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September 01, 2014

New Test to Identify People at Risk of Permanent Hearing Loss from Loud Noises

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In any industrialized country like the United States, everybody has been exposed to loud noises whether from a lawnmower, playing in a band, shooting guns, or going to a rock concert. It also seems that some people compared to others appear more prone to temporary hearing loss after such loud noise exposure. You know... it's the ringing, fullness, and hearing loss after leaving the loud noise event. And than over a few hours or days, the hearing comes back to normal.

This temporary hearing loss after a loud noise event is called temporary threshold shift (TTS). Genetics play a factor in how resistant an individual is to TTS. Repetitive TTS also leads to permanent noise-induced hearing loss which is why there are rules for hearing protection for workers regularly exposed to loud noises. See charts.

However, especially in industries where workers are exposed to loud noises (or children who constantly listens to music loudly), this leads to the main question of identifying exactly who is at risk for permanent noise-induced hearing loss as steps could be taken to ensure extra protection or monitoring.

That's where TTS itself can be used to identify such at-risk individuals.

Researchers at the University of Vienna have figured out that by deliberately exposing patients to a 200-500 Hz sound at 100 decibels for 20 minutes and than measuring the TTS at 4 kHz within 10 minutes after end of exposure (2.5 minutes), they can predict with some degree of accuracy those who will eventually suffer permanent hearing loss in the future with continued loud noise exposure.

Based on a study population of 311 steelworkers (including controls) using a TTS cut-off of 14dbHL, the test had an 82% sensitivity and 53% specificity for predicting permanent hearing loss due to repetitive loud noise exposure over time.

In other words, this TTS test was accurate 82 percent of the time identifying workers considered vulnerable to hearing loss who actually did lose hearing over the years. However, when predicting who was NOT likely to experience hearing loss, the TTS test was correct only 53 percent of the time.

This TTS test can be administered in any office who can currently perform hearing tests as the equipment is the same. (Our office can administer this test.)

Just be aware that the TTS test is performed by deliberately exposing to the ear a 100 decibel sound for 20 minutes. A 100 decibel sound is about the level of sound produced by a motorcycle standing 3 feet away. A typical rock concert occurs at about 115 decibels. Pain begins at about 125 decibels.

Lest people think this test may be illegal itself, OSHA does permit a worker to be exposed to 100 decibel sound for no more than 2 hours per day, so a 20 minute long exposure is "legal" from that perspective.

Also, this test is not covered by insurance at this time given its novelty.

Reference:
Early prognosis of noise-induced hearing loss. Occup Environ Med doi:10.1136/oemed-2014-102200

August 31, 2014

JCAHO Mandates Time-Out for Emergency Tracheostomy

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Due to confusion from readers, please note that this is a work of satirical fiction.

Washington DC August 31, 2014 - Effective September 1, 2014, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) has mandated that time-outs must be performed prior to emergency tracheostomy due to any reason, no exceptions. Due to numerous incidences of "never" events and lack of consistent acquisition of consent prior to emergency tracheostomy to treat catastrophic airway loss, this rule has been implemented to ensure the highest level of safety for patients in critical need of airway.

As with any surgical procedure, full informed signed consent by the patient must be present in the chart. If the patient is unable to provide informed consent (since unable to breath), consent must be obtained from next-of-kin or someone who has power-of-attorney (POA). If next-of-kin or POA is not available, than an ethics committee must be convened with attorney representation and POA assigned by judge as quickly as possible.

Once consent obtained, the neck needs to be marked and initialed by the surgeon so the surgeon does not get confused where the tracheostomy is to be performed. Surgeon must also specify side of tracheostomy (right or left or both) to be performed. Site confirmation and side needs to be confirmed independently by anesthesiology, circulating nurse, and independent third party. Most importantly, the patient should also confirm surgical site and side in a clear loud voice. If patient lacks vocal clarity, he should write on a piece of paper confirming surgical site and side.

Relevant imaging needs to be present and confirmed. Duration of surgery needs to be determined to the nearest 10 seconds given how important obtaining airway is as quickly as possible. If this accuracy level of surgical duration cannot be provided, the surgeon needs to provide surgical duration of last 30 emergency tracheostomies time range, average duration, and standard deviation. If documented surgical duration is not within an average of 5 minutes, another surgeon must be found who can provide such documentation given airway loss may occur with death if not able to be accomplished quickly. If no surgeon is available that meets this highest standard level of care, a committee must be convened to allow a special exemption. This committee shall include director of nursing, director of surgical services, chairperson of anesthesiology, chairperson of the surgery department, and elected designated layperson.

Once a surgeon has been selected, the surgeon must provide an estimate blood loss (EBL) to the nearest 1cc. The surgeon must provide documentation certifying this estimate based on past history and if unable to provide one, another surgeon must be selected who can provide such certified EBL. If EBL is anticipated to be higher than 50 cc, T&S must be obtained prior to incision.

Detailed patient positioning must be declared including exact angle of head relative to neck to nearest 1 degree, where right/left arms should be placed, where legs should be positioned, height of bed from ground to nearest 1.5mm, etc.

DVT prophylaxis must be stated whether SCD will be used or whether lovenox or other medical form of DVT prophylaxis will be administered. Some form of DVT prophylaxis must be utilized and if not,  another informed signed patient consent must be obtained making patient aware of the risks/benefits of DVT prophylaxis.

Time-outs will occur in the presence of the surgeon, circulating nurse, scrub technician, anesthesiology, floor nurse, ICU nurse, and elected independent layperson.

Every individual will clearly state their name and role. Government issued photo IDs will be displayed to every individual for confirmation with verbal acknowledgement.

Finally, before incision is made, the surgeon will clearly explain to everybody the critical steps of the procedure. Anesthesiology will do the same as well as other staff members present.

Any concerns raised during the time-out process can be raised by anybody and must be thoroughly and comprehensively addressed before proceeding. If there is a dispute over any concerns, an ad hoc committee will immediately be convened involving three uninvolved registered nurses who will listen and decide on course of action after all parties state their case.

When these new regulations were told to practicing surgeons, many voiced their pessimism that patient safety is not being served by adding such onerous steps to an already stressful and time-limited situation. "If a patient is not able to breath, is turning blue, is not intubatable, and is at death's door due to lack of oxygen, I fail to see how making time-out mandatory prior to a life-saving tracheostomy is in the patient's best interest," stated a well-respected surgeon who spoke only on condition of anonymity. "By the time time-out is done, the patient may already be dead!"

However, according to JCAHO spokesperson Aimee Adams, BSN, MS, MPH, etc, etc, etc, time-outs have raised the level of safety for patients suffering from a critical airway loss to a new level of safety. "It is our duty to ensure that everything that can be done is done to ensure patient safety is carried out to as high a level as possible before anything invasive is done to a patient, especially when at their most vulnerable."

If you have not already figured this out, this blog article is a work of satirical fiction. However, time-outs DO happen in reality and can be carried out in ludicrous situations. 

Here's a few mandatory (for real) time-out rules that make no sense:
- Why does the anesthesiologist have to declare whether beta-blockers (an adult blood pressure medication) are being administered in a 3 year old undergoing ear tubes for chronic ear infections???
- Why does an ophthalmologist have to declare patient positioning? It's always going to be supine! (Same goes with ENT cases.)
- Why does an ophthalmologist have to declare estimated blood loss for any eye surgery? It's always going to be miniscule.
- In a tiny community hospital, why does everybody have to declare their name and role?

etc, etc, etc

August 28, 2014

Joan Rivers Suffers Respiratory Arrest During "Throat" Procedure

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Image by David Shankbone of Wikipedia
It was reported today 8/28/14 that comedian Joan Rivers suffered some type of respiratory arrest during some type of sedated endoscopic procedure. According to reports, the endoscopy was done to "check her vocal cords."

It was also reported that this procedure was performed at Yorkville Endoscopy in New York City.

Just based on this limited information released to the public, I suspect the following...

1) The endoscopy procedure was probably an EGD which actually is an endoscopic procedure performed to check the esophagus and stomach, typically to evaluate for reflux damage. It is doubtful that the endoscopy was done specifically to evaluate the vocal cords mainly because sedation is not required to look at vocal cords alone.

Furthermore, Yorkville Endoscopy does not have listed laryngoscopy (endoscopy to check the vocal cords) as part of its services. Click here to see their list of services. Also if you look at the list of physicians at Yorkville Endoscopy, they are all gastrointestinal (GI) specialists... it's the wrong medical specialty if a vocal cord procedure was being performed. With vocal cord procedures, it's the ENT doctors and not the GI physicians who do them.

2) If respiratory arrest occurred during sedated endoscopy, it could be due to one of several factors:
  • Aspiration (that's why patients are instructed to eat and drink nothing after midnight before the procedure)
  • Severe laryngospasm
  • Over-sedation from the anesthetic (propofol is the typical anesthetic agent to sedate which also happens to be the drug that led to Michael Jackson's death)
3) She may have suffered a heart attack. Sometimes anesthesia and a procedure causes enough stress on the heart to trigger a heart attack. This is why most patients over age 50 must have an EKG done before the procedure to ensure the heart is in good health.

As more information is provided, the answers to questions that ultimately lead to Joan River's respiratory arrest will become apparent.

Stay tuned!

Sources:
'Please pray': Joan Rivers, 81, rushed to hospital after she stopped breathing during surgery as her daughter asks for prayers. MailOnline 8/28/14

Joan Rivers Hospitalized Following Throat Surgery, Reportedly In Stable Condition. Huffington Post 8/28/14

Distractions During Surgery is Common

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Patients often consider surgery to be performed in a setting where there are no distractions so that the surgeon can focus on the task at hand. Unfortunately, this impression is far from the truth where distractions abound and sometimes can approach on the chaotic.

Although anecdotal stories can be told, perhaps it is better to mention a few studies where third parties observed the goings on in the operating room.

A study done in 2013 observed 3,557 distractions over 32 separate surgical cases (averaging 111 distractions per case). 33% of the distractions were considered significant. The most common cause of the distraction was the circulator nurse or the anesthesiologist.

study in 2006 found a distraction occurred during surgery on average every 3.4 minutes.

Another study in 2007 found a significant number of case-irrelevant distractions which was felt to interfere with highly sensitive work. In this particular study, they noted that the surgeon himself accounted for 1/3 of the distractions.

What are some of these distractions that occur DURING surgery?

- Being informed of missing orders on next case or preceding case
- Time-Outs
- Preceding or next surgical patient wanting to ask a question
- Consult on an inpatient
- Equipment related questions for preceding, current, or following case
- Gossiping
- Missing equipment
- Door opening and closing (constantly)
- Change in OR staff personnel
etc, etc, etc

Most surgeons learn to block out such distractions in order to focus and operate safely. However, there are moments when distractions may reach a critical level of aggravation that the surgeon may need to speak up.

Also, a certain level of common sense must be present... Does the surgeon really need to be bothered in order to ask whether a tylenol can be given to a patient complaining of a headache... or can it wait until after the surgery is over.


References:
Distractions and the anaesthetist: a qualitative study of context and direction of distraction. Br J Anaesth. 2013 Sep;111(3):477-82. doi: 10.1093/bja/aet108. Epub 2013 Apr 16.

Distracting communications in the operating theatre. J Eval Clin Pract. 2007 Jun;13(3):390-4.

Measuring intra-operative interference from distraction and interruption observed in the operating theatre. Ergonomics. 2006 Apr 15-May 15;49(5-6):589-604.

August 27, 2014

Best Headphones for Kids

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MacWorld did a nice review on the best headphones for kids which is important given the increasing use of electronic devices in the classroom. It should be noted that the best headphones for adults are not the best headphones for kids due to important discrepancies in size, durability, and absence of volume-limit controls.

From an ENT perspective, volume-limit controls are the most important factor when picking a set of headphones for a child as such circuitry prevents the headphones from playing audio at damaging levels (above 85 dBHL per CDC).

In any case, to summarize the findings from MacWorld in rank order from cheapest to the most expensive... (highest rated was the most expensive)

Sony MDR-222KD  (2.5 out of 5)

Cheapest, but worst of the bunch. Volume-limit controls are absent and has an open design which allows others to hear what you're listening to.





Kidz Gear KidzControl  (2.5 out of 5)

The volume-limit control comes via a separate adapter cable which I think is a bad idea. If a child wants to listen to music loudly, they can just remove the adapter. This model was also the least comfortable of the bunch.




Griffin Technology Crayola MyPhones  (3.5 out of 5)

Volume-limit circuitry works to prevent sounds from being damaging to young ears. Sound isolation is limited however.




MarBlue HeadFoams  (3 out of 5)

Probably the most "organic" of the headphones because the entire thing is made from semi-rigid EVA foam that is BPA-free without any visible metal or plastic components. The headband is also not adjustable. Volume-limit controls do not work either.





JLab JBuddies (2.5 out of 5)

Volume limit circuitry does not work. However, earpieces are hypoallergenic.





Lil Gadgets Untangled Pro  (3 out of 5)

Had the best sound, but NO volume limiting controls.



Fuhu Nabi Headphones (4.5 out of 5)

Designed for kids and adults and therefore can be used as a child becomes older and bigger. Offers excellent sound-limiting controls (as long as the child does not figure out the hidden switch that activates this feature). Offers excellent sound isolation.

August 25, 2014

Steroid Injection Into the Ear May Help Bell's Palsy

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Intratympanic steroid injections are typically performed for sudden nerve hearing loss. However, preliminary research suggests that it may also help resolve facial paralysis due to Bell's Palsy.

In this prospective, double-blinded, randomized study, one group of patients received standard treatment with oral steroids and antiviral medications whereas the experimental group received the same medications PLUS intratympanic steroid injection as well. (I should mention that antiviral medications has not been found to be helpful in the treatment of Bell's Palsy.)

Although complete recovery rate was the same for both groups, time to recovery was shorter and better in the injection group.

Now why would injecting a steroid into the ear theoretically help with facial paralysis?

It's because the nerve that governs facial movement goes through the ear!

Facial Nerve in Yellow. Image from BrainMind.net

Watch a video showing steroid injection into the ear below.

Reference:
Intratympanic Steroid Injection for Bell's Palsy: Preliminary Randomized Controlled Study. Otology & Neurotology: August 13, 2014. doi: 10.1097/MAO.0000000000000505


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