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?)

Get Ready!

Start hoarding -- water, food, gold, ammo, anything you can get your hands on. Make sure your home is as defensible as possible. Buy a Street Sweeper. Get on your knees and pray. The apocalypse is upon us:

Astros one win away from World Series

While that may be enough to kickstart earthquakes, roil the oceans, and initiate generalized mayhem, take a look at who cracked college football's top ten list for the first time in 28 years --- a sure sign that either the second coming is upon us, or the sun is about to go dormant:

AP Top 25

The Top 25 teams in The Associated Press college football poll, with first-place votes in parentheses, records through Oct. 15, total points based on 25 points for a first-place vote through one point for a 25th-place vote, and previous ranking:


Record Pts Pvs
1. USC (57) 6-0 1,617 1
2. Texas (8) 6-0 1,566 2
3. Virginia Tech 6-0 1,495 3
4. Georgia 6-0 1,426 5
5. Alabama 6-0 1,306 6
6. Miami 5-1 1,279 7
7. LSU 4-1 1,201 10
8. UCLA 6-0 1,085 12
9. Notre Dame 4-2 1,020 9
10. Texas Tech 6-0 1,007 13

Lord, help us. My alma mater in the top ten and the only baseball team I ever rooted for in my childhood, both in a position to do great things. I'm not sure what will be worse -- the massive MI I'll suffer if Tech beats Texas, or the stroke I'll have if the Astros win the World Series.

Sunday, October 16, 2005

Where there's a bias, for some there's a way to express it

Murdoc Online has a nice, succinct roundup of the media's preoccupation with forecasting terrible outcomes in Iraq. What happened there yesterday (just as in Afghanistan not so long ago) was nothing short of historic. Just don't go looking in your local papers for that analysis; the Washington Post buried this story in the middle of the paper, as did The Denver Post.

Friday, October 14, 2005

Mumble, Mumble, Mumble

Dr. Kent Bottles, a pathologist who runs the SoundPractice.Net site, has an interesting series of podcast interviews available. Some are interviews with medical bloggers, and he was kind enough to ask me to talk to him the other day. The result is here, for those who might be interested. I can't say I ever anticipated anyone being interested enough to interview me about blogging when I started!

Wednesday, October 12, 2005

Go Read a Great Post

This article on a credentialling nightmare at Cut to Cure is a must read for all physicians who sit on peer review committees, credentials committees, and even those academic physicians who are in charge of passing residents through the educational system. It documents a series of system failures, that ultimately resulted in the apparent failure of appropriate patient care. In our profession, "buyer beware" is not good enough. Red State Moron has a few good thoughts on this as well.

Tuesday, October 11, 2005

Grand Rounds

Grand Rounds, Volume 2, Number 3 is being held at Doulicia. She has a nice roundup of this week's best medical posts --- check it out!

Friday, October 07, 2005

Doc in the Box at Wally World?

I caught a reference to this at Symtym, and have not been able to find much else about it; the original article was in the Wall Street Journal, but has been fanned out since to other papers:

In a development that has broad implications for the nation's primary-care system, a rising number of major pharmacy and retail chains -- including CVS Corp., Wal-Mart Stores Inc. and Target Corp. -- are opening in-store health clinics. They offer patients fast access to routine medical services such as strep-throat tests, sports physicals and flu shots. The clinics, which typically charge between $25 and $60 per visit, don't require an appointment and are open during pharmacy hours including evenings and weekends. To keep costs down, they are staffed by nurse practitioners, who can legally treat patients and write prescriptions in most states.

The trend is rapidly spreading in pharmacy chains as they look for ways to stem losses to mail-order pharmacies and big-box stores. Three of the nation's largest drugstore chains -- Rite Aid Corp., Brooks Eckerd Pharmacy and Osco Drug -- have announced plans to open health clinics in the coming months. All three have partnered with a Pennsylvania-based health-care start-up called Take Care Health Systems LLC that will lease space inside the pharmacies and operate the clinics.
Interesting, n'est ce pas? Wearing my "specialist" hat, I can say that many of my colleagues have been predicting this for the past few years. Many primary care practices employ a variety of "physician extenders," nurse practitioners or PAs who provide a large amount of the routine care for the patients in the practice. So, that means that many patients, while nominally patients of a family practitioner or internist, never see said physician, and receive all of their care from the NP or PA.....and many of these patients (unfortunately) don't really see much of a difference. This MinuteClinic service, quite frankly, may serve these patients just as well, with a whole lot of convenience thrown in to boot.

Wearing my "doctor" hat, I find a few things about this that are troubling. Will there be a true caregiver-patient relationship established, or will visits simply devolve into a series of one-time transactions? While the clinics will limit themselves to a relatively small number of problems, all physicians know that patients frequently come in with one problem, only to really want to discuss several others. What type of patients will be referred out, and to whom? This is particularly important for the patient who arrives with, say, severe hypertension, and has no physician --- does the local ED then become the treating facility? And, of course, do the deep Wal-Mart pockets become fertile soil for malpractice attorneys?

Health insurers don't seem to have many questions. I am no great fan of health insurance companies and their methods of operation (i.e., denial, denial, obfuscation, and denial), but I will grant them this -- they know a good business deal when they see one:
Health insurers have embraced the concept because the clinics promise considerable savings. While a typical doctor visit for a basic illness costs an insurer about $110, a visit to one of the clinics usually costs under $60. In addition, the clinic services are far cheaper than the emergency room, which is where patients often wind up when they need medical care outside business hours. (A strep throat test at the emergency room can cost over $300.)

Some insurers are actively encouraging patients to use the clinics by lowering the co-pay. In Minnesota, companies including Blue Cross Blue Shield of Minnesota and Graco Inc., have reduced or eliminated co-pays for employees who opt to use a MinuteClinic instead of a doctor. Take Care has deals in place with several insurers in Portland.

In all honesty, I think that we in the medical profession have to recognize this for what it is -- businessmen with customer service experience (the CEO previously ran Arby's; the chairman of the board ran a travel company) recognizing a business opportunity, and exploiting it. We have seen the same sort of thing with so-called "specialty" hospitals, boutique practices, etc. In response, we need to do borrow a phrase from Clint Eastwood in "Heartbreak Ridge:" we need to adapt, improvise, and overcome!

To Tub or Not To Tub

I love this time of the year in the mountains. Cool, crisp air. Bright sun in the daytime. Great colors. And, unlike last fall, hockey to watch! SWIMBO was kind enough to let me get a hot tub a few years ago, and I was able to place it outside our TV room....so I can see the Avalanche play through the sliding glass window. Wednesday night was perfect --- opening night for the NHL, an ice cold and dry as the Sahara desert martini in hand, and I was strategically positioned to watch hockey until I was as wrinkled as a California raisin. All was right in the world!

So, Thursday, I'm thinking "I'm not on call; why not have another soak tonight?" Unfortunately, a little spill on the mountain bike persuaded me to stay out of the hot water ---- let's just say there is more of my skin on the ground than on my face or forearms. That first scrub this morning was none too pleasant, either! Oh, well, just a flesh wound. I hope my hide will be ready for another hot tub session by Sunday (or you may hear the yelp on either side of the Rockies).

Tuesday, October 04, 2005

Grand Rounds Vol. 2, No. 2

Grand Rounds is being hosted at The Haversian Canal this week --- check out the second edition of the sophomore effort from the medical blogosphere.

Monday, October 03, 2005

Clowns in the OR

According to this report, a new Italian study has found that the presence of a clown in the operating room may help to ease the anxiety of young patients and their parents. Unfortunately, the report does not reference the study directly, authored by Laura Vagnoli of Anna Meyer Children's Hospital in Florence, so we will have to await its formal publication to get any meaningful information. The study included 40 children, with ages ranging from 4 months to 4 years, who were taken to the OR with at least one parent, where a clown was present.

OK, OK, just stop right there! It's just not right to call my anesthesia colleagues clowns!
As it turns out, the study reported that the clowns were successful in distracting the patients until anesthesia was induced, and that the clown's presence "significantly reduced anxiety levels for both child and parent." I'm not sure how the anxiety level was measured, but I'm pretty sure it had to be a fairly subjective evaluation.

I enjoyed my pediatric surgery rotations during residency immensely, and considered pursuing a fellowship fairly strongly for a while (until long-suffering SWIMBO pointed out that we would by then have 3 surglings, with an intense fellowship relegating her to a few more years as essentially a single parent). I can categorically state that there was never a time during those rotations that I felt having a clown in the OR would be of any help whatsoever. It would be yet another distraction that would keep the staff from proceeding in a normal, routine fashion -- when things go as they are supposed to, the stress experienced by the nurses, anesthesiologists, and surgeons is vastly reduced. So, I anticipated this comment:
"The questionnaire for health professionals indicated that the clowns were a benefit to the child, but the majority of staff was opposed to continuing the program because of perceived interference with the procedures of the operating room."
The concept behind this type of anxiety-reducing suggestion is a thoughtful and well-intended one --- we in medicine need to be cognizant of, and try to reduce, patient and family anxiety. Another example of this type of thinking is displayed by those who advocate the presence of family members in the trauma resuscitation room (i.e., while a critically injured patient is being cared for). My thoughts on this are similar to those of Dr. Ken Mattox of Baylor Medical School:
In my view, this is a sick discussion. Any one who is pushing the family members to be present at the time of a trauma resuscitation, including open chests in the shock room, either has not been there or has a special problem of their own. This is a non-subject, families simply should not be there during the heat of the battle with blood and knives are flying. They simply would not understand and it would create more hurt and confusion than it would cause understanding and healing. Lets get on to another subject.
I think we do our best work when the team assembled is allowed to proceed as expediently as possible, with as few distractions as possible ---- and that leads to better outcomes. Anyone feel differently? Would it be better if I showed up in the OR wearing this?
Just asking! I'd appreciate thoughts from those who agree, and those who don't. A tip of the clown hat to SondraK.