MedWorm.com provides a medical RSS filtering service. Over 5000 RSS medical sources are combined and output via different filters. This feed contains the latest items from the 'Passing Gas and Other Pursuits' source. Sat, 16 Aug 2008 14:46:17 +0100 http://anesthesiamania.blogspot.com/2007/02/nurse-practitioners-iii.html The ice cracks.My patient gets a non-verbal order for midazolam as a premed prior to coming to my OR. The surgeon has his preop discussion with the family, it is decided that the procedure would be cancelled for the day (the kid has a basketball game to play later that day). The nurses discharge the patient home only 30 minutes after the midazolam. This is usually the time of peak effect that we like to have preoperatively. Instead he is out the door.My name on the chart, an order I never gave, for a patient I never saw, a discharge order I never gave on a patient I had not evaluated and the time of discharge is way earlier than I ever would have agreed to. I try to call the family with the contact numbers available, without success. This one is going to create havoc. I have no option but to document my non-involvement in this patient's care at every step of the way. The documented verbal order for midazolam that was never spoken, now documented overtly as a fabrication on the chart. My non-involvement, the lack of phone calls, the decision to discharge without any doc's input is all clearly recorded. Copies are made and to cover my ass (is this kid getting apneic in the back seat of the car as I CYA?) file them with risk management so that nursing cannot retroactively document anything else. When this hits the fan the stink will be everywhere. (Source: Passing Gas and Other Pursuits) Passing Gas and Other Pursuits blogs http://www.medworm.com/rss/comments.php?id=464352 Mon, 05 Feb 2007 17:58:00 +0100 464352 http://anesthesiamania.blogspot.com/2007/02/5-out-of-6-players-satisfied.html In Russian Roulette 5 out of 6 players rate their satisfaction with the game as 'very good', or 'excellent'. Rephrased even more optimistically, 100% of respondents are happy with the result.Innumeracy shows its head many ways. This morning a typical matter presented itself when I was being somewhat more probing into the child's cardiac history than the family thought was necessary. I asked if there was any prior heart health issues or murmurs; answer no. As I'm listening to the chest, and keep listening because things don't sound quite right for a quick screening listen, mom says 'well there was that murmur, but it was supposed to go away'. Ahhh.... So loud P2, systolic crescendo/decrescendo murmur at the right precordium might not be just my imagination. Go on mom, tell me more. Seems there was an echocardiogram done at the Gods Chosen Hospital just down the road. Records from a cardiologist with echo results just 3 miles away, but the line to their records department is on voicemail. Mom notes that the last anesthetics went fine, can't we just do the same. But what is the same I ask, those records are where? Yet a third hospital? Mom's annoyed with me for not proceeding, stating overtly that I'm just being too cautious and protecting myself. I concede that indeed, I'm being professionally meticulous, but the child is also one that we are trying to protect too. Some times prior success is the result of the patient being healthy, sometimes it is the result of the anesthesiologist having a complete knowledge of the cardiac physiology and treating accordingly, sometimes it is just plain dumb luck. So I try to explain risks to mother. We can describe risk for the various cardiac conditions, but we have no way to assess risk in the present situation: cardiac physiology is abnormal, but I don't know in what way; consequently I don't know what actions might be helpful or harmful. Mom is fixated on the prior anesthetic success elsewhere, this is a children's hospital why can't we do at least as good. So I break out my roulette analogy, '... Even 5 out of 6 people playing Russian Roulette come though without a problem, but that doesn't mean they should keep on playing or that the gun is unloaded.' Ultimately she was not satisfied with my caution, but outside records were eventually obtained, care rendered and outcome fine. She told me so. (Source: Passing Gas and Other Pursuits) Passing Gas and Other Pursuits blogs http://www.medworm.com/rss/comments.php?id=464350 Fri, 02 Feb 2007 22:10:00 +0100 464350 http://anesthesiamania.blogspot.com/2007/01/nurse-practitioners-ii.html Nurse practitioners cannot prescribe schedule drugs in Missouri. That's the law and there is no way around it. Collaborative practice agreements cannot permit narcotic prescription. The PNPs (pediatric nurse practitioners) nevertheless have a system where they write for controlled substances as a V.O. (verbal order) from a physician. They have often not been careful about documenting which physician even, sometimes using the name of someone who is at another hospital that day, or even someone on vacation. The problem is I don't always agree with the orders I never gave in the first place. So when this happens I'm stuck with several unpalatable choices: 1) sign it and take responsibility, 2) don't sign it and passively get stuck with the responsibility, or 3) don't sign it and document that such verbal order was never given. I've tried all of these. #3 puts the nurse's license at jeopardy potentially, creates a large liability issue for her, her insurer and the hospital, and got my boss all but insisting that I needed to be a team player and go with option #1. The boss is a physician/manager, and needs to keep the veneer of individual physician autonomy present lest professional liability of the individual doc gets shifted to the boss through executive order. (Source: Passing Gas and Other Pursuits) Passing Gas and Other Pursuits blogs http://www.medworm.com/rss/comments.php?id=464353 Wed, 10 Jan 2007 16:39:00 +0100 464353 http://anesthesiamania.blogspot.com/2007/01/nurse-practitioners-i.html Zero situational adaptability.The patient arrives on time but the Same Day Surgery processes are bogged down and slow. This is a separate matter that boils down to not asking the patients to arrive sufficiently early. Having all the patients arrive just one hour before the scheduled start overloads the system and causes at least half the patients to not be ready for the scheduled first case start time. The nursing rationale for this planned delay is patient satisfaction; if we bring patients in any earlier then they complain about that, and satisfaction scores go down. Never mind the ripple effects a late start has on every subsequent patient's satisfaction. But this is a digression.The PNP seeing my patient still at 8:35 (scheduled start 8:30) still needed to talk with the patient about their 'options'. So she launches into a discussion about an oral sedative and topical anesthetic cream for the hand, LMX, which reduces the pain from the IV start. She just has no clue. Either of these drugs, to be effective, would have to have been used at least a half hour earlier. Just no situational awareness, no adaptability, no forethought to consider these measures at the start of her history and physical when it would have been possible to consider their use. But now while she mindlessly discusses options that don't exist I have to plan my diplomatic means of explaining to the patient how the time for options has passed. (Source: Passing Gas and Other Pursuits) Passing Gas and Other Pursuits blogs http://www.medworm.com/rss/comments.php?id=464354 Wed, 10 Jan 2007 16:26:00 +0100 464354 http://anesthesiamania.blogspot.com/2007/01/now-nurses-write-orders-for-doctors-to.html 'Doctors orders' used to mean a request for action comming from a physician; now it can mean a nurse or other health care worker directing a physician. Today a nurse practitioner decided that she was going to manage the perioperative care of my patients. Further, rather than discuss her concerns with me, she wrote an order on the chart directing me in my care.The order, "Type and screen to be drawn in the OR", was benign on the surface. But it was medically incorrect to begin with, and a slap in the face to me also.The patient was undergoing a splenectomy for ITP, and had had prior transfusions. This meant that the patient had a reasonable probability of requiring transfusion today, making a T and S less appropriate than actually crossmatching blood. Also the patient had an increased probability for having antibody incompatibilities with bank blood, making the discovery of such incompatibility in the middle of the surgical procedure unwise. So the more reasonable order would have been 'type and crossmatch in SameDay Surgery Center'. But her nursing decisions are influenced by patient satisfaction surveys, and one way the nurses here improve patient responses on such surveys is to tell patients they don't have to have a needle stick. They also don't tell the patient that they then bear a risk (blood not ready in this case) in order to gain a benefit (avoid needle stick). If I then ask that the appropriate action be taken then I look like the bad guy for doing that which was standard care. (Source: Passing Gas and Other Pursuits) Passing Gas and Other Pursuits blogs http://www.medworm.com/rss/comments.php?id=464357 Thu, 04 Jan 2007 19:20:00 +0100 464357 http://anesthesiamania.blogspot.com/2007/01/some-father-would-have-stroke-if-he.html A 15 year old girl was here for hymen resection. The history on the chart was imperforate hymen, but the rest of the history gleaned by the same day nurse was that menstrual flow worked just fine. In fact the only problem was that the hymen present was quite tough and despite repeated attempts her boyfriend just couldn't penetrate. So her real surgical procedure was deflowering so that she could get it on with her boyfriend. If her father knew what he was paying for he would be so proud! (Source: Passing Gas and Other Pursuits) Passing Gas and Other Pursuits blogs http://www.medworm.com/rss/comments.php?id=464356 Tue, 02 Jan 2007 21:18:00 +0100 464356 http://anesthesiamania.blogspot.com/2006/12/lady-tobacco-beccons.html A mother is waiting with her child outside the OR doors. She needs to be present while the surgeon and I meet her, review the child's health, confirm patient identity and correct surgery site. But, she is a nicotine feind disappearing for 45 minutes to feed her habit. So the kid waits. Did we have enough information to start? probably, but did she really intend for us to begin, to take her child to the OR for general anesthesia and have a chunk of bone excised from the leg. Her kid was somewhat upset about sitting there alone with us strangers, yet used to this situation, excusing his mother for her absence. What king of parent ditches their kid at such a time. (Source: Passing Gas and Other Pursuits) Passing Gas and Other Pursuits blogs http://www.medworm.com/rss/comments.php?id=464355 Fri, 22 Dec 2006 23:17:00 +0100 464355 http://anesthesiamania.blogspot.com/2006/12/protocols-rule.html The Joint Commission is now practicing medicine. Antibiotic prophylactic prior to surgical skin incision is one goal they have sought to promote. This is a good thing, as essentially all well designed studies confirm the efficacy relating to wound infection rates. Further, mortality, length of hospitalization, and costs are reduced, making the benefits global; the patient's win (their lives), the hospital wins (saves money), and docs win (every disease not caused is the same as a disease treated). But the guidelines for which antibiotics are chosen to be the best single regimen for a wide population. There is accommodation for patient allergy to a specific medicine but no room for a physician to prescribe more specifically for the patient's condition if more is known about the patient than the broad guideline can accommodate.So today I have a patient with a new abscess of the leg. The right thing to do, confirmed by our infectious disease department, is to give clindamycin. But the guideline says cefazolin. Not the right drug according to specialists in infectious disease, but the only one that will get me credit for compliance. And compliance is king. Anything less than 100% gets you a letter from the department chair admonishing one to be more thorough. These letters sit in my file, awaiting review by my boss at performance review time. Further, the department's compliance with antibiotics is reviewed by the Joint Commission periodically. If we get a ding here, then we'll really get administrators breathing down our necks. So which drug to give, the one now practically prescribed by JCAHO through its processes, or the one prescribed by specialists who have evaluated the patient personally?So I gave both, then sent it to the hospital lawyers to sort out. The cefazolin is charted and pharmacy is generating a bill. It was medically unnecessary as judged by me and the ID folk; billing for it would be fraudulent. Yet is was necessary as required by process. The hospital needed the process, not the patient, so it would seem unfair to bill. What if there had been a reaction to the drug? Then who is going to step up to pay. The hospital has a process that dictates the drug's administration. (Source: Passing Gas and Other Pursuits) Passing Gas and Other Pursuits blogs http://www.medworm.com/rss/comments.php?id=464358 Wed, 20 Dec 2006 22:00:00 +0100 464358 http://anesthesiamania.blogspot.com/2006/12/dilbert.html My favorite Dilbert cartoon depicts the pointy haired boss having to make layoffs. He issues the general announcement that all non-essential personnel can take the remainder of the day off and then is shown watching the employee parking lot with a pair of binoculars saying to himself "This is like shooting fish in a barrel"St. Louis had a typical winter storm beginning yesterday afternoon. An inch or two of sleet was followed by a couple inches of snow. The roads were slick but never impassable. Of the OR staff: 14 Anesthesia physicians all arrived on time (100%). Most were early; a meeting scheduled to begin an hour before the OR start attracted unusually strong attendance. 14 nurses were no shows. I don't know what the total count should have been, but this was from the planned staff required for 9 operating rooms. I was out shoveling my drive last night, then again at 4:30 this morning. Though my power was out (and still is) the car was warmed and scraped, coffee perked on a gas stove and breakfast prepared for the kids. I left home plenty early so as to not have to feign surprise at the slowness of travel. Those who can adapt to life's curves can excel. Those who cannot stay on the lower rungs. Or as Dilbert's boss would surmise, the non-essential personnel never even got to the parking lot today. (Source: Passing Gas and Other Pursuits) Passing Gas and Other Pursuits blogs http://www.medworm.com/rss/comments.php?id=464359 Fri, 01 Dec 2006 20:43:00 +0100 464359 http://anesthesiamania.blogspot.com/2006/11/half-brain-and-other-crass-comments.html “Epilepsy surgery in childhood: Half a brain may be better than seizures and other remarkable facts”. This was the title of a lecture provided by Dr. William Shields from UCLA last winter at Children's. I didn't get to attend, as it was in the middle of the work-day, but I did have some first-hand knowlege of the human side of procedure, hemispherectomy, that he discussed. Here is the body of the letter I sent him in advance of his lecture. He has not offered any response.Dear Dr. Shields,I noted an advertisement for your upcoming presentation at St. Louis Children’s Hospital, “Epilepsy surgery in childhood: Half a brain may be better than seizures and other remarkable facts”.My nephew is a study of the effects of the surgery you describe. In 1986 Paul Ryan Douthit developed intractable seizures following perinatal CMV. With medical control failing and health deteriorating, his parents accepted Dr. Goldring’s now eponymous surgical procedure. Paul’s seizure frequency did diminish substantially following the procedure, and were reasonably medically managed. All seizure drugs were stopped by age 14 with only a few seizures during the last 6 years. No doubt in Dr. Goldring’s published data and mental scorecard Paul represented a success. Medical successes however are not always defined in long-term quality of life outcomes, but often utilize surrogates measures. The quality of life outcomes for Paul and his family have not been quite so good as the objective seizure count might suggest. Paul’s milestones were quite delayed and he suffered significant hemiplegia. He did eventually learned to walk by age 4, speak simple sentences, feed himself, and become continent by age 10. Most debilitating were OCD like behaviors apparent by age 4. In his early teen years his compulsions and obsessions became not mere matters of annoyance to deal with, but because of his adult size and propensity to tantrum he could pose some injury risk to others. He ‘graduated’ from our Special School District, and tried living in various sheltered group homes. At each he was asked to leave because his behaviors could not be controlled. Medications to modify aggressiveness were rotated, escalated, and tried in numerous combinations. The State was hesitant to take him as a ward even as he was becoming impossible to manage at home. His parents housed him in a separate residence on their rural property separate him from his three younger siblings out of fear for their safety. On September 8, 2005 while his mother, my sister-in-law, was tending to his midday meals and medications, Paul bludgeoned her to death. Paul is now a permanent resident of the Biggs unit of the Missouri State Hospital for the criminally insane. The procedure was a success, but the patient never lived. Health care is and always will be an imperfect practice. “Half a brain may be better than seizures and other remarkable facts.” Then again, having done nothing at all twenty years ago might have been better than having half a brain. No one in the family holds a grudge against Paul. He functions at a level of 4-5 years cognitively and emotionally. He does not understand death, and does not understand why his mother does not visit him. As an anesthesiologist at St. Louis Children’s I participate daily in the provision of both established curative care, and also care that is desperately uncertain and unlikely to provide any lasting benefit. What rarely happens is for a pediatrician or surgeon to discuss implications of long-shot last hope procedures in terms of what can go wrong even if the procedure should happen to go right. When the chance for a ‘save’ is low, the chance for a save with a quality of life is even lower. Families are shown only the minimal superficial description of what constitutes success and failure. The full details of what constitutes failures of therapy are hardly covered well; the sometimes worse outcomes that can be associated with medical successes are fully glossed over. I do not relate this patient history to indict hemispherectomy or any other heroic and still experimental therapy. It is to illustrate that the narrow definitions of medical success do not always represent success for the patient, that families can and should be told that doing nothing is as correct and moral as playing for the long-shot, and that the health care establishment needs to accept and support families when they choose to do less than everything offered. In a file cabinet one floor up in this building I sit is a record that declares Paul a medical success. Half a brain may not be as good as the data might lead one to believe.Sincerely,Charles , M.D.Department of AnesthesiologySt. Louis Children’s Hospital, 5S31One Children’s PlaceSt. Louis, MO 63110 (Source: Passing Gas and Other Pursuits) Passing Gas and Other Pursuits blogs http://www.medworm.com/rss/comments.php?id=464362 Fri, 24 Nov 2006 21:37:00 +0100 464362 http://anesthesiamania.blogspot.com/2006/11/thousand-little-cuts.html We all want the day to go well, proceed efficiently, yet safely with no cut corners.My first patient had a Rapid Strep test ordered overnight for a sore throat; no result was yet available at the appointed OR start time. Waiting 15 minutes to know whether the patient would be at increased risk for post-op pneumonia seemed like a good thing to do. But the OR was delayed, and the charge nurse had to document someone as being at fault; so the fickle finger of fate denotes me, 'anesthesia', as being the source of the delay. Nothing about this was in my control beyond the practice of good medicine. The surgery was not booked until after I had gone home yesterday, the sore throat was noted overnight, the lab was ordered, but not followed up by the surgeon in the morning; but I was the one to say that there was a situation that prudence dictated waiting for. So it was simply concluded that it was my fault. How often does one get nicked for doing the right, reasonable, prudent thing? With each little nick, does my willingness to endure another wane? The system is geared toward wearing one down. And then I'll shift my threshold just a little one day, and odds are 100:1, maybe 1,000:1, or even 10,000:1 that I'll get away with it. But the odds aren't zero. It is just a matter of time before some patient suffers from an avoidable event. Probably when it does happen it will appear as one of those unavoidable things; I'll feel badly, but not really badly in a responsible sort of way. So I try to do what's right. At my annual review my statistics will be there, just how many late OR starts were (mis)attributed to me. But I gotta do what's right for my career. I'm actually sitting pretty well on the mortality statistics, my CPR rates are low too. Perhaps improving on-time starts can be accomplished without looking like a poor performer on other accounts; if only I would be willing to let some of these things slide... (Source: Passing Gas and Other Pursuits) Passing Gas and Other Pursuits blogs http://www.medworm.com/rss/comments.php?id=464363 Wed, 22 Nov 2006 04:38:00 +0100 464363 http://anesthesiamania.blogspot.com/2006/11/gu-system-all-clear.html Everything came out alright. A followup with my urologist and an x-ray reveals no further stones present and nothing more to do other than hydrate and avoid sources of oxalate. Calcium oxalate is apparently the most common stone type. We should not cut back on calcium consumption (causing brittle bones) but have no requirement for oxalate. There goes black tea, chocolate, many fruits, many beans, most high fiber grains. This whacks many of the dietary changes I've gradually adopted over the last few years that have otherwise improved my health, allowed me to loose (and keep off) 20 pounds and function as a pretty fair weekend cyclist (typical rides 35 miles/2hours, centuries in 6). I need to do a little plowing through the medical liturature on this one. The non-peer reviewed stuff on various health sites suggests magnesium citrate is of benefit; citrate with the calcium in the urine keeps things more soluble and supposedly the magnesium helps too. Of course in large amount this could also be a problem, as Magnesium citrate is the compound used in bowel preps; dosing must be careful.While at the urologist's office I was giving a urine sample in the restroom where I was to place it in this small stainless steel air-lock where someone on the other side could retrieve it. It adds a measure of clinical 'cleanness' to the biologic process of producing urine. No awkward moments of walking around in the hall with a cup of pee looking for someone to pass it too. Also remarkable about this little door is that it reminded me of the last time I was a patient in a physician's office out of necessity. This was some 30 years ago when I had a Colles' fracture casted. I'm 42 years old and this is the first time I've been to see 'the doctor' in decades. My only other contact was a required well visit upon matriculation to medical school (age 20) and again upon taking my first job (age 31). Good health I guess is the norm; as best I can tell from evidence based preventative health care, I will not need to see a physician again until at earliest age 50. The data for colon and prostate screening is iffy even then, especially with no family history of these problems. I'll just take a watch and wait approach to these, waiting to see if any long term outcome data support their use. (Source: Passing Gas and Other Pursuits) Passing Gas and Other Pursuits blogs http://www.medworm.com/rss/comments.php?id=464361 Wed, 08 Nov 2006 21:49:00 +0100 464361 http://anesthesiamania.blogspot.com/2006/11/passing-stones-not-gas.html Having my first renal stone was an interesting experience. I say first, because the natural history is that I'm not finished with whatever might be left in my renal pelvis, and recurrence is >50% in the next 5 years.Some lessons learned, which I'll note even before the clinical story:Having insight into a condition makes my experience, though probably similar to other's in the number of noxious neurologic impulses sent to the brain, not generalizable to the typical patient. I knew the diagnosis within minutes, recognized that it was benign (i.e. not going to kill me or do lasting harm), self limited, and endurable. The non-physician would not take such a dispassionate, clinical approach to such an event. Second, vital signs are a poor indicator for objective assessment of pain. I emphasize this for my anesthesia residents, but novices desperately want objective measures and correlations. "His heart rate is 60 and respiration is 12, how can he be in pain?" That's just what mine was. Not a suprise really as the pain, quite excruciating at times, was not causing anxiety and I was deliberately using distraction and guided imagery to keep myself somewhat dissociated, techniques I attempt to teach to my pain patients, often with little success. Also, the pain was mediated by the vagal nerve, so bradycardia, my rate did dip below 50, was to be expected. So my day yesterday went like this:13:00 Took son to Soccer game.13:15 Note slight ache in right flank. This gradually increases, with slight radiation into right groin and teste. A slight urinary urgency develops.13:30 Increasing discomfort but I can still carry on normal socially with parents at the game. I've figured out what is going on with almost complete certainty. 13:45 Soccer game has commenced. I decide to drive home (1 mile) with my daughter who wanted to come watch the game. 14:00 800 mg ibuprofen, lots of water and a call to a med-school buddy/urologist. 14:30 read about ureteral colic with what I can find on a web search (almost all my books are at my office). 15:00 talk with Jay (urologist), confirm that there is no reason for acute action beyond analgesia. I don't want an IV shot of opiates, especially as it would take hours to move through the ER system. The ER visit would get the flat plate and CT imaging done, but these can be accomplished in a few days if things are uncomplicated. Much easier to do these scheduled and when not in pain. 21:00 Colic is at times absent, then can be back full force within minutes; this continued through the afternoon and evening. Just about nine-ish or a little after resolution of colic is near complete (some psoas irritation evident with movement).23:00 The tea strainer catches a 1.5 mm stone. Microscopy reveals (yes, I have a microsope at home; lots of fun for the kids) a smooth oblong brown mass with very fine spindled crystals within its makeup. I've not found any good descriptions of the appearance of stone material on the web. My pathology microscopic atlas has not been unboxed since 1994 and I don't feel like looking for it now. Pain scales have become crap; that's my considered opinion as an anesthesiologist/sometimes pain-doc. Throughout my experience I did consider how I would respond to the ubiquitous pain inquiry from nurses (had I elected to join the health care system as a patient). The problem with pain scales is that the patient has a motivation to increase the rated number, especially since analgesic treatment and dose size will be determined by their response. If you think you need analgesics to cope with the pain say 7 or higher; if you can deal with the discomfort and wish to pass on meds, or head the lower potency route, say 5 or less. It is a numbers game to state in code what was once stated simply and directly. The other problem with pain scales is the lack of imagination of the patient. Ten is the worst pain imaginable by definition; most patients don't seem to get this. To someone with little prior experience or a poor imagination, an ingrown toenail can be a 10. Of course if everything is a 10 then their health care providers rapidly begin to ignore patient complaints of pain. Even at my worst, I knew the pain was probably only a 7 because I recognized that the body's capacity for sending noxious stimuli to my brain could still increase dramatically. Perhaps some people merely need a demonstration. When a patient who is clearly not in maximal pain reports a 10, just try examining where it hurts to show them what 10 really is. (Source: Passing Gas and Other Pursuits) Passing Gas and Other Pursuits blogs http://www.medworm.com/rss/comments.php?id=464360 Sun, 05 Nov 2006 15:45:00 +0100 464360 http://anesthesiamania.blogspot.com/2006/10/quantum-differences.html Popular usage of the word 'quantum' has tended to connoted large changes or differences. However, as used by scientists it refers to usually small but discretely different states; these states have no finer resolution between them. By analogy, a standard light is either on or off with no possible in-between state; this contrasts with the non-quantal condition that between the colors black and white there is an infinite gradation of grays. Ultimately in medicine a continuum of data must be translated into a specific action. Some actions are quantal, such as either deciding to treat hypertension or not. Other decisions may be made less quantal, such as how much drug to give for the treatment of hypertension; though in reality this too is often forced by the available convenient to use doses of the pills available. The problem is that patients see quantal difference as always having great significance. My patient today had sleep apnea and I elected to have him watched overnight in a monitored bed following a major orthopedic procedure. Mom protested that the last 4 procedures had not had such precaution taken and couldn't fathom why my decision would be different. I did try to describe my reasoning and how I arrived at a risk assessment for what events we were trying to avoid by the extra monitoring overnight. Here I was faced with a quantal decision; monitor or not. It looks completely different to the patient, yet functionally there is no in-between; the difference in choices is as small as is functionally possible. Decision making is at best a series of educated guesses often times. One creates an estimate of the likelihood of various events and estimates the severity of the possible outcomes. After creating the mental bell-curve one must ultimately turn this into discrete plans. If the decision making process and estimates of risk for this patient were to be compared by the 4 prior anesthesiologists and me there would probably be little difference. Yet only when we are required to take a continuum of risk-assessment and force it to fit available treatment options does there appear to be any material difference. In the end what is the patient to do? He has received in this instance not just one second opinion, but 4 second opinions. Each doc has a probability of being every so slightly wrong. I made my decision after a similar patient arrested on the ward a few weeks ago, while for the others that event had not yet happened. Would the patient view the 4 out of 5 doctors decision differently if I told him that? Reluctantly the parent agreed to my plan. As expected (my guess 99% no serious cardio-respiratory sequellae would occur) nothing did occur; mother was smug in her assessment of my ability. In the end the patients also don't appreciate risk. If nothing happens bad before will nothing happen bad again? Try to find a career Russian Roulette player and ask them. Prior luck does not portend future luck. (Source: Passing Gas and Other Pursuits) Passing Gas and Other Pursuits blogs http://www.medworm.com/rss/comments.php?id=464364 Fri, 27 Oct 2006 17:45:00 +0100 464364 http://anesthesiamania.blogspot.com/2006/10/what-is-race.html I got in a fight with my local ethics committee (aka Institutional Review Board). The function of this group is to ensure that research involving humans is ethical, adequately safe, and within the realm of sound science. It is also charged with various social considerations, such as the equitable access of various groups to become research subjects - this seems to presume that being a research subject is a good thing. As a matter of habit I do not record the race of any participant in any of my research studies as there has never been an instance when race seemed even remotely material to the performance or valid interpretation of the results. That and there is no serious validation of race having much biologic meaning anyway. It also seems better from a privacy standpoint to not record useless patient demographics about subjects. The quality of race information is also suspect - my guesses about race are guesses based largely on skin color. Patients might have a group with which they identify, yet this might not be the predominantly correct description of their genetic heritage and race descriptors are often socio-political rather than the original 3 race system (caucasoid, mongoloid, and negroid). Race choices like African-American, Asian/Pacific islander, native American tend to encompass even greater heterogeneity than sticking with skin color. My department illustrates the difficulty with the above concepts of race descriptors. We have a genuine African-American in the sense that I understand census pollsters; west African black skinned and descended from slaves brought to this country. But we also have an African-African, citizen of the east African country of Kenya. She has a very different appearance (other than similarly dark skin) and genetic heritage from the west Africans; she also is not American. We have two South Africans, neither is American. One is has very dark skin with very European features; he differentiates himself from South African "Blacks" by noting that his South African race designation is 'colored' and thus he has been treated differently than the 'black' race in South Africa. Finally, we have a fellow as pasty white as me descended from a dozen generations of South Africans with nearly pure Dutch blood lines. Now with us US citizenship he is an official African-American and has not avoided using this designation when is suits his purposes. (Source: Passing Gas and Other Pursuits) Passing Gas and Other Pursuits blogs http://www.medworm.com/rss/comments.php?id=464365 Fri, 27 Oct 2006 17:28:00 +0100 464365