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April 25, 2015

Medical Alarm Fatigue

Alarms are an important part of clinical care as it serves as a warning to a possible medical error or an impending medical emergency. But when they occur frequently, most of which end up being "false-alarms," they become worse than useless and actually contributes to an unsafe patient environment because a life-threatening event may be missed due to such sensory overload.

In one fascinating research article performed in an intensive care unit (ICU) where the sickest of the sick are cared for in a hospital, they documented 2.6 million unique alarms in a 31 day period of time. There were 381,560 audible alarms for an audible alarm burden of 187/bed/day. Of cardiac arrhythmias actually annotated, 88.8% of the alarms ended up being totally wrong.

Remember the tale of the boy who cried wolf too many times?

Imagine that tale, but magnified a thousand-fold and you have some idea of what it is like to work in an ICU.

But it's not just in the ICU... in any clinic setting where electronic medical records are being used, ask any doctor, nurse, or pharmacist how many times a medical error message pops up in a typical day.

If my experience is any example, I probably get prompted by such an alarm about 6x per hour or about 240 alarms in a typical 40 hour work week, typically in e-prescribing situations. How many end up being legitimate alarms? Probably about one a week.

Only ONE legitimate alarm out of 240 alarms a week.

You can see how this alarm fatigue may become a problem where being bombarded by so many alarms may cause the one real alarm to be accidentally dismissed out of habit.

Insights into the Problem of Alarm Fatigue with Physiologic Monitor Devices: A Comprehensive Observational Study of Consecutive Intensive Care Unit Patients. PLOS One October 22, 2014DOI: 10.1371/journal.pone.0110274

Beware of the Robot Pharmacist. The Overdose

April 22, 2015

The Longer Hoarseness Lasts, the More Expensive it Becomes to Treat

It is generally accepted that if a voice is hoarse for over 2 weeks, an ENT evaluation is recommended.  The main concern is whether there is something more serious going on that would require specialist treatment whether it be unusual medications or even surgery.

Researchers have also found out that patients who see an ENT after 3 weeks of hoarseness also pay substantially more money than if they had seen an ENT earlier. The longer patients wait, the more expensive it becomes to correct the problem.

Based on 260,095 unique patients who initially saw a primary care doctor for hoarseness, 8999 (3.5%) subsequently saw an otolaryngologist with 6 months post-ENT follow-up data. Statistical analysis revealed that compared with patients who saw an ENT ≤1 month after the first primary care visit, patients in the 1-3 months period paid a mean cost of $271.34 more.

Those patients who saw an ENT 3+ months after initial doctor visit had relative mean cost increase of $711.38.

Saw not only from a health perspective, but from a cost perspective, it is worthwhile to see an ENT sooner rather than later.

Click here for more information about the hoarse voice.

Delayed otolaryngology referral for voice disorders increases health care costs. Am J Med. 2015 Apr;128(4):426.e11-8. doi: 10.1016/j.amjmed.2014.10.040. Epub 2014 Nov 18.

April 17, 2015

Pollen Death Star


Check out this humorous picture depicting a microscopic image of a pollen grain and compare that with the Death Star.

Pollen as you know is responsible for allergies.

This image has been floating around on the web and as such, not able to provide appropriate credit. Let me know if there is an original source.

April 13, 2015

Acupuncture Helps with Tonsillectomy Pain

Back in 2013, I blogged how acupuncture may help with pain after tonsillectomy in children [link]. This was based on a study by Dr. Ochi published in Dec 2013 on 56 children. Another study has been published in April 2015 on 59 children by a different group of researchers which support Dr. Ochi's findings.

Although no significant differences in the amount of opioid medications administered or total post-anesthesia care time was found between the placebo and study cohorts, home surveys of patients (but not of parents) revealed significant improvements in pain control as well as earlier improvement in oral intake in the acupuncture treatment group.

In the 2015 paper, the acupuncture points used are shown in the diagram below.

Image taken from Research Paper

The 2013 research paper used different acupuncture points shown in the following diagram:

Image taken from the Research Paper

Perhaps the next study should try to determine which acupuncture points work the best!

For full disclosure, I personally have no experience in providing acupuncture and I would suggest taking these research findings to a reputable and licensed acupuncturist to get this done in those who are interested.

Intraoperative acupuncture for posttonsillectomy pain: A randomized, double-blind, placebo-controlled trial. Laryngoscope. 2015 Apr 7. doi: 10.1002/lary.25252. [Epub ahead of print]

Acupuncture instead of codeine for tonsillectomy pain in children. International Journal of Pediatric Otorhinolaryngology Volume 77, Issue 12 , Pages 2058-2062, December 2013

April 10, 2015

Weight Loss After Tonsillectomy in Adults

An adult undergoing tonsillectomy experiences some of the worst pain they could potentially encounter in their lifetime. Not only that, it may last up to 3 weeks. With such pain, it is not surprising that dehydration is one of the most common risks of this surgery. Along with such pain, weight loss is a not unexpected occurrence given oral intake substantially decreases for such a long time.

Typically, I've told patients around a 10 pound weight loss is not unusual, but that's just based on patient feedback over the years.

But now, there's a study that looked into this question and a more precise answer can now be provided. Keep in mind that the study population was taken from the military (Naval Medical Center Portsmouth) which may skew the results. (I would think that the military contains personnel that are in better overall physical health than the average non-military population.)

SO... how much weight loss on average occurs in an adult after tonsillectomy?

In a study group of 138 adults (age 18-40 years), the average weight loss was 4.77 pounds. They also found that older patients typically suffered greater weight loss after surgery.

• 5.72 pounds in 40+ years
• 4.95 pounds in 31-40 year-olds
• 5.44 pounds in 20-30 year-olds

Furthermore, it took an average of ~5 months for patients to regain the weight that they lost.

Posttonsillectomy Weight Loss in Adults. Otolaryngol Head Neck Surg. 2015 Apr 6. pii: 0194599815578110. [Epub ahead of print]

April 06, 2015

16th Century Nose Job (Video)


Nose jobs or rhinoplasty have come a long way since the 16th century...
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