Thursday, January 10, 2019

Should residency program directors look at applicants’ social media activity?

Please take a look at my new post on Physician's Weekly: My thoughts on whether residency program directors should review applicants' social media activity.

Friday, January 4, 2019

For longevity, is it better to be short or tall?

Being short is associated with worse outcomes for critically ill adults.

A large retrospective study of 233,000 men and 184,000 women consecutively admitted to 210 ICUs in the UK over a six-year period found hospital and ICU mortality decreased with increasing height after adjusting for available potential confounders. The difference was statistically significant.

The definition of short or tall was based on the median height of the subjects—175 cm (5’9”) for men and 162 cm (5’2”) for women. These figures are nearly the same as the averages for non-hospitalized adults.

The study had several limitations. Height was measured in just 44.5% of the group while the rest were based on estimates. However, the authors noted the median estimated height was exactly the same as the measured height for men and only 1 cm different for women, and measuring height in critically ill patients is difficult.

Friday, December 7, 2018

A fatal medication error

A 75-year-old woman died at Vanderbilt University Medical Center after receiving intravenous vecuronium, a drug that causes muscle paralysis, instead of Versed, a sedative.

Here’s what happened.

She had been recovering well from an intraparenchymal brain hematoma after a fall. While awaiting a full body positron emission tomography (PET) scan in the radiology department, the patient said she was anxious about being in the machine because she was claustrophobic.

A doctor ordered Versed 2 mg IV in the electronic medical record at 2:47 PM. Two minutes later, the pharmacy verified the order. The radiology department staff said they could not give the medication because they were very busy and the patient would need to be monitored.

So nurse A, who was functioning as the “help all” nurse was asked by the patient’s nurse, nurse B, to go to radiology and give the medication. At 2:59 PM, nurse A went to the automated dispensing cabinet (ADC) and searched for Versed in the patient’s profile. When she couldn’t find the drug listed, she selected the “override” setting to search for the drug. She entered the first two letters of the drug, VE, and clicked on the first medication that popped up.

Wednesday, November 28, 2018

Can you be held liable for resuscitating a patient who has a DNR order?

A New Mexico woman, suffering from Dercum’s disease (adiposis dolorosa) which causes painful fatty tumors, is suing a Santa Fe hospital and an emergency physician claiming she was the victim of two negligent acts in 2016.

One, according to the Albuquerque Journal, she told hospital personnel she was allergic to Dilaudid but went into cardiac arrest after receiving an injection of the drug.

Two, despite the presence of a lawfully executed “do not resuscitate” (DNR) advance directive, she was successfully resuscitated and now faces continued pain and medical bills.

The staff had been aware of her DNR order and had even issued her a purple bracelet labeled “DNR.” However since the cardiac arrest was allegedly caused by an allergic reaction to Dilaudid, the staff may have felt her problem was not related to her illness and would likely result in a successful resuscitation.

While researching this subject, I found several instances of patients or families suing hospitals and doctors for failing to heed a DNR order or what some have called “wrongful life.”

However, I found only one major case that had gone to conclusion. A Georgia woman had both an advance directive and a healthcare proxy—her granddaughter. She was admitted to a hospital for a cough and eventually required a thoracentesis. The healthcare proxy agreed to allow the procedure to be done but specifically said her grandmother did not want intubation or mechanical ventilation.

A 2017 paper in The Journal of Clinical Ethics said the patient was temporarily intubated and ventilated during the thoracentesis. She was extubated, but a bout of respiratory distress was treated with intubation and mechanical ventilation again without consulting the granddaughter. The patient died two weeks later.

The granddaughter sued, and the hospital settled for $1,000,000. I believe this is the first such case settled for that much money. The biggest problem was failure of the doctor to communicate with the healthcare proxy.

Many issues in medicine are not black or white. Here’s the other side of the story. An elderly Boston man suffered a cardiac arrest in a hospital CT scanner and was resuscitated. The resident who treated him wrote that during the code, a nurse discovered a 6-year-old advance directive saying he did not want to be resuscitated in his chart.

But the code team noted he had walked into the hospital for the test and felt certain they could save him. They contacted his son and healthcare proxy who said “My father would want everything done to save his life.” The code was successful. He was weaned from mechanical ventilation and extubated after a few hours. He thanked his doctor and was discharged from the hospital two days later.

Some take-home points:

A DNR order and an advance directive may not necessarily be the same. For more information, read an interview with the plaintiff’s lawyer in the Georgia case.

Whether to resuscitate a patient or not may depend on the circumstances [e.g., whether an event is likely reversible or not], the wording of an advance directive, and/or the wishes of the healthcare proxy.

If possible, explain the possible scenarios and outcomes of resuscitation and DNR to your patients and their families well before a cardiac arrest occurs.

Communicate with patients and their healthcare proxies.

Thursday, November 1, 2018

Appendectomy outcomes in the modern era

Finally we have some data on the current rate of complications of appendectomy for uncomplicated appendicitis. But that’s not all. This new paper, published online in the journal Surgery, reveals much about the diagnosis, technique, and outcomes of appendectomy in the United States.

Using data from 115 hospitals participating in the National Surgical Quality Improvement Program, researchers at UCLA analyzed the results of 7778 adult patients undergoing appendectomy for simple appendicitis in 2016.

Thursday, October 4, 2018

A Venezuelan surgical resident appeals for help

I received the following email. It has been edited for length and readability.

I assume you know is happening in my country, Venezuela. Basically a communist-socialist party has taken control of the government for 20 years now and has the citizens under the worst economic crisis of South America along with one of the most important refugee situations of the continent.

I can write 300 pages about it, but I believe I’ve said enough. As you may know, EVERYTHING has gone to bad situations in this country: public services, roads, HOSPITALS, UNIVERSITIES, food shortage, lack of water and electricity, freedom of speech, and the list goes on and on.

Tuesday, October 2, 2018

A Revolutionary Experience!


Listen as renowned surgeon Leo Gordon reads his epic story about pancreatic insufficiency and the American Revolution. Based on a true story. The podcast is 15 minutes long and worth every second of it.