Waking Up Costs via MedWorm.com

Highmark/blue shield criticism

Waking Up Costs — Sat, 02 Aug 2008 14:55:48 +0100

Heard in our household this morning: "They [Highmark Blue Shield] send there bills out in two seconds and their payments in two years." It makes me wonder if all their clerical errors which delay payments to providers are a strategy rather than a mistake... (Source: Waking Up Costs)

Not so fast, sugammadex

Waking Up Costs — Sat, 02 Aug 2008 09:55:42 +0100

The U.S. FDA has declined to approve Sugammadex secondary to concerns over rare allergic reactions. From Schring-Plough:" KENILWORTH, N.J., Aug. 1 /PRNewswire-FirstCall/ -- Schering-Plough Corporation (NYSE: SGP) today announced that the U.S. Food and Drug Administration (FDA) has issued a "not-approvable" letter for sugammadex sodium injection for the reversal of muscle relaxation during general anesthesia. "We are surprised and disappointed with this action, especially given that sugammadex received a unanimous recommendation for approval by the FDA Advisory Committee on Anesthetics and Life Support in March of this year," said Thomas P. Koestler, Ph.D., executive vice president and president of Schering-Plough Research Institute. "Sugammadex represents the first major pharmaceutical innovation in the field of anesthesia in two decades. We remain committed to bringing this important medical advance to those who are waiting for it in the United States, and plan to work with the agency to address the issues, which are primarily related to hypersensitivity/allergic reactions." There were no issues related to the efficacy of sugammadex." (Source: Waking Up Costs)

Depodur warnings

Waking Up Costs — Sat, 24 May 2008 14:54:32 +0100

I was preparing to submit a pharmacy request to add DepoDur (liposomally encapsulated epidural morphine) to our formulary what I ran across this nugget: FDA Warns of Settings That Increase Risk for Respiratory Depression From Morphine Sulfate Extended-Release Liposome Injection (DepoDur) On December 14, 2007, the FDA approved safety labeling revisions for morphine sulfate extended-release liposome epidural injection (DepoDur; Skye Pharma Inc) to warn of settings associated with an increased risk for respiratory depression. Although the formulation is intended for administration by the epidural route only, postmarketing reports have included cases of intrathecal use. In all cases, signs of prolonged respiratory depression required use of a narcotic antagonist (naloxone) or ventilatory support. Because a breached dural membrane can lead to intrathecal leakage, particularly when the epidural drug is administered in a bolus, vigilant monitoring of respiratory function for a prolonged period (48 hours) is advised when extended-release morphine sulfate liposome injection is administered after a recent dural puncture. Provision should be made for emergency ventilation to minimize the risk for serious respiratory depression. Subarachnoid puncture during epidural administration of the product has also been linked to cases of prolonged and serious respiratory depression or apnea, occurring within 12 hours of injection and after apparent recovery from anesthesia. Respiratory depression can be successfully treated with a naloxone bolus or, more commonly, a naloxone infusion; intubation and mechanical ventilation may be necessary in some cases. Morphine sulfate extended-release liposome injection is indicated for single-dose epidural administration at the lumbar level to treat postoperative pain; it is given before surgery or after clamping the umbilical cord during cesarean delivery. The injection is not intended for intrathecal, intravenous, or intramuscular administration. (Source: Waking Up Costs)

Excellent resource on screening for von willebrand disease

Waking Up Costs — Sat, 19 Apr 2008 18:57:43 +0100

From the National Heart Lung and Blood Institute: The Diagnosis, Evaluation and Management of von Willebrand Disease [PDF] (Source: Waking Up Costs)

Asa: details on malignant hyperthermia

Waking Up Costs — Sat, 29 Mar 2008 12:24:16 +0100

From our national organization, the American Society of Anesthesiologists, Details on Malignant Hyperthermia which may in part explain the recent tragic death of a high school student. "In light of the recent tragic death of a Florida teenager from a reported case of malignant hyperthermia, ASA recognizes the importance for patients to know the facts behind the occurrence of this rare genetic disorder...." (Source: Waking Up Costs)

Anesthesiology: adverse respiratory events in children who are obese.

Waking Up Costs — Fri, 07 Mar 2008 14:51:45 +0100

Incidence and Risk Factors for Perioperative Adverse Respiratory Events in Children Who Are Obese. "[O]bese children had a higher incidence of difficult mask ventilation, airway obstruction, major oxygen desaturation (>10% of baseline), and overall critical respiratory adverse events. Logistic regression analysis revealed several risk factors for adverse events, including procedures involving the airway, obesity, age younger than 10 yr, and a history of obstructive sleep apnea." (Source: Waking Up Costs)

Aetna doing the right thing (at least temporarily)

Waking Up Costs — Thu, 28 Feb 2008 00:43:30 +0100

Aetna to Still Pay for Colonoscopy Drug "Bowing to critics who contended it was putting profits before patients, Aetna said Wednesday that it has suspended — at least temporarily — a plan to stop paying for routine use of a powerful anesthetic in a procedure to screen for colon cancer. " (Source: Waking Up Costs)

Jama: effectiveness and efficiency of root cause analysis in medicine

Waking Up Costs — Wed, 13 Feb 2008 03:08:39 +0100

Effectiveness and Efficiency of Root Cause Analysis in Medicine "Not all actions aimed to mitigate risk are equal. Some actions, like redesigning a product or process, are strong and have a high probability of reducing harm. Other actions, like reeducation or writing a policy, the 2 most common recommendations in health care RCA, are weak and have a low probability of reducing risk." (Via JAMA current issue.) (Source: Waking Up Costs)

Aetna, colonoscopy, and money

Waking Up Costs — Mon, 11 Feb 2008 21:52:38 +0100

I suspect that there is much more to Aetna's recent decision (pdf) to stop paying for Propofol for all (exceptions exist) colonoscopies than either Propofol or colonoscopies. At first glance it just look like they're trying to save themselves the additional cost the anesthetist or anesthesiologist that is needed if endoscopists want their patients to receive propofol adds. But I think there's more to it than that. Let me state at the outset that my practice does not derive significant income from providing anesthesia for colonoscopies. The vast majority of colonoscopies done with propofol use RN's with anesthesia training (CRNA's) to provide the service. I point this out because it seems that having any financial involvement at all is cause for discounting ones opinion--it should not be, but it is. Using propofol allows colonoscopies to be done without patient awareness of discomfort, true, but the real advantage is that patients recover from the drug fast. By way of example, if a colonoscopy is done the 'old fashioned way' using the sedative midazolam and the narcotic demerol or fentanyl, the patient will likely need to remain in the center for one to two hours before they meet discharge criteria (assuming they don't have any nausea). Propofol allows them to go home in about 30-45 minutes. Roughly twice as fast from completion of colonoscopy to discharge. That means they occupy a recovery bed for less time and that's the limiting step for many centers. Once all the recovery beds are full, you can't do any more procedures until one opens up. Being able to quickly discharge patients after their exam allows much greater throughput in terms of exams per day that can be done . Here is where I think the policy change will have its real effect. Either endoscopy centers will continue to provide the option of propofol sedation but charge the patient for it (in which case the insurance company will pay less), will provide it as part of the facility fee as a way to compete more effectively for patients (in which case the insurance company will pay less), or centers will go back (and I do mean back) to using older drugs but sacrifice throughput (in which case the insurance company will pay less). Is having a colonoscopy easier with propofol? Don't take my word for it. Ask any endoscopy nurse which way he or she would prefer having a colonoscopy done. Aside from cost and cost savings there's the issue of who decides what appropriate care is. If insurance companies are allowed to dictate who can and cannot get a certain kind of anesthesia, what will they do next? Get rid of anesthesia payments for cataract surgery? How about for trigger finger releases and carpal tunnel surgery. Vasectomy? See where I'm going with this? (Source: Waking Up Costs)

Ipods and pacemakers

Waking Up Costs — Sun, 03 Feb 2008 04:01:28 +0100

iPods and Pacemakers: " (Via Medgadget.) (Source: Waking Up Costs)

Good summary on bis

Waking Up Costs — Sun, 03 Feb 2008 03:48:27 +0100

Is there a consensus concerning the routine use of BIS monitoring during general anesthesia? (Source: Waking Up Costs)

My macbook air shipped!

Waking Up Costs — Wed, 30 Jan 2008 11:19:37 +0100

"MACBOOK AIR 13/1.6/2GB/80GB-USA Shipment Date: Jan 30, 2008 Delivers by: Feb 04, 2008 " (Source: Waking Up Costs)

George carlin, 'a place for your stuff', and the macbook air

Waking Up Costs — Sun, 20 Jan 2008 16:06:12 +0100

My uber-cool sister-in-law gave me the George Carlin Reads To You boxed set. George Carlin's "A Place For Your Stuff" exactly summarizes my dilemma about how to keep my computer 'stuff' handy. Thanks to Apple, 'there's all different ways of carrying your stuff.' Let me explain. All my 'stuff' is on my 24" Core2Duo iMac. That stuff is automatically copied every hour to an external hard drive via Time Machine so my stuff is safe from a computer hard disk problem. My really important stuff is backed up online using dotMac. Every night at 2 in the morning. Really. I want to take some of my stuff with me wherever I go. I use my 60 GB video iPod to carry stuff around on but I need to plug it in to another Mac to see my stuff and, let's face it, there aren't a lot of Macs around in the workplace. Right now I use my iPhone to carry important stuff, but there's lots of stuff I can't carry on my iPhone, like the article on how to use Google Reader that I'm working on, or the PDF files I'd like to read. Going from my iMac to the outside world means I have to leave a lot of stuff behind.....until now. Thanks to the MacBook Air I can now take most of my important stuff with me and it will only weigh three pounds! (Source: Waking Up Costs)

Openid for non-superusers

Waking Up Costs — Sun, 20 Jan 2008 02:50:34 +0100

OpenID for Non-SuperUsers (Source: Waking Up Costs)

Macbook air

Waking Up Costs — Tue, 15 Jan 2008 20:53:57 +0100

MACBOOK AIR 13/1.6/2GB/80GB-USA MB003LL/A $1,799.00 Ships by: Feb 6 Delivers by: Feb 11 (Source: Waking Up Costs)

16,707 spam e-mails in one month

Waking Up Costs — Fri, 11 Jan 2008 01:04:24 +0100

My group uses Google Apps for Your Domain for one of our domain names. That particular domain had been compromised before it went to GAFYD. A trojan had infected an unprotected office PC and harvested our addresses. I logged in to the account for the first time in a month today. In one month, Google's SPAM filters blocked 16,707 spams from getting to our inboxes. Thanks, Google. (Source: Waking Up Costs)

My predictions for apple's new laptop--3g wireless

Waking Up Costs — Tue, 01 Jan 2008 14:05:01 +0100

The one feature for Apple's new laptop that no one has mentioned but that I'm hoping for is the option to add a 3G wireless card. Give me a 3 pound, 13", solid state memory, 12 hour battery life (or even 8) laptop that is connected anywhere ATT has 3G wireless and I'd pay a premium to get one. (Source: Waking Up Costs)

Clark venable, m.d.

Waking Up Costs — Mon, 31 Dec 2007 08:53:24 +0100

Lifehacker suggested setting up a nameplate site way back in February of 2006. This post is my attempt to get Google to index it: http://www.clarkvenablemd.net/. (Source: Waking Up Costs)

Pay for performance: physicians pay for insurers better financial performance?

Waking Up Costs — Sat, 29 Dec 2007 00:19:58 +0100

I've always been suspicious of the pay for performance movement. Thinking cynically (which I do more and more these days), it seemed to me that pay for performance has the backing of the insurance industry because they could use it as an excuse to pay physicians less. Show me a pay for performance program that actually increases costs to insurers and I'll show you an out-of-work actuary. Mark Vonnegut, a pediatrician, has a perspective article in the December 27, 2007 issue of the NEJM titled Is Quality Improvement Improving Quality? A View from the Doctor's Office. I found the following a much better statement of the issue than I could ever come up with: "I can't help suspecting that underneath all these quality-improvement and pay-for-performance initiatives lies yet another scheme that will work out very well for insurers and very badly for providers and patients." Unfortunately, it's not free full text, but it should be (meaning you'll need a subscription to read the whole piece). (Source: Waking Up Costs)

Nih-funded research to be free (after one year)

Waking Up Costs — Fri, 28 Dec 2007 03:51:01 +0100

I was browsing the Wall Street Journal Health Blog and ran across this item regarding the new federal budget: "The results of NIH-funded research must be made available for free online one year after they’re published in an academic journal. That’s a big deal, because the NIH is one of the biggest funders of medical research and subscriptions to the academic journals where that research is published can cost thousands of dollars a year. Some researchers and academic institutions have been pushing for this for years, and the multibillion-dollar journal-publishing industry hired a PR guy known as “the pit bull of public relations” to fight the change." (Source: Waking Up Costs)

Medscape cme: an introduction to the surgical care improvement project (scip)

Waking Up Costs — Fri, 28 Dec 2007 03:33:50 +0100

Surgical Care Improvement Project (SCIP) Module 1: Infection Prevention Update Maximum of 1.5 AMA PRA Category 1 Credit(s)™ for physicians (Source: Waking Up Costs)

Medscape cme: systemic lidocaine good

Waking Up Costs — Fri, 28 Dec 2007 03:30:06 +0100

Annals of Surgery: Systemic Lidocaine Shortens Length of Hospital Stay After Colorectal Surgery: A Double-blinded, Randomized, Placebo-controlled Trial. 1.0 AMA PRA Category 1 Credit(s)™ for physicians (Source: Waking Up Costs)

Health care reform distilled

Waking Up Costs — Wed, 19 Dec 2007 02:49:57 +0100

GruntDoc has an excellent distillation of the choices to be made in health care reform: "Price. Quality. Access. Pick any two" Sort of a permutation of C. Everett Koop when he said that Americans want the best medical care in the world, they want it for free, and they want it now. (Source: Waking Up Costs)

Patients pay only 14% of health care costs? wow.

Waking Up Costs — Sun, 16 Dec 2007 20:55:06 +0100

Free the market; Government interference hampers healthcare reform "In a system in which medical care seems free or is artificially inexpensive, with someone else paying for one's healthcare, medical costs spiral out of control because we are encouraged to demand medical services without having to consider their real price. For every dollar's worth of hospital care a patient consumes, that patient pays only about 3 cents out of pocket; the rest is paid by third-party coverage. And for the healthcare system as a whole, patients pay only about 14%." This article has several nice pieces of data. (Source: Waking Up Costs)

Saving 2660 megabytes on your new macbook

Waking Up Costs — Sun, 16 Dec 2007 02:28:04 +0100

A friend asked me to set up a new Macbook he bought for his wife. With recent Apple laptop sales being what they are, I bet many people will be doing the same thing, so I thought I'd pass along one thing I've learned: always erase the hard disk and re-install OS X. As loaded by Apple, a new MacBook running Leopard has a hard drive that contains 18.4 gigabytes of software. That 18.4 GB includes language translations and fonts you will probably never actually need. Reinstalling OS X and not installing language translations saves 1.9 GB. Skipping foreign language fonts saves another 141 MB. Not installing X11 saves more, so that skipping all these things saves 2.6 GB (or 2660 MB) of disk space. (Source: Waking Up Costs)

Nyt: google gets ready to rumble with microsoft

Waking Up Costs — Sat, 15 Dec 2007 22:35:06 +0100

If you're long GOOG (or even if you just like Gmail), read this in the New York Times. (Source: Waking Up Costs)

Pennsylvania's ed rendell playing games with mcare abatement

Waking Up Costs — Sat, 15 Dec 2007 22:00:17 +0100

The Governor of my state, Ed Rendell, has decided he wants to spend any surplus from the catastrophic malpractice insurance fund (which pays awards and settlements over $500,000) on providing insurance for uninsured adults in Pennsylvania. He wants this so much that that he's threatened not to renew the Mcare program unless he gets what he wants. Thought he State Senate has voted to extend the abatement, the House adjourned before voting. Here's an interesting quote from Rendell: "We're not going to go through the pain initially of having the doctors send in their checks, and then having to return them if we continue the (subsidy)," Rendell said after speaking at a nurses' conference in Hershey." What about the pain of the physicians who will have to figure out how to get the money to pay the full amount in January rather than April? Does the Governor think it's harder for the State to issue a refund than it is for doctors to get their hands on that kinds of money? There should be no linkage between renewal of Mcare abatement and funding of the Cover All Pennsylvanians insurance program. Mcare funds should be used to cover the program's unfunded liability and make it easier to privatize later. The Governor's Cover All Pennsylvanians should get funding in a way that does not impact Mcare's ability to retire unfunded liability and he should stop playing political games to fund it otherwise. (Source: Waking Up Costs)

Schneier: how to protect your laptop and portable disks

Waking Up Costs — Sat, 15 Dec 2007 13:03:50 +0100

Bruce Schneier writes an excellent security newsletter called Crypto-Gram. This week there's something especially important for physicians who keep patient data on portable computers or drives: How to Secure Your Computer, Disks, and Portable Drives. "The reason you encrypt your entire disk, and not just key files, is so you don't have to worry about swap files, temp files, hibernation files, erased files, browser cookies or whatever. You don't need to enforce a complex policy about which files are important enough to be encrypted. And you have an easy answer to your boss or to the press if the computer is stolen: no problem; the laptop is encrypted." (Source: Waking Up Costs)

On 'waking'

Waking Up Costs — Wed, 05 Dec 2007 22:41:34 +0100

Haven't seen it. Will probably wait for the DVD. My national society, the America Society of Anesthesiologists, has a very nice patient education page on anesthesia awareness here and the referenced video is on YouTube here. No, I don't think Congressional hearing would solve anything. Aspect stock has not done as well as I thought it would in the last five days.... (Source: Waking Up Costs)

Anesthesiology: predictors of postoperative acute renal failure

Waking Up Costs — Sat, 01 Dec 2007 13:20:33 +0100

Predictors of Postoperative Acute Renal Failure after Noncardiac Surgery in Patients with Previously Normal Renal Function "Background: The authors investigated the incidence and risk factors for postoperative acute renal failure after major noncardiac surgery among patients with previously normal renal function. Methods: Adult patients undergoing major noncardiac surgery with a preoperative calculated creatinine clearance of 80 ml/min or greater were included in a prospective, observational study at a single tertiary care university hospital. Patients were followed for the development of acute renal failure (defined as a calculated creatinine clearance of 50 ml/min or less) within the first 7 postoperative days. Patient preoperative characteristics and intraoperative anesthetic management were evaluated for associations with acute renal failure. Thirty-day, 60-day, and 1-yr all-cause mortality was also evaluated. Results: A total of 65,043 cases between 2003 and 2006 were reviewed. Of these, 15,102 patients met the inclusion criteria; 121 patients developed acute renal failure (0.8%), and 14 required renal replacement therapy (0.1%). Seven independent preoperative predictors were identified (P < 0.05): age, emergent surgery, liver disease, body mass index, high-risk surgery, peripheral vascular occlusive disease, and chronic obstructive pulmonary disease necessitating chronic bronchodilator therapy. Several intraoperative management variables were independent predictors of acute renal failure: total vasopressor dose administered, use of a vasopressor infusion, and diuretic administration. Acute renal failure was associated with increased 30-day, 60-day, and 1-yr all-cause mortality. Conclusions: Several preoperative predictors previously reported to be associated with acute renal failure after cardiac surgery were also found to be associated with acute renal failure after noncardiac surgery. The use of vasopressor and diuretics is also associated with acute renal failure." (Source: Waking Up Costs)

Catalogs clogging your mailbox?

Waking Up Costs — Sat, 24 Nov 2007 11:57:39 +0100

I am convinced that the fact that two of our letter carriers have gone on disability is in large part due to the number of mail order catalogs we receive each day at home. For a while I was actually calling companies to ask we be taken off their list. Now I've found something better--Catalogchoice.org. "The mission of Catalog Choice is to reduce the number of repeat and unsolicited catalog mailings, and to promote the adoption of sustainable industry best practices. We aim to accomplish this by freely providing the Catalog Choice services to both consumers and businesses. Consumers can indicate which catalogs they no longer wish to receive, and businesses can receive a list of consumers no longer wanting to receive their catalogs." I've declined twenty catalogs so far and can't wait for today's mail to arrive so I can decline some more! (Source: Waking Up Costs)

Find big files in os x

Waking Up Costs — Fri, 16 Nov 2007 12:05:43 +0100

I just found a nifty freeware application for OS X to help scan my hard disk and graphically represent the file sizes present. It seems to run well on OS X, too. From the developer: "GrandPerspective is a utility application for Mac OS X that graphically displays the disk usage of a file system." I asked it to look at my documents folder and found a 1.5 GB file associated with an app I tried out but then deleted: Though it's a free app, donation are appreciated, I'm sure. (Source: Waking Up Costs)

Sums up my experience regarding tight glycemic control in non-diabetics

Waking Up Costs — Sun, 11 Nov 2007 03:50:26 +0100

"A stupid man's report of what a clever man says can never be accurate, because he unconsciously translates what he hears into something he can understand." --Bertrand Russell (Source: Waking Up Costs)

Up the creek without an os x 10.5 paddle

Waking Up Costs — Sun, 28 Oct 2007 10:24:36 +0100

The new version of Mac OS X has been released. Yea! And, although it will be delivered to my door at home Monday, I'm at a conference on a small island in a state that doesn't have a single Apple Store (South Carolina--who knew?). Poor planning on my part. Note to self: always check conference dates for conflict with major apple announcement dates or OS update releases. Stupid. Stupid. Stupid. (Source: Waking Up Costs)

At least somebody thinks having a doctor around is good....

Waking Up Costs — Mon, 15 Oct 2007 22:50:46 +0100

Micromat, publisher of TechTool Pro (own it!) has released Syphone, an OS X applications which allows you to 'view, save, and backup' SMS messages. This is handy for when you have a particularly funny series of text messages like this: (Source: Waking Up Costs)

Cdc creates new flu web site

Waking Up Costs — Mon, 15 Oct 2007 04:00:00 +0100

The CDC has created a new web site with influenza-related information that is a) informative and b) pretty. Take a look: http://www.cdc.gov/flu/ . (Source: Waking Up Costs)

There are six sigma specialists already at your hospital

Waking Up Costs — Sun, 14 Oct 2007 14:18:23 +0100

Six sigma. Lean six sigma. High reliability organizations. Hospital administrators seem to drool over this stuff. Many are willing to go out and spend lots of money on six sigma consultants to come in to their hospitals and integrate the buzz words. What many don't realize (or conveniently forget) is that anesthesiology is a six sigma specialty within medicine. That is, there are fewer than six mishaps per million events. That safety attitude is ingrained in us from the first day or residency. We live and breath six sigma and evidence-based medicine. So, hospital administrator, the next time an endocrinologist comes to you with a plan to give insulin to non-critically ill, non-diabetic patients with a blood glucose over 120 right before their general anesthetic and the entire group of anesthesiologist says 'I don't think that's a very good idea,' pause, take a deep breath, and listen to what they have to say. Six sigma is a way of thinking. Six sigma trumps three sigma any day of the week. (Source: Waking Up Costs)

Transfer password wallet entries to iphone

Waking Up Costs — Thu, 27 Sep 2007 17:44:31 +0100

I've been a long time user of Password Wallet from Zelznick Scientific Software. A password manager with 448-bit keys, it can launch url's and autofill usernames and passwords. Love it. This morning they announced the availability of Password Wallet for iPhone. I purchased and installed it right away. It's slick, so I thought I'd post some screenshots. After exporting my selected Password Wallet records to Safari as a bookmarklet, I synced my iPhone with iTunes. I next went to that bookmarklet: After entering my (correct) password I saw: Selecting one of the records yielded (username and password erased, of course). (Source: Waking Up Costs)

The latest in controlling or heat loss

Waking Up Costs — Tue, 25 Sep 2007 00:01:57 +0100

Keeping patients warm in the operating room can be a challenge. On call two weekends ago I had an 'Aha' moment--give them knit caps! Below is the protype--a scullcap made from 6 inch stockinette. [note: this photo was taken with an iPhone!] (Source: Waking Up Costs)

Tool of the trade: lidocaine

Waking Up Costs — Sun, 16 Sep 2007 01:11:20 +0100

Dr. Wes' post on the proper way to inject lidocaine got me to thinking about how I do it and I think I have some tips to share, too. I inject lidocaine in people's back while they're in labor, in their groins, necks, and arm pits when I do blocks, and of course in their hands and arms when I place IV's. (I inject it into their IV's, too, but there's no trick to that, really.) When I have time, I like to add about a one fourth volume of bicarbonate to the lidocaine I'm injecting. (This doesn't work with bupivicaine as it will cause it to precipitate out.) I've testing this on myself, on nurses in labor, and in patients in labor and I am convinced this removes most of the burning sensation that comes with injecting lidocaine. After having selected my injection site and cleaned it (with alcohol, betadine, chloraprep, duraprep, etc.) I wait for the prep to dry so that the prepping agent doesn't cause any stinging. I place a drop of lidocaine on the skin and insert the needle through the drop of lidocaine to make contact with the skin (after warning the patient, of course). This works, not because it numbs the skin under the drop (you need a eutectic mixture of local anesthetics for that) but because it caries some lidocaine in on the tip of the needle. I inject while inserting the needle intradermally. You should inject slowly, advance slowly, and see a skin wheal if it's truly an intradermal injection. This is easiest on horizontal surfaces but can also be done on a vertical surface like a back. In my opinion the wrong way to do inject lidocaine is the way tuberculin skin test are often placed: jab in the tiny needle (ouch!) inject the antigen quickly (ouch!). When I watch trainees inject lidocaine I often see them stop to aspirate to make sure they're not in a blood vessel. This is unnecessary a) if you keep the tip of the needle moving and b) because the total dose of lidocaine in the 3cc syringe is not enough to cause toxicity even if injected intravascularly. We now return you to your regularly scheduled programming... (Source: Waking Up Costs)

Give me $200 off my next iphone

Waking Up Costs — Sun, 09 Sep 2007 15:22:30 +0100

People at the hospital gleefully point out to me that my iPhone is now $200 cheaper than when I bought it ten weeks ago. I'll tell you what I'd like more than a $100 rebate now: A $200 rebate on my next iPhone (you know, the one with 3G wireless). (Source: Waking Up Costs)

Your history can haunt you

Waking Up Costs — Sun, 09 Sep 2007 15:14:43 +0100

A cardiologist in San Diego is accused of striking a patient during a heart cath: Dr. Maurice Buchbinder, a prominent cardiologist, and Scripps Memorial in La Jolla are under federal investigation because he allegedly hit a patient several times during a procedure at the hospital, physicians and health officials have confirmed. Having been called to the cath lab on several occasions to intubate his patients I can say that this report does not surprise me and is completely consistent with past behavior (though he never struck anyone in my presence). I'm quite sure he refrained from striking me only because of my size and ability to fight back. (Source: Waking Up Costs)

Nothing can stand between me and my bluegrass

Waking Up Costs — Sun, 09 Sep 2007 13:44:29 +0100

On call at the hospital today. The work is done and we're getting ready to order Chinese food. Time for some computer work and bluegrass. But wait! The hospital has decided to block XM streams! Thank you iTunes: Bluegrass Radio 128 kbps 100 Percent Pure Acoustic Bluegrass Life is good (again). (Source: Waking Up Costs)

Got aperture, want to upload to picasa? think ubermind.

Waking Up Costs — Wed, 01 Aug 2007 00:48:16 +0100

I just found a nice plugin for Aperture which automates uploading photos to Google's Picasa Web Album site--Aperture to Picasa Web Albums. My unfrozen caveman anesthesiologist review? Grrr. Upload easy. Good. Grrruh. (Source: Waking Up Costs)

Dr. anna poe of new orleans not to be charged

Waking Up Costs — Sun, 29 Jul 2007 17:06:35 +0100

Grand jury refuses to indict Anna Pou "Closing one of the most sensational chapters in post-Katrina New Orleans, Dr. Anna Pou said Tuesday that she fell to her knees and thanked God when she learned that a grand jury had refused to charge her with murdering patients in dark, fetid Memorial Medical Center in the nightmarish days after the hurricane struck on Aug. 29, 2005." Four civil suits are pending so her legal ordeal isn't over yet. As I understand it, the burden of proof in a civil suit requires only that the plaintifs version of the facts is 'more than likely' to be true (ref). (Source: Waking Up Costs)

Safety tip: nerve block needle disposal

Waking Up Costs — Wed, 04 Jul 2007 23:43:42 +0100

I most commonly use a 2 inch B-bevel insulated needle for nerve blocks. It is often not convenient to dispose of the block needle right away after completing the block, so I started placing it in the barrel of the empty syringe from the plunger side and holding it in place with by depressing the plunger. Like this: Safer for myself and my assistant (when I have an assistant). (Source: Waking Up Costs)

Dark chocolate proven healthy, again

Waking Up Costs — Wed, 04 Jul 2007 10:29:18 +0100

JAMA: Effects of Low Habitual Cocoa Intake on Blood Pressure and Bioactive Nitric Oxide "Results: From baseline to 18 weeks, dark chocolate intake reduced mean (SD) systolic BP by –2.9 (1.6) mm Hg (P < .001) and diastolic BP by –1.9 (1.0) mm Hg (P < .001) without changes in body weight, plasma levels of lipids, glucose, and 8-isoprostane. Hypertension prevalence declined from 86% to 68%. The BP decrease was accompanied by a sustained increase of S-nitrosoglutathione by 0.23 (0.12) nmol/L (P < .001), and a dark chocolate dose resulted in the appearance of cocoa phenols in plasma. White chocolate intake caused no changes in BP or plasma biomarkers. Conclusions: Data in this relatively small sample of otherwise healthy individuals with above-optimal BP indicate that inclusion of small amounts of polyphenol-rich dark chocolate as part of a usual diet efficiently reduced BP and improved formation of vasodilative nitric oxide." With a change of roughly 3 systolic points and 2 diastolic points I'm not going to stop taking my Prinivil just yet..... (Source: Waking Up Costs)

Muslim first, doctors second

Waking Up Costs — Wed, 04 Jul 2007 00:07:37 +0100

The news that several Muslim physicians were allegedly involved in the UK and Scotland bombing plots did not surprise me as much as it did some others. It made me think back to a conversation I had with a Muslim anesthesiology resident shortly after September 11th. This resident physician was from Iraq, was a doctor in Saddam's army , surrendered to Canadian troops during Gulf War I and was granted political asylum in Canada. He was very well trained and was a wonderful resident to work with--good work ethic, felt responsible to his patient, a pleasure to teach, a natural in many respects. I'd like to think we became friends during those years. In fact, he gave my an anesthetic for my own appendectomy. We'd had several conversations about Islam previously and I asked him what he would do if Grand Ayatollah al-Sistani instructed all Shia Muslims to kill Americans? Without even a pause he answered 'I would do it.' Muslim first, doctor second. (Source: Waking Up Costs)

Swapping 3g sim card into activated iphone fails

Waking Up Costs — Mon, 02 Jul 2007 00:16:21 +0100

Having settled on giving my wife the iPhone I wanted to see if I could insert her 3G SIM into the already activated iPhone so that her cellular number wouldn't change. No joy. I saw a brief message about it being the wrong SIM (even though the SIM cards appear identical on the outside). The device worked, but I had no cellular signal strength indicator or carrier name. What I've done instead is set her original number to forward calls to her iPhone number when it's off. (Source: Waking Up Costs)

The other london car bomb

Waking Up Costs — Sun, 01 Jul 2007 18:35:02 +0100

Surveillance camera's in London have captured video of what looks to be another car bomb attempt near central London. This one used a Volkswagen rather than a Mercedes. (Source: Waking Up Costs)