in the venture.

But the Judge recognized that Houston had a slight climate problem --- unbearable heat and humidity, violent summer weather, and mosquitoes the size of vultures would make the idea of enjoying a major league baseball game in the open air a bit less than desirable. And so the credit for first proposing what would become the Harris County Domed Stadium rightly goes to the Judge, who was also politically savvy enough to sell the idea of public financing for the project. A National League expansion franchise, the Colt .45s, was awarded, and a $22 million tax-supported bond election narrowly passed in 1961.
A site was chosen for the stadium, which just so happened to be on land owned predominantly by the Judge and Bob Smith. It is hard to overestimate the “can-do” attitude present in Houston at the time, with NASA and the burgeoning space program just down the road. But many questioned which was the more outlandish proposition – NASA putting a man on the moon or the Judge managing to build an air-conditioned domed stadium, which could hold 50,000 spectators. Undeterred by these nay sayers, the seven members of the Houston Sports Authority, armed and dressed in cowboy hats, met on the outskirts of downtown Houston on January 3rd, 1962. They drew their Colt .45s and fired them into the dirt to break ground for a building the likes of which had never before been seen.
While the Colt .45s played in a nearby temporary stadium, construction started and a 24 foot deep 700 foot wide hole was dug. Soon, however it was apparent more money was needed. The likelihood of passing a new bond issue was very questionable, so the Judge turned to support from local black leaders, promising the new facility would be fully integrated. The issue narrowly passed and he got the additional $9 ½ million he needed.

Soon the building began to rise – 218 feet in the air with an outer diameter of 710 feet. The dome created a clear span of 642 feet, more than double the size of any previous enclosure; it was the largest open room in the world. The domed roof itself, created by an elaborate series of lamella trusses, sits on a 300 foot tension ring mounted on 72 steel columns, each being capable of supporting 220,000 pounds. 37 separate erection towers resembling oil derricks were needed to put up the steel framework of the roof; these were then removed by lowering all 37 simultaneously 1/16th of an inch at a time until the 9,000 ton roof settled onto the tension ring and support columns like a huge Tupperware lid. 4,596 Lucite panels were installed to let in light, patterned after the Lucite gunner’s dome in the B-17 Flying Fortress. The roof was designed to handle sustained winds of 135 mph with gusts up to 165 mph to keep it from flying off like a gigantic Frisbee during a hurricane. Adjacent to the building was the world’s largest parking lot, built to handle 30,000 cars.
Several things we now take for granted were first used in the Dome. 54 luxury “skyboxes” were built, holding 24 people each, initially leased at $15,000 for 5 years. All fans were treated to plush seats upholstered in just about every color of the rainbow; it was an orgy of color ready-made for the first color television broadcast of a major league baseball game. It was designed from the start as a multi-use facility; seating capacity varied from 54,000 for baseball to 63,000 for football. A 64 foot diameter gondola was suspended from the center of the dome, providing previously unheard of aerial views of games in progress.

The $2 million dollar scoreboard was truly Texan in scope – over 4 stories high, 474 feet long, with over a ½ an acre of programmable lights. With each home run blasted by the home team, the scoreboard operator would unleash the Home Run Spectacular. The wall of lights and speakers would erupt for a full 45 seconds, sending snorting and stomping steers draped with Texas and US flags racing across the screen, followed by cartoon cowboys firing off bullets that ricocheted to and fro. It was as loud as a freight train, and opposing pitchers absolutely hated it.

The Texas A&M agriculture department was enlisted and determined that Bermuda Tiffway grass would flourish in the stadium’s light and humidity. The Judge however was never convinced this would work, and was already looking into what he called “undertaker’s grass” before the dome’s inaugural season. And of course, there was cool refreshing air conditioning powered by equipment that provided 6,600 tons of cooling capacity and moved 2 ½ million cubic feet of air per minute. Given the size of the building and outside conditions, temperatures could vary as much as 40-50 degrees at different levels in the stadium, so a system of multiple separate sensors and controls was established; these were run and adjusted by “The Brain,” a complex system of electronic components made by Honeywell that did the equivalent amount of work as 280 men. This was no small task to accomplish in the early 1960s. As well, a weather station was installed on top of the dome to feed outside climate information to The Brain.
The Dome was finally ready for the beginning of the 1965 baseball season. A new name was needed for the team to reflect the new stadium’s grandeur. Taking a cue from the space program, the Judge decided on the Houston Astros, and soon the name Astrodome was applied to the stadium. All stadium workers wore space-themed uniforms. The groundsdskeepers were called “Earthmen” and wore mock space suits. The official opening night festivities were attended by the Gemini Twins, Gus Grissom and John Young, who had just 3 weeks before been the first astronaut pair sent into space. They came with 21 other astronauts, all of whom were given lifetime passes to Astrodome games. The Judge’s friends and also filed in, including Governor John Connally and President Lyndon and Lady Bird Johnson, for whom the presidential suite was specifically built. Celebrities galore filtered through the Judge’s private suite, which was garishly decorated with antiques, numerous television sets, and gold plated toilet fixtures.

Aside from a troubling problem with glare from the Lucite panels during day games, the Astrodome was an unqualified success. As is well known, the panels were painted, the Aggie-approved grass died, and the last 2 weeks of the season were played on spray-painted dirt. The solution devised by the Judge and Monsanto, Astroturf, was finally installed by early morning hours of the opening day of the 1966 season. Monsanto beat the Judge to the punch and quietly registered the name Astroturf, but it took a full 7 years for the product to become profitable. Interestingly, most of the money Monsanto made off of Astroturf came from sales of doormats, not fields, but it became its most widely used trademark.

The Judge eventually surrounded the Astrodome with the Astrohall, several Astrodomain hotels, and the Astroworld theme park. This ultimate promoter and huckster also bought the Ringling Brothers Barnum & Bailey Circus, booking it into extended runs in the Dome. As one observer put it, Goldfinger tried to knock off Ft. Knox, while the Judge built his own.

But the Astrodome itself was the Judge’s crowning achievement. When he died in 1982, his long funeral motorcade slowly circled the Dome twice on its way to the cemetery. He had long since given up control of the Astrodomain Complex, the victim of massive debt and the outrageous interest rates of the 1970s.

The Astrodome went through a few facelifts over the years, and a few other domed stadia were built as well. But they were mere imitators. The Astrodome is a true original, not named after a corporation or even the man who built it. There is a building near the Dome that is named after him you may have heard of; the next time you are watching a basketball game broadcast from the University of Houston’s Hofheinz Pavillion, think instead of baseball and the Astrodome, and think of the imagination, drive and vision of a man named Judge Roy Hofheinz.
While the Astrodome may be considered a relic by some, to me it will always stand as a reminder of a time when Americans felt anything dreamed could be made a reality, a time when there were only solutions and no problems, a time when even sophisticated electronic and engineering projects could be assembled in my father’s garage. I have a soft spot in my heart for that time and that building -- you see, my Dad worked for Honeywell to design it's AC, assembled the dome-top weather station and installed it atop the Astrodome (yes, that's really my Dad on top of the Dome in the photo below):
(Much of this info is found in The Grand Huckster: Houston's Judge Roy Hofheinz, Genius of the Astrodome, by Edgar W. Ray. Lots of photos and Astrodome history can be found here.)

Tuesday, October 18, 2005

Grand Rounds Vol. 2, No. 4

Grand Rounds is being held this week at Diabetes Mine --- Joe Bob says "check it out!"

Monday, October 17, 2005

Stress and Friendly Fire in the OR

On call today, with a light schedule, so I have been able to catch up on my journal reading. I found two articles in the October edition of the Journal of the American College of Surgeons (subscription required but free for medical students). And no, one was not Prognostic Significance of Ploidy, MIB-1 Proliferation Marker, and p53 in Renal Cell Carcinoma; I'm just not that kind of guy.

The first item of interest is takes on a challenging question: the quantification of stress. Entitled Quantification of Surgical Resident Stress "On Call," (by multiple authors from UCSF-East Bay) the article describes measurement of heart rate (with 24 hour Holter monitoring) and WBC levels in interns, junior residents, and senior residents both on and off call. The conclusions reached were:

When heart rate is used as an indicator of combined physiologic and psychologic stress, surgical residents achieve stress levels of tachycardia "“on call."” Surgical residents also exhibit an increase in circulating WBC count "“on call."” Both the degree of tachycardia and the increase in WBC count are inversely related to the level of training. Senior residents cope better with stress "“on call"” than junior residents and interns.
In other words, surgery residents get stressed while on call, and lower level (i.e., less experienced) residents are more stressed than their senior counterparts. This is further illustrated by the amount of 1-hour time periods with heart rates >120 that were seen (emphasis is mine):
Interns had significantly more 1-hour time periods during which their HR was greater than 120 bpm (7.0 ± 1.3 1-hour periods "“on call"” versus 0.3 ± 0.3 "“off call,"” p = 0.003). During the 24-hour "on call"” work shift, some interns had as many as 16 1-hour time periods during which their HR was more than 120 bpm. This is compared with a mean of less than 1 1-hour time period of elevated HR among senior residents "“on call." Senior residents incurred only 0.8 ± 0.5 1-hour time periods during which their HR elevated "“on call" versus 0.4 ± 0.2 off duty (p = 0.5). Junior residents were in the intermediate range, with 6.2 ± 2.6 1-hour time periods of elevated HR "on call"” versus 1.3 ± 0.6 off duty (p = 0.14).
I would love to see some follow-up studies with this tool --- comparing surgery and medical residents, cardiology fellows and GI fellows, etc. Most importantly (to this old man with way too much gray in his beard), what about practicing surgeons --- perhaps one, five, and ten years after residency. Neat stuff overall. Interestingly, the authors pointed out an important side issue to this, namely work hour restrictions (emphasis is mine).
The senior residents who participated in this study trained in a period before Accreditation Council for Graduate Medical Education guidelines on work hour limitations went into effect, so they were exposed to longer work hours in the early phases of their training. In contrast, the interns and some junior residents have always trained under the current Accreditation Council for Graduate Medical Education guidelines. Exposure to longer work hours may have preconditioned the senior residents to respond better to stress "“on call." Preconditioning has been studied in athletes and animal exercise studies. Preconditioning confers a well-documented influence on the cardiovascular system and alters a subject'’s approach to psychologic challenges. As surgeons, constructive preconditioning will play an important role in how we approach critical problems and how we deal with stress.
I freely admit that I am biased; I really, really do not like the current imposition of work hour restrictions on surgery training programs for a whole host of reasons, and this article illustrates one of those reasons.

Which leads me to the second October JACS article in this overly long post: Biliary Injury in Laparoscopic Surgery: Part 1. Processes Used in Determination of Standard of Care in Misidentification Injuries (by Steven Strasberg, MD from Washington Univ. in St. Louis). In discussing opinions about negligence and standards of care in laparoscopic cholecystectomy, Dr. Strasberg employs a great analogy:
... the problem of misidentification might be best illustrated by analogy: identification of an enemy by the military during combat. Every branch of the military has a set of rules for identifying the enemy. The goal is positive or conclusive identification of the enemy. The main purpose is to avoid injury to one'’s own or allied troops. Positive identification is a key element in the rules of engagement, which govern whether an enemy shall be attacked. This system for protection of friendly troops works well in most circumstances, but it can fail. When failure occurs, it seems to be for one of three reasons. The first is that the system is not used or not used as instructed. In some cases this will be due to carelessness and an action below the standard of care will have occurred. The second is that the battle conditions are so severe that even with proper application of the rules, the system will sometimes fail. And the third possibility is that there is an unforeseen flaw in the rules, possibly because of changing conditions of war such that under certain conditions, the system will fail. The second and third conditions result in injuries, which are not from negligence because they can happen as a result of activity of the reasonably prudent soldier. To extend the analogy to cholecystectomy, the cystic duct is the enemy to be correctly identified and the other bile ducts are friendly.
I think that's a great analogy for much of what happens in surgery, and particularly in urgent/emergent/complicated surgery. So, in light of the first study mentioned above, I kind of wonder: is the surgeon who has been to "boot camp" in the training era prior to work hour restrictions better able to handle stressful cases in the OR and avoid "friendly fire" injuries? Or will the next generation of sureons be no different once they get into practice? Time will tell.

(Also, as someone who has no military background, are there "work hour restrictions" at
Camp Lejeune?)