Archive by category 'Musings'
June 23rd, 2010
Two clinical problems this editor has experienced in clinical practice are controlling ruptured arteries such as the aorta and positioning transplanted livers into place so that the cut ends of the common bile ducts align sufficiently to prevent leakage of spewing bile.
One commonly used method for placing stents and catheters in rupturing blood vessels is called the Seldinger technique. One commonly used technique for sewing in liver grafts is called the parachute method.
The following two techniques described below to control the leak without capping it (along with accompanying sketches) is a combination and adaptation of the principles used to solve the surgical dilemmas as described above.
These two possible solutions will avoid having to overcome the immense pressure at the leak site (estimated at 10,000 psi) and would avoid the crystal formation that has plagued the capping attempts. For further details, the editor can be contacted at insidesurgery then the at sign then dot then com.
Technique 1
1. A mile long steel wire or cable is dropped from the surface into or more likely next to the leaking riser pipe. Positioning the cable next to the riser pipe and onto the sea floor avoids having to overcome the pressure head coming from the leaking well, which is many thousands of psi. (see fig. technique 1 A and B below)
2. To prevent movement of the cable end on the sea floor it can be dropped with a weight on it and guided into place by the robotic submarine (fig. technique 2 B – sub not shown).
3. A long oil containment sleeve that will reach from surface to sea floor made of flexible material that is impervious to oil is manufactured with a weighted rim on one end that is large enough to easily fit over the riser pipe and is large enough in circumference to avoid the pressurized plume of oil.
4. This sleeve should be double-layered to lessen the risk of tears and can either be manufactured in one piece and spooled on the deck or field joined as it is being lowered down the guide cable.
5. The rim and the oil containment sleeve is then placed over the free end of the guide cable and parachuted down the cable (fig. technique 1 C.)
6. The rim of the oil containment sleeve will come to rest on the sea floor around the riser pipe and will contain the leaking oil and gas in the sleeve, where it will rise to the surface and can be collected (fig. technique 1 D.)
Technique 2
1. For more control of the oil containment sleeve as it drops to the sea floor, smaller sleeves can be sewn on the outside of the oil containment sleeve (fig. technique 2 A.)
2. Two weighted cable ends are dropped from the surface and positioned (fig. technique 2 B)
3. The oil containment sleeve is then threaded over the surface ends of the cables and dropped/lowered to the sea floor, with the rim coming to rest on the sea floor around the leaking riser pipe (fig. technique 2 C.)
4. The oil plume with its high pressure head is the captured by the oil containment sleeve and collected on the surface.
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June 14th, 2010
ABC News is reporting the story of Sarah and Nicholas Prokos of Port Charlotte, Florida, who survived a crash of their car after Sarah suffered a seizure and lost control of her car which was heading toward a roadside pond.
Eight year-old Nicholas, who was strapped into his backseat booster seat, scrambled to the front seat and steered the car into the guard rail, after which it hit two other motorists on the busy four lane highway, one of whose vehicle was flipped upside down.
In the interview with ABC, Sarah Prokos explains that she had a seizure the week before the accident and took care to explain to her son what a seizure was. In the interview, Prokos beams at her son as she tells the story. Nico is rightfully being lauded as a hero. His mother Sarah’s behavior, however, borders on unconscionable.
What is noteworthy about this story is not the eight-year old saving his mother but why Prokos got behind the wheel in the first place and why she also seems to have no sense of remorse or regret about placing other motorists in jeopardy.
Driving one week after a seizure is nothing short of reprehensible behavior. Patients who have a recent history of seizures should not be driving under any circumstances.
All trauma surgeons have seen devastating motor vehicle accidents resulting in fatalities resulting from patients with seziure disorders who think it is safe to drive.
Many states require physicians to advise patients with new onset seizures to not drive and some require notification of state authorities. Generally, patients are prohibited from driving until they are cleared by their physicians, are stable on anti-seizure medications, and have been seizure-free for six months.
But, apparently, she did not feel that the rules and laws about patients with recent seizures applied to her. By getting in the car and driving, she put herself, her son, and every motorist on the road (and the two she crashed into) into harm’s way of serious injury or death. This is a stunning absence of caring.
If I was in the truck that was struck and flipped over by the Prokos car, I would be contacting my lawyer right quick.
April 6th, 2010
As a former trauma surgeon in West Virginia, this author has noted with sadness the death of twenty five miners in an explosion at the Upper Big Branch mine in Boone County, West Virginia. Dozens more are reported to be seriously injured.
West Virginia coal miners are some of the toughest people on earth. Despite advances in mine safety, it is still incredibly dirty, difficult and dangerous work.
Mine injuries generally fall into one of four categories – blast injuries, crush injuries, asphyxiation, and drowning.
Blast Injury
The traumatic injury to internal organs in mining blast injuries is more severe than other situations where blast injury occurs (refineries, battlefied) because the concussive force is multiplied by the small space of the mine shafts, unlike in open terrain where the force can dissipate.
Mine explosions can generate an horrific amount of energy and have been responsible for many of the biggest mining disasters in history.
February 8th, 2010
Although none of the editors of InsideSurgery participated in his care, we have noted reports that Pennsylvania Congressman John Murtha has died from complications following removal of his gallbladder.
The Associated Press is reporting tonight that Pennsylvania Congressman Bob Brady of Philadelphia has stated that Murtha suffered from injury to his large intestine during the operation at Bethesda Naval Hospital to remove his gallbladder.
The gallbladder was reportedly removed laparoscopically or as it is sometimes described via a minimally invasive technique.
Murtha was apparently discharged to home and then presented to the Virginia Hospital Center complaining of abdominal pain and a fever.
Several days ago he was reported to be in the intensive care unit, indicating that a serious complication had developed which he eventually succumbed to.
Despite being widely performed and viewed as a routine and straightforward operation by patients, laparoscopic cholecystectomy or gallbladder removal can be technically difficult to perform in certain situations.
There are many ways that injury to the intestines can occur in this procedure. An understanding of the anatomy of abdomen and the pathophysiology of gallbladder disease is useful.
The gallbladder is a sac-like structure hanging from a system of ducts leading from the liver in the right upper quadrant to the duodenum.
Immediately adjacent to the gallbladder is the hepatic flexure of the right colon.
When the gallbladder becomes inflamed, the walls of the gallbladder and the surrounding tissue literally becomes red and swollen and the normal tissue planes become obscured, particularly if there have been repeated attacks of cholecystitis or gallbladder inflammation.
To put it simply, “everything gets stuck together” including the gallbladder and colon.
When removing the gallbladder one of the first steps is to peel the colon off the underlying gallbladder wall, without tearing the colon in the process.
While large holes in the colon are fairly easy to notice, smaller perforations in a bed of inflamed tissue are easier to miss.
A second way that the colon can be injured during the procedure is inadvertently perforating it with a retractor or dissecting instrument.
This generally occurs as the tissue is being gently pulled down off of the cystic duct. The sweeping motion of the grasper is towards the area of the colon, which may get “poked” by the tip of the retractor.
A third way the colon can be injured is through a thermal burn from the Bovie electrocautery used to stop localized bleeding from tissues.
This injury may present as a delayed finding and is not uncommon when patients re-present to the hospital with colon injury after being discharged home.
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January 17th, 2010
The following is a partial list gleaned from media reports of surgeons, nurses, and other medical personnel who have gone to Haiti to volunteer their services.
If you know of anybody who is there who you would like listed, please email us at insidesurgery then the at sign then gmail then dot com.
This list will be forwarded onto the American College of Surgeons who is developing a central database of surgeons who are or will be deployed to better assess the needs of the participating surgeons.
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American College of Surgeons Database for medical volunteers wishing to go to Haiti
Surgeons – trauma, general, pediatric, neurosurgical, ob/gyn
Angus, Lambros George – trauma surgeon, Nassau University Medical Center
August, Louis – surgeon, Northshore Long Island Jewish Hospital
Benjamin, Ernest – Mt. Sinai Medical Center, New York
Campbell, Sylvia – Tampa, Florida
Cestero, Ramon – trauma surgeon, USC-LA County Hospital
Donohue, Tim – Director of Surgery, Commander, USNS
Eachempati, Soumitra – trauma surgeon, Weill Cornell Medical Center, New York
Eastman, A. Brent – Board of Regents, American College of Surgeons
Ford, Henri – general surgeon
Garvey, Julius – surgeon, Long Island Jewish
Ginzberg, Enrique – trauma surgeon, University of Miami
Gupta, Sanjay – neurosurgeon, Emory University, CNN reporter
Hobar, Craig – plastic surgeon, Dallas
Loggie, Brian – general surgeon, Creighton University, Omaha, Nebraska
Malsby, Robertt – Surgeon, Lt. Col. United States Army
Melosh, Robert - general surgeon, University of Florida, Gainesville, Florida
Miller, Ale – plastic surgeon, Dallas Texas
Moll, John – general surgeon, Southeast Hospital, Cape Girardeau, Missouri
Mooney, David – trauma surgeon, Boston Children’s Hospital, Boston, Massachusetts
Pust, Daniel – trauma surgeon, University of Miami
Rhynhart, Kurt – trauma surgeon, Dartmouth Hitchcock Medical Center
Scalea, Thomas – trauma surgeon, University of Maryland Shock Trauma
Rogers, Selwyn – general surgeon
Schneider, Karen – pediatric surgeon, Johns Hopkins Hospital
Seneca, Russell – surgery, Inova Fairfax
Sharpe, Richard – trauma surgeon, United States Navy
White, Ken – trauma surgeon, Wilmington, North Carolina
Orthopedic Surgeons
Alexander, Ted – Walter Reed Army Hospital
Aversa, John
Boutin, Georges -Ft. Lauderdale, Florida
Boutin, Pier – Fairview Hospital, Great Barrington, Massachusetts
Dombrowski, Derek – University of Pennsylvania Health System
Gdalevitch, Marie – Sinai Hospital, Baltimore, Maryland
Hansen, Steve – St. George, Utah
Helfel, David – Weill Cornell Medical Center, New York
Hurley, Phillip – Owensboro, Kentucky
Ivankovich, Daniel – Northwestern Memorial Hospital
Kahlon, Randeep – Delaware Medical Relief Team
Keen, Jeff - Jacksonville, Florida
Keeve, John – Washington state
Ligier, Robert
Lorich Dean – Weill Cornell Medical Center, New York
Lovejoy, John
McLean, Michael – Nacogdoches
Mehta, Samir – University of Pennsylvania Health System
Meier, Josh W. – pediatric orthopedic surgeon, Norton Healthcare, Kosair Children’s Hospital, Louisville, Kentucky
Montijo, Harvey – Royal Palm Beach, Florida
Plowman, Donald – Operation Smile
Risch, David – University of Florida
Standard Shawn – pediatric orthopedic surgeon, Sinai Hospital, Baltimore, Maryland
Todd, William – pediatric orthopedic surgeon, USNS Comfort
Ware, Anthony – Melbourne, Florida
Zirkle, Lewis – Surgical Implant Generation Network (SIGN), Richland, Washington
Anesthesiologists
Crowe, Todd – Blue Ridge Orthopedic Surgery Center
Floyd, Thomas – University of Pennsylvania Health System
Pepple, James – Sinai Hospital, Baltimore, Maryland
Salzarulo, Henry – Blue Ridge Orthopedic Surgery Center
Shroff, Ashok – Medical Teams International, Washington State
Physicians
Auerbach, Paul – emergency medicine physician, Stanford University
Bader, Tarif – pediatrician, Israeli Defense Force
Benjamin, Ernest – Mt. Sinai Medical Center, New York
Bonnet, Jean Paul – New Jersey
Brown, Ian – emergency medicine physician, Stanford University Hospital
Davey, Kurt – pediatrician, Creighton University, Omaha, Nebraska
D’Cruz, Brian – emergency room, Inova Fairfax
Diamond, Dan – Medical Teams International, Redmond, Washington
Dole. Micheline – pediatrician
Furin, Jennifer – Harvard Medical School
Gaines, John – internist, University of Florida, Gainesville, Florida
Garner, Gary – pain specialist, Doctors Without Names
Greene, Linda – California
Gresseau, Shirley
Hyman, Mark – Lenox, Massachusetts
Ivers, Louise – infectious disease physician, Harvard Medical School
Lewis, Mark
Lorblanches, Jacques – Medicins du Monde
Louis, Dominique – Green’s Children House, Pompano Beach, Florida
Lyon, Evan – primary care physician, Partners in Health
de Marchena, Eduardo – cardiologist, University of Miami
Markee, Joe – Medical Teams International
Menon, Anil – emergency medicine physician, Stanford University Hospital
Meurer, David – emergency room physician, University of Florida, Gainesville, Florida
Morris, Bob – emergency room physician, Stanford University Hospital
Martsolf, Robert – family practice physician, Sharon, Pennsylvania
Nelson, Craig – Doctors Without Names
Peterson, Chuck – Doctors Without Names
Pierre, Claire – Cambridge Health Alliance
Remillard, Brian – nephrologist, Dartmouth Hitchcock Medical Center
Rhynhart, Kurt – trauma surgeon, Dartmouth Hitchcock Medical Center
Slavery, Yanik – Association of Haitian Physicians Abroad
Stephan, Michel – Forest Park Medical Center
Toussaint, Richard – Forest Park Medical Center
Waldman, Ronald – Columbia University, New York
Nurse Practitioners
Bethart, Sally – University of Florida, Gainesville, Florida
Gallagher, Colleen – Captain, United States Navy
Oetjen, Cheryl – Inova Fairfax Hospital, Virginia
Smith, Brenda – Disaster Response Team, Massachusetts General Hospital
Nurses
Ahmad, Azura – OR nurse, University of Pennsylvania Health System
Alexander, Erin – Inova Fairfax Hospital
Blaufaus, Anne – Providence Medical Center, Portland, Oregon
Domingo, Erica – PACU nurse, University of Pennsylvania Health Care System
Dorcie, Lunie – Antelope Valley Hospital
Goss, Kathy – Inova Fairfax Hospital
Jeudy-Cox, Jeunie – Beth Israel Hospital, New York, New York
Kim, Amy – PACU nurse, University of Pennsylvania Health System
King, Deanna – Washington
Markee, Linda – Medical Teams International
Martsolf, Donna – School of Nursing, Kent State University
Miller, Suzie – ER nurse, Inova Fairfax, Virginia
Thamas, Claudel – USC-LA County Hospital
Williams, Joy – Massachusetts General Hospital, Boston
Medical/Disaster Responders
Gautney, Brad – One 5 Foundation of Leawoods
Kruschke, Gary – Florida One Disaster Medical Assistance Team, Ft Walton Beach, Florida
Lindsay, Keith – Director, Massachusetts Disaster Medical Assistance Team
Lipin, David – Director, Disaster Medical Assistance Team, San Carlos, California
Stokes, Mickey – Lumiere Medical Ministries
Vojak, Michael – EMT
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Comments Off
December 31st, 2009
Although none of the editors of InsideSurgery are involved in his care, we are following news reports that radio personality Rush Limbaugh has been hospitalized with chest pains and is listed in serious condition.
Limbaugh, 58, was taken to Queen’s Medical Center in Honolulu by an ambulance crew. He has no previously reported hospitalizations for chest pain.
Chest pain in a 58 year old man can have multiple causes, some several potentially very serious such as myocardial infarction (MI or heart attack or aortic dissection or rupture).
Limbaugh, who has lost a significant amount of weight in the last year, would be at an increase risk of cardiovascular disease because of his age, morbid obesity, and known affinity for smoking cigars.
When a patient arrives to the emergency room with a complaint of chest pain, most emergency rooms activate protocols to rapidly diagnose and treat the causative condition.
Below is a description of what typically happens to a patient with this complaint after they get to the emergency room.
Patients who arrive via ambulance with chest pain are given a high priority for treatment and are usually triaged immediately to a bed where they can be seen and examined (that is, they generally do not have to wait in the waiting room.)
If they are awake and talking as Limbaugh reportedly was, immediately after admission they are assessed by a nurse who takes vital signs – a heart rate, blood pressure, and temperature.
Usually, supplemental oxygen is then applied through a nasal cannula (plastic prongs inserted into each nostril that is attached to an oxygen supply from a wall outlet.)
The patient is then fairly quickly placed on a heart monitor where a one-lead heart tracing can be seen second-to- second – usually the V2 lead. Generally, the one-lead electronic heart monitor tracing is used to detect irregular heart beats and not ischemic disease.
Most emergency rooms in large hospitals have heart monitors that can also produce a paper 12 lead electrocardiogram (ECG) that is the first test used to detect whether the patient might be having cardiac ischemia.
Typically the 12 lead ECG is obtained both before and after treatment for chest pain to assess whether the ECG changes with treatment.
The nurse will then take a history asking the patient if they have ever had chest pain before, when it started, the nature of the pain (stabbing, dull, crushing, whether it radiates to the chin or down either arm or towards the back.)
If the patient still is having pain, typically they are given nitroglycerin under the tongue to dilate the coronary arteries. Resolution of chest pain with administration of nitroglycerin most typically is suspicious for cardiac ischemia but can occur with conditions other than heart attack.
If the patient is still relatively stable, a blood draw for laboratory testing is then done. The specfic tests done depend on the patient’s medical history but should always include troponin level and “cardiac enzymes”.
Troponin is a substance that is released when muscle dies. There are three types of troponin that can be release and the blood test should always investigate for an increase level of fractionated troponin – most generally troponin T.
The term “cardiac enzymes” generally refers to a serum test for the enzyme CK-MB, which is the specific enzyme in that class released into the blood in heart attacks.
Limbaugh undoubtedly received both of these blood tests shortly after arrival in the emergency room.
December 7th, 2009
Although the editors are not participating in his care, we have noted reports that Tiger Woods was intubated (i.e., placed on a breathing machine) and admitted to the intensive care unit (ICU) in the hospital where he was treated after his accident in the early morning hours of Friday, November 27.
MSNBC columnist Courtney Hazlett is reporting that an unnamed physician who did not participate in Woods’s care said that Woods was taken to the ICU where he was extubated and then shortly afterwards released to home. This source is stating that he felt not going to a step down unit before discharge was a highly unusual move.
In addition, the MSNBC column is reporting that Woods had taken alcohol earlier in the day and is reportedly on Ambien and vicodin and there was a request for a subpoena to obtain blood test results for Woods from Health Central Hospital.
There appear to be some unusual aspects to these reports and some thoughts on these alleged facts are as follows:
First and foremost, the physician who is leaking this information is not acting in the most professional manner possible, even if he is not technically violating Woods’s right to privacy.
Woods’s treating physicians would be bound by the privacy rules in the Health Insurance Portability and Accountability Act (HIPAA) that prevent healthcare professionals from publicaly disclosing details of a patient’s care without their permission, except in certain circumstances.
But physicians (even those not technically bound by HIPAA guidelines) generally should not be revealing specific details of care of ANY patient without permission, even if they are not personally involved in that care.
The intent of the HIPAA legislation is that patients have a general right to privacy concerning their personal healthcare and a physician repeating to the press details heard in the doctor’s lounge violates this trust.
Secondly, the report on MSNBC states that the neighbor who called in the accident told dispatchers that Woods was asleep on the ground and snoring. The physician source then states that this is a sign of an unstable airway and was the reason he was intubated after he got to the hospital.
The physician source is correct that Woods may have had an unstable airway that is possibly lifethreatening.
If, in fact, Woods was unarousable for any reason (head trauma, sleeping, intoxication) and making sounds that sounded like snoring, he should have been intubated at the scene, assuming the first responders unit was an advanced life support crew that included paramedics that were trained to do so.
It is not considered standard of care to wait for intubation to take place at the hospital. Patients can and do die if a needed intubation is delayed.
Stridor caused by laryngeal spasim in an unconscious patient is often mistaken for “snoring” and is an indication for emergent intubation.
Almost certainly, if Woods was unconscious or semiconscicous and had unstable airway signs and had not been previously intubated in the field, he would be immediately after being seen at the hospital by a trauma surgeon or an emergency room physician. All emergency room physicians are trained to intubate.
Thirdly, what happens next to a patient who is injured and brought into an emergency room intubated in the field or shortly after arrival depends on whether the hospital has a formal trauma care program.
If the hospital is a designated trauma hospital, the trauma surgeons would be notified either before Woods arrived or shortly thereafter and would assume care immediately after notification and presentation to the emergency room.
After the surgeons take over, Woods would have been evaluated for injuries and,if stable, sent through the CT scanner to check for injuries before he was admitted to the ICU.
Fourthly, the source for MSNBC said that once admitted to the ICU you “don’t go straight home” and are usually sent to a step-down unit and the fact that Woods was discharged from the unit indicated some unusual and extreme privacy measures were being taken.
Unfortunately, this is just not true.
There are many trauma patients who come into the trauma bay intubated or who are intubated shortly after arrival who receive their radiographic studies and who are then extubated in the trauma bay, particularly if all radiographic scans are negative.
In fact, some patients come into the trauma bay intubated, get their scans, get extubated, and are discharged to home from the trauma bay without ever being admitted to the hospital.
Likewise, it is not uncommon for patients who are intubated but not immediately extubated to be transferred to the ICU on the ventilator and then subsequently to get extubated in the next several hours and to be discharged from the ICU to home, particularly if the patient is reliable and does not live alone.
The fact that Woods was not sent to a step-down unit before discharge is in no way an unusual occurrence, especially for a young person with no serious injuries and no preceding medical illness.
Fifthly, Woods allegedly may have been driving with Vicodin and Ambien in his system and there was concern that he may have been driving while impaired.
Patients generally are told by physicians not to operate any vehicle while actively taking narcotics (Vicodin), generally within the previous 24 hours.
Although narcotics levels in the body rapdily decrease with time and a small amount of narcotic in the body probably does not significantly impair driving performance, the lab tests routinely used in the trauma bay (urine testing) to detect recent narcotics ingestion are qualitative (not quantitiative) in nature.
Thus, there is no way to tell how much or how little narcotic has been ingested and how much impairment it has caused.
But, it is serious legal development for a driver to be in an accident while there are narcotics “on board.” And, as such, almost universally, any driver in a single motor vehicle accident is tested for the presence of alcohol and drugs.
But, despite the fact that the tests are widely performed in trauma patients, the police do not have the right to access this information unless a subpoena is granted by the legal system.
Although the alleged request for a subpoena in Woods’s case was apparently denied, this is highly unusual for the driver in a middle of the night, single vehicle motor vehicle crash.
November 17th, 2009
The federal government released new guidelines this week that recommend some startling changes in how women should be screened for breast cancer.
Current recommendations call for most women to get a baseline mammogram at the age of 40 and to get yearly screenings thereafter.
However, the 16 member panel of the United States Preventive Services Task Force (none of whom are oncologists or breast specialists) that made the recommendations now say that women who are of average risk of contracting breast cancer should, in consultation with their physicians, begin regular, routine mammograms at the age of 50 and that yearly mammograms are not necessary.
They are also recommending that women abandon the practice of self breast exams.
When considering these new guidelines it is important to understand that the vast majority of breast cancers present as a mammogram finding or as a palpable mass in the breast.
Should one infer then that if the panel is not recommending mammogram screening and not recommending self-exam, they are then not recommending any attempt at diagnosis of breast cancer before age 50?
After receiving several phone calls from women family members looking for guidance on what to do, this surgeon (who has not done an insignificant amount of breast surgery) is recommending these new recommendations go right where they belong – in the garbage.
And, it looks like I have some company in this position. Dr. Otis Brawley, the chief medical officer of the American Cancer Society, voiced his disagreement in the USA Today, saying “The task force is essentially telling women that mammography at age 40 to 49 saves lives; just not enough of them.”
Let’s take a quick look at some numbers.
An estimated 1.5% of women will develop a breast cancer between age 40-49 and approximately 6300 women each year die of breast cancer that was diagnosed in their 40s.
Many thousands more women in their 40s each year who are diagnosed and treated for breast cancer survive.
In other words, there are tens of thousands of women each year who develop breast cancer while in their forties.
Everybody agrees (including the task force) that routine mammorgram screening cuts the risk of dying from breast cancer by 15% for women in the 40s and 50s.
The rationale given in part for the new recommendations is that the benefit of picking up the breast cancers in women age 40-49 is offset by the disadvantages of doing the procedure – the expense and physical discomfort of the test and the possibility of false positives causing ultimately unnecessary biopsies and the attendant anxiety of waiting for test results.
In addition, their argument is that it is not necessary to pick up breast cancers early when they are smaller in size as many breast cancers are slow growing and can be treated with equal outcomes at a larger size.
This is double garbage.
Mammograms are a non-invasive test and if done by an experienced mammogram radiology technologist take a few seconds of moderate pressure on the breast for two views of each breast. The discomfort is trivial. Breast ultrasounds and MRIs are completely painless.
Even the pain of breast biopsies has been reduced. Most biopsies are now done via a minimally invasive technique called stereotactic biopsy that uses one injection of local anesthestic and involve a needle only being placed into the breast.
The most disturbing and patronizing argument in this whole rationale is that doing mammograms (and possibly finding breast cancers at a smaller size) might cause women to worry unnecessarily. It is estimated that after ten yearly mammograms the risk of having a false positive is between one and ten percent.
So what? The task force wants to replace saved lives with less weekend biopsy anxiety in a single digit percentage of women getting mammograms?
“Don’t worry your sweet little head about getting that biopsy, honey. Never mind that it might save your life.”
All experts agree that prognosis in breast cancer is, in part, dependent on how large the tumor is when it is removed. And although some data exists that purports that breast cancers can actually regress, the natural history of this is not clear.
What is clear is that no experienced breast surgeon diagnoses a breast cancer and then “watches it.” Treatment is begun urgently as delay will likely result in an interval increase in tumor size, thus likely worsening the stage at resection (surgical removal).
I think that women in their 40s who were diagnosed and cured of their breast cancers would not trade their cures for a slightly longer “worry-free” time in their lives coupled with a subsequent diagnosis of a much larger, palpable mass.
How many women would trade the diagnosis of a 1 cm tumor with a 90% five year survival at age 46 for a 6 cm tumor with lymph node involvement with a 25% five year survival at age 50?
It also comes down to the money. I can’t help but think about the timing of this release in view of the likelihood of healthcare reform that will possibly allow 20 million new females to obtain full access to elective healthcare and the attendant costs to the system.
Breast MRIs are expensive at $1500-$2000 but are never performed as a first step in diagnosis. Charges for mammograms run in the $80-$120 range. Ultrasounds run about $150-$300.
Compared with the tens of thousands of dollars spent on patients with terminal illnesses in the last 30 days of life, these tests that everyone agrees saves lives of women raising families and in peak professional years seem like a bargain and well worth the money.
I wonder if any of the 6300 women who die each year after getting their diagnosis in their 40s would pay $80 or $300 or even $2000 for the opportunity to have had their cancers diagnosed even earlier.
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November 5th, 2009
Although this editor is not participating in the trauma care being given to the victims of the Fort Hood shooting today, as a trauma surgeon and physician who has worked for the United States Army and has taken care of solidiers who are readying for deployment, I am following closely the developments being reported on multiple news outlets.
CNN is reporting that at approximately 1:30 PM Central time Major Hasan, a formally trained medical doctor and psychiatrist, allegedly entered a building containing soldiers who were completing preparations for overseas deployment and opened fire with two handguns, killing 12 soldiers and wounding 31.
News media are saying that Dr. Hasan was stationed at the Darnall Army Medical Center and himself was to be deployed in the upcoming weeks. He was reportedly upset about this.
Although there is much to learn about this sad event and it is unbelievably horrific on many levels, I am particularly revulsed that this act was allegedly committed by a physician and a trained mental health professional.
Any person who murders another deserves condemnation, but the fact that it appears that a physician who has taken an oath to put his patients’ well-being above all else committed this act on the very population that he has sworn to protect is beyond vile.
In addition, no person who joins the military should be surprised or upset about being sent to war. That is the reason why armies exist – to engage in combat.
While there are certainly people whose main reason for joining the military is that they see it as the only economic ladder out of poverty, this is more typical of young, less-educated soldiers who truly have constrained circumstances.
This is not the case for doctors. Physicians who stay in the civilian health care system are largely guaranteed access to federal financing for their education and training, if they are willing to undergo the inconvenience of handling a debt load of up to $300,000 upon graduation.
Some doctors in training, however, do not wish to take on that debt and have traditionally seen the military as a way to get solid medical training on an all-expenses-paid billet, with a relatively short six year commitment of service to “pay back their education.”
Up until the terrorist attacks on 9/11 and the subsequent wars in Iraq and Afghanistan, this six year commitment was usually spent practicing medicine in a civilian-like setting on peacetime military posts.
But, living and practicing in a war zone make the cost of the military track much more “expensive” and perhaps open the military doctor trainee to regret at the path chosen.
The brutal fact is that Dr. Hasan might have gambled that there was going to be no war during his service commitment, but war there is. Was Dr. Hasan incensed that his well-laid plans were going awry and was he projecting his rage onto innocent soldiers because he was being forced to pay his part of the bargain?
Finally, of all medical professions, psychiatrists are trained to be able to deal with difficult human emotions in themselves and others and should be able to summon more than the average cohort of coping skills.
Psychiatrists seeking therapy for themselves is well-accepted by the profession and even encouraged. Dr. Hasan had a moral obligation to get help if he felt his control or coping ability was slipping or if he was not able to handle the upcoming stress of deployment. Not to do so is inexcusable and as we now know, tragic for those around him.
August 24th, 2009
Although none of the editors of InsideSurgery.com participated in his care, we have followed closely the news reports of his death and the developing story that physician-prescribed sedatives might have contributed to an overdose that caused a cardiorespiratory death.
Major news organizations are now reporting that the coroner is likely to rule Jackson’s death a homicide. The reported exact doses and schedule of the powerful sedatives prescribed to Jackson are being detailed.
The author of this post is a critical care physician who has wide experience with administering Valium, Ativan, and propofol to patients and who has received propofol as a patient. Some thoughts on the use of these drugs and the care that Jackson reportedly received is below:
Propofol
First and foremost, propofol (Diprivan) should never be given in a home setting: this is grossly outside of the scope of acceptable practice. This drug is a cardiac and respiratory depressant and should only be given by anesthesia and intensive care physicians with wide experience.
Propofol has a relatively short onset of duration and a short duration of effect – if the patient is drug naieve to it. That is, if you only see the drug when you have your colonscopy every five years, it works within seconds of onset and “goes away when it is turned off.”
However, it can and will build up in the tissues in patients who have received long infusions of it or shorter, frequent exposure to it and can potentiate additional doses.
Jackson’s doctor reportedly said that he injected Jackson and then left the room for a few minutes and when he returned, Jackson had stopped breathing. Patients should NEVER be left alone after being administered propofol, even for a few seconds.
Patients being given this drug must be placed on a heart monitor that detects heart rate and a blood pressure monitor of some type. It is not clear from reports if this was done by Dr. Murray
Jackson’s doctor claims he placed an oxygen saturation monitor on the patient. This device is a measure of oxygenation or “O2 saturation” only.
This type of monitor does not measure the respiratory status of a patient or how deeply and how fast a patient is breathing. It does not measure the patients partial pressure of carbon dioxide or PCO2, which is the important respiratory fvalue to monitor when giving propofol and “benzo’s”.
For example, it is possible to be dead and have a normal oxygen saturation for several minutes.
A physician who does not understand the above described limitations of monitoring is by definition not qualified to administer the drug.
When giving propofol to a non-intubated patient (i.e., without the breathing tube), the maximum initial dose I will use is 10 mgs. Dr. Murray administered 25 mgs after several doses of benzodiazepines (Ativan, Valium, and Versed), which will increase the heart and lung depression effect of propofol.
Patients sedated with propofol are not asleep (as Michael Jackson wished to be) and the use of propofol as a sleep inducer in the United States is outside the scope of standard care.
There is no reversal drug or antidote available to treat a propofol overdose, unlike Ativan, Valium, and Versed (which can be treated with the drug flumazenil.)
Patients who have respiratory depression with propofol need artificially controlled respirations by one of several methods.
A bag mask can be placed over the mouth and nose with air or oxygen forced into the lungs by squeezing it. Alternately, an endotracheal tube (breathing tube) or laryneal mask airway can be placed into the pharynx with air or oxygen delivered to the lungs.
It is not clear from reports if Dr. Murray had these items available when he administered the propofol, but if he did not it would be grossly negligent.
Benzodiazepines (Valium, Ativan, Versed)
Unlike propofol, these drugs are used as sleep inducers, but they are also strong sedatives that have the same respiratory and cardiac depressant effects as propofol.
Reports claim that Jackson was injected with these drugs. It is not clear if the injection was into a vein (intravenously) or into the muscle (intramuscularly or IM.)
Almost universally in the United States, benzodiazepines administered at home are given orally in pill form.
After Jackson was found to be in arrest, it is not clear if he was given flumazenil to reverse the effect of the Valium, Ativan, or Versed or if this was even available.
In medical settings, this reversal drug is typically available in case of overdose.
The dose and timing of the benzo’s given to Jackson is not inordinately high for an intensive care setting for a patient on a ventilator, but it is more than would be considered prudent in an outpatient, home setting.
Criminal Charges/Medical Malpractice
If accurate as reported, the administration of these drugs in this manner to Michael Jackson by Dr. Murray is widely deviant from standard of care. It may even be criminally negligent. However, although I am not an attorney or judge, it seems difficult to see how this would fit the charge of murder. It seems unlikely that Murray was intentionally giving Jackson these drugs to harm him.
June 25th, 2009
Although none of the editors of InsideSurgery.com have participated in his care, we have noted the news reports that entertainer Michael Jackson has died of sudden cardiac arrest. He was 50.
Continue reading "Michael Jackson’s Sudden Cardiac Arrest"
June 21st, 2009
Although none of the editors of InsideSurgery.com are participating in his care, we have noted reports that Apple Founder and Chairman Steve Jobs received a liver transplant earlier this spring.
Fortune magazine is reporting that he received the transplant in Tennessee and is said to be recovering well. Jobs began a well-publicized job leave earlier this year for medical issues that were later deemed “more complex” than originally believed.
Jobs received surgical treatment in 1994 for an insulinoma of the pancreas.
Liver transplantation is a highly complex surgical procedure and management that is done by surgeons who commonly make this procedure the focus of their careers. Patients undergoing liver transplantation go through three phases of treatment.
Pre-transplantation and Listing
Liver transplantation in the United States is performed under a hybrid “public/private” arrangement between the United Network for Organ Sharing (UNOS) and individual transplant centers. UNOS is the agency that has been awarded exclusive jurisdiction by the federal government in deciding which patients on the transplant waiting lists receive available organs and tissue.
Liver transplant programs require considerable hospital financial and personnel resources. It is generally acknowledged that these operations are best performed by centers who perform large volumes of the procedure by professionals who devote themselves largely to this procedure and patient population.
Individual centers have broad leeway in deciding which patients to place on the waiting list for transplantation. Each center has their own exclusion criteria and protocols for evaluating prospective patients.
Most patients who receive a liver transplant are classified as having either chronic or fulminant (i.e., rapid) liver failure. A small percentage of patients receive a liver transplant to remove a liver containing a malignancy or to correct an underlying physiological defect when they are not in frank liver failure.
Generally, patient evaluation for liver transplant include a detailed history and physical, a financial means test, and an evaluation of likely compliance with the lifelong regimen needed to maintain the viability of the graft.
It is important to determine that the patient has enough physiological reserve to withstand the rigors of the operation and following regimen of immunosuppression.
A diligent search for the reason for liver failure and remaining liver reserve is made. Lab tests commonly drawn include serologies for hepatitis and HIV, blood type, liver function tests, Ebstein Barr virus (EBV), cytomegavirus (CMV), complete blood count, albumin, ammonia, serum electolytes, and urine and blood drug tests.
Other tests performed include computed tomography of the abdomen and pelvis, magnetic resonance imaging, electrocardiogram, and cardiac stress tests.
The most common etiologies in the United States include alcohol and substance abuse and infection with the hepatitis C virus. In cases of substance abuse, many (but not all) centers require a period of abstinence before the patient is entered onto the waiting list.
After a patient is deemed acceptable for transplantation a MELD score is calculated for them and is used as an indicator of severity of liver disease. The variables used in determining the MELD score are age, serum bilirubin, serum creatinine, and INR (internationation normalized ratio, a measure of coagulopathy or “thinned blood”.)
The Liver Transplant Surgical Procedure
Immunosuppression and Post-transplant Period
May 26th, 2009
Multiple news agencies are reporting this morning that President Barack Obama will nominate Second Circuit Court of Appeals Judge Sonia Sotomayer to fill the vacancy on the United States Supreme Court created by the resignation of Justice David Souter.
While none of the editors of InsideSurgery.com have participated in her care, we have noted the reports that Judge Sotomayor has suffered for the last forty-six years with diabetes mellitus.
Diabetes type 1 is a serious physiological condition caused by the body’s inability to produce sufficient insulin to control glucose regulation in the body. It is marked by a shortened life expectancy and severe morbidity, including cardiovascular disease, nephropathy, retinopathy, neuropathy, and immune dysfunction.
In short, patients with long-term type 1 diabetes as a population are considered by physicians to be seriously and chronically ill and to have little physiological reserve. Life expectancy for the type 1 diabestes population is estimated to be reduced by ten years as compared to the general population.
However, it is difficult to predict the course that diabetes type 1 will take over forty-five years for any one patient. Many diabetics with careful and constant glucose control and other diet and lifestyle modifications can live into their sixties and seventies with relatively few major health problems.
Prognosis for the diabetic patient must be considered in terms of both short-term and long-term complications.
Short-term complications
Acute adverse events related to diabetes are related to derangements in the serum level of glucose and other substances. High serum glucose levels (hyperglycemia) result when the administered insulin dose or schedule is not sufficient to promote adequate uptake of glucose into the cells or a patient consumes more food than the administered amount of insulin can process.
Lack of sufficient fuel for the cell can result in diabetic ketoacidosis (aka DKA), a condition where the body switches to an alternate fuel source to provide nourishment to the cellls. Diabetic ketoacidosis is a life-threatening emergency that requires admission to an intensive care unit and immediate medical care.
Hypoglycemia (low blood sugar) occurs when an excess of insulin in the body causes too much glucose uptake and deprives the brain of its’ need fuel. In its’ most severe form, it results in seizures, confusion, and coma. In its most severe form it is a medical emergency of the highest order and requires intervention within seconds to prevent injury and death.
On a short-term basis, diabetes is monitored by subjective reports of the patient (i.e., how they are feeling) and laboratory surveillance.
The most important laboratory value to monitor when dealing with diabetes on a day-to-day basis is the serum glucose level. The most important laboratory value to monitor when evaluating diabetes control on a week-to-week basis is the serum hemoglobin A1c value, which is a measure of the glycosylation of the hemoglobin molecule (i.e., how much glucose is attached to the hemoglobing molecule.)
May 9th, 2009
Although none of the editors of InsideSurgery.com were involved in the case, we have noted with interest the news reports alleging that Drs. Paolo Bolognese and Thomas Milhorat were guilty of patient abandonment in a recent incident at North Shore University Hospital.
Both prominent neurosurgeons, they were initially suspended by hospital officials for two weeks until the news media broke the story. The suspensions were then lengthened while the hospital considered how best to proceed. Dr. Milhorat’s resignation was announced on May 8, 2009.
Although the details remain sketchy, the main complaint revolves around a patient who was anesthetized and whose head was shaved without attending neurosurgeon Dr. Bolognese being present in the operating room. When attempts to notify him that his patient was “asleep” and ready for surgery failed, Dr. Milhorat was then contacted and told to report to the operating room to do the case.
Milhorat apparently refused to operate on the patient. It is not clear at this time whether the patient received the planned surgery from a third neurosurgeon or whether she was brought out from anesthesia without the surgery being performed.
Bolognese and Milhorat were both suspended for patient abandonment.
The suspension of Bolognese is questionable depending on the particular circumstances and the suspension of Milhorat is an outrage.
Certainly, attending surgeons who schedule elective cases have every obligation and duty to be present to start the case as planned. However, life events happen to people on the way to work (operating room). Cars crash, children become ill, coronaries occlude.
The operating room and anesthesia staff bear some responsibility in starting the anesthesia induction and preparation of the surgical site without ascertaining the Dr. Bolognese was in the operating room suite and available for surgery.
Most large hospitals now have policies that empower the operating room and anesthesia staffs to delay starting cases until the attending surgeon (not just the resident or physician assistant) is actually physically present in the operating room. A phone call from a cell phone reporting the position of the attending surgeon “just pulling into the parking garage” is generally not sufficient.
However the blame is proportioned in this case of an asleep, shaved patient without Dr. Bolognese present, there is no justification in assigning any of it to Dr. Milhorat.
Assuming Milhorat had no previous agreement with the patient to participate in her operation, he has no ethical or legal responsibility to step in and start the operation on a patient he has not met, nor prepared for.
To do so would be gross negligence and indefensible. Almost universally, surgeons would make the same decision as Dr. Milhorat when faced with his predicament. As the surgical incision had not been made, the best course is to “bring the patient up” from anesthesia and avoid the possiblity of a catastrophic blunder.
The fact that Dr. Milhorat’s refusal of a corporate directive to operate on this patient resulted in a suspension and the destruction of a long and illustrious career is a chilling warning about the increasing risk and loss of autonomy in surgical practice. Healthcare systems apparently are now having little hesitation in telling doctors how and when to practice.
Surgeons more than most physicians use invasive procedures to try to eliminate disease and heal patients. But, even the most aggressive practitioners keep foremost in their minds the first lesson taught through the centuries to physicians – first, do no harm.
April 30th, 2009
Vice President Joe Biden has been roundly criticized for remarks he made on NBC’s Today Show concerning his level of concern over the burgeoning type A H1N1 influenza situation.
He is quoted as saying, “I wouldn’t go anywhere in confined spaces now,” in response to a question about what advice he would give a family member who was contemplating traveling to Mexico.
Good for Joe Biden. Neither would we.
Critical care physicians the world over who will be charged with caring for the sick and dying of this disease are feeling moistness around the collar when thinking about what possibly lies ahead.
The cold, hard fact of this newly emerging disease pattern is that no one knows the likely course of this pathogen. Scientists are mystified over several characteristics of this near pandemic, including why the infections in Mexico seem to be more lethal than anywhere else.
In an attempt to develop an understanding on the possible future events, scientists, government officials, and healthcare professionals are looking backwards in history – especially to the flu pandemic of 1918.
What is clear from a study of history of influenza is that non pharmaceutical interventions such as voluntary quarantine and social isolation were helpful in places they were deployed, both in lowering the number of infections and the number of deaths.
Histories of the 1918 pandemic such as John Barry’s The Great Influenzadetail the astonishing speed of the virus as it tore through the overcrowded barracks and troop transports of American soldiers being readied for WWI
Modern day epidemiological computer programs also provide rationale to avoid overcrowding whenever possible to lower the influenza infection rate.
What is also clear from a study of 1918 is that sound public health decisions were obscured by short term political and commerical agendas. Tens of thousands of Philadelphians died needlessly because public health and government officials ignored the public health catastrophe before their eyes so as to not disrupt commercial activity in the city.
From a financial and commercial viewpoint, Biden’s suggestion is inconvenient and, if followed, would no doubt cause damage to local economies, something that the federal, state, and local governments wish to avoid.
However, from a viewpoint of personal safety and health, they seem prudent. What is the reason not to avoid being in overcrowded spaces? Because people shed the virus and are infective for several days before showing symptoms, simply avoiding people that are obviously ill does not assure that a person will not contract influenza.
From the not so veiled criticism and backtracking of the federal government, it is clear the Obama administration felt that Biden’s obviously sincere worry was too strongly focused on preventing individual cases of influenza infection.
Correcting, balancing economic health and the safety and well being of the public will depend on the competency of the federal, state, and local governments in prioritizing these competing interests. The governments do not want to needlessly alarm its citizens but when is the policy of reasurance worth the risk of preventable illness and possibly death?
The question for the public will be how much trust it has in the government to get it right and effectively manage this crisis?
What is known now is that the global health alert network was slow to activate, with private companies whose business it is to monitor for global disturbances repeatedly contacting the World Health Organization and the Centers for Disease Control and Prevention to spur them to action and public notification.
The “health authorities” were asleep at the switch it appears. Although efforts have appeared to be more coordinated in the last several days, there exists a possibility that the scope of the likely pandemic may overwhelm government efforts of even the richest of countries.
Experts are unanimous in stating that the solution of this possible pandemic and future ones is the widespread administration of an effective vaccine.
However, there is no vaccine for this strain of H1N1 and in a best case scenario there will not be for months. The earliest doses available will be given to “essential personnel” – government officials, law enforcement officers, the military, and health professionals.
The majority of the public will be on their own to manage as best as possible. The best strategy for surviving an influenza pandemic is to not get it at all. Avoiding crowded places, starting today, is one thing people can do to improve the odds of that happening.
One thing is for certain – in the days ahead, there will not be many intensive care physicians riding the subways of New York city.
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