Corner left
Corner right

September 30, 2011

Woman Survives Live Grenade Lodged in Face

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A 32 year old Mexican woman, Karla Flores, survived extraction of a live grenade from between her jawbones. Apparently, she was minding her own business when she was knocked out after something hit her face. Read report here.

In the hospital, it was realized that rather than a stone as initially thought, it was a live grenade!

Due to fear of it going off, 3 volunteer doctors and one nurse surgically removed the live grenade in an open field under direction of two explosive experts from the military.

Due to airway compromise, a trach was first performed prior to extraction.

Bear in mind, that the doctor who removed the grenade did not wear any armor.

Read more on Fox News here.

Cat with Two Faces (Literally)

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Frank and Louie are an extremely rare type of cat known as a Janus cat. Born with two faces, he (they) are the longest living Janus cat in existence.

Watch video here.


Cigarettes Contain Radioactive Polonium

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Cigarettes are known to cause cancer...

But we now know there's another reason why... they contain radioactive material, specifically polonium-210!

Tobacco companies also have known about it since 1959. As reported in ABC, historical documents reveal tobacco companies not only knew about the radioactive substance, but studied it, then refused to do anything about it!

They figured out that:

1) It caused "cancerous growths" in the lungs of smokers,
2) Calculated how much radiation a regular smoker would ingest over 20 years

Then they kept the research secret. The level of deception is breath-taking.

The radiation alone from cigarettes can account for up to 138 deaths for every 1,000 smokers over period of 25 years.

Even more disturbing, is that ALL tobacco products on the market today still contain radioactive polonium. This is in spite of washing techniques available since 1980 to remove the radioactivity but refused by tobacco companies to perform whether due to cost or the fact that washing would remove the addictive nicotine component as well.

Take home message?

STOP smoking! It's killing you through not only harmful chemicals, but also radioactivity!

Read the ABC article here.

Reference:
Cigarette Smoke Radioactivity and Lung Cancer Risk. Nicotine Tob Res (2011) doi: 10.1093/ntr/ntr145

Not All Spinning Motions Cause Dizziness

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In one of the stranger research projects I've encountered in awhile, French scientists reported on why in the sport of discus throwing, athletes tend to feel more dizzy than those who hammer throw.

Whether discus or hammer throwing, both require spinning on part of the athlete before letting the discus/hammer go for long distances.

59% report dizziness with discus throwing, but none with hammer throwing. Why?

This occurred even among athletes who did both sports eliminating individual susceptibilities to dizziness.

Based on slow-motion video analysis, it was conjectured that visual bearings can be used more easily with hammer throwing than during discus throwing. Moreover, less foot contact with the ground for ground-body tactile feedback and generation of head movements liable to induce motion sickness from acceleration were felt to be contributing factors.

How do these findings translate to patients who are dizzy?

1) Visual bearings - Fixate on objects that you know to be still
2) Increase body-ground contact - Wear flat shoes instead of stiletto heels as well as cane/walker use
3) Minimize sudden turning head motions - Turn with the body rather than the head, or turn the head slowly

Of note, this research project won the 2011 Ig Nobel Prize for Physics.

Reference:
Dizziness in discus throwers is related to motion sickness generated while spinning. Acta Otolaryngol. 120 (3), 390-5.

September 27, 2011

HIPAA Allows for Regular Email Communication Between Patients and Physicians

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There is a widespread mistaken belief that HIPAA prohibits physicians from communicating with patients using regular un-encrypted email as well as with other physicians about patient care.

HIPAA, for those who don't know, is a law that requires patient information to be kept private with safeguards. Email (such as yahoo, gmail, aol, etc) is not considered a secure form of communication.

However, HIPAA does allow for such un-secured email communication under certain circumstances. I quote from the horse's mouth:
"Patients may initiate communications with a provider using e-mail. If this situation occurs, the health care provider can assume (unless the patient has explicitly stated otherwise) that e-mail communications are acceptable to the individual. If the provider feels the patient may not be aware of the possible risks of using unencrypted e-mail, or has concerns about potential liability, the provider can alert the patient of those risks, and let the patient decide whether to continue e-mail communications."
As such, it may be worthwhile for a patient to acknowledge the following statements before an email can be sent from a practice website using un-secured email:
"I understand email is not considered secure and as such, is not considered a confidential method of communication."  
"By your sending an email to us, you are giving permission for us to reply by email."
Even if private health information may be included, that's fine if, I quote from the horse's mouth:
"Further, while the Privacy Rule does not prohibit the use of unencrypted e-mail for treatment-related communications between health care providers and patients, other safeguards should be applied to reasonably protect privacy, such as limiting the amount or type of information disclosed through the unencrypted e-mail."
Read more about un-secured email communication as it relates to HIPAA here from the Department of Health & Human Services.

MRI Scans CAN Cause Vertigo

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Researchers at Johns Hopkins published a study that reports that MRI scans CAN cause feelings of dizziness induced by magnetic fields causing motion of the electrically charged fluid of the inner ear.

In both ears, there is a "gyroscope" called the labyrinth. Whenever the head turns or a force like gravity is exerted on this system, fluid moves within which tells the brain that motion has occurred. It's much like looking into a glass of water and based on the way the water tilts in the glass, you can guess which way motion is occurring.

In any case, the study took two groups of people, one with an intact labyrinth system and another without a functioning labyrinth system. Only those individuals with an intact labyrinth system suffered vertigo while getting an MRI. Furthermore, the stronger the MRI's magnetic field, the worse the vertigo.

Beyond the "that's interesting" trivia, these results are VERY important in any type of brain activity research. Why? Well, if a person is feeling dizzy, the brain activity you may be studying using the MRI may be attributable to the dizziness itself and the patient's coping mechanisms to deal with it rather than whatever brain activity research you may be investigating.

On a more science-fiction note, based on these findings, an MRI can theoretically be used to potentially diagnose and treat dizziness due to the inner ear. After all, if it can cause dizziness, it certainly can be used to help it as well!

Reference:
MRI Magnetic Field Stimulates Rotational Sensors of the Brain. Current Biology, 22 September 2011. doi:10.1016/j.cub.2011.08.029

September 25, 2011

Oral Exam Using a Finger

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For a good physical exam, physicians use their senses (eyes, ears, nose) to detect disease processes that may not necessarily be obvious to a lay person. Beyond these obvious senses, fingers and hands are also utilized to feel for unusual bumps or masses that may not be obvious to the naked eye.

Take a neck mass for example. Neck masses may not be necessarily visible, but by feeling the neck, may become obvious. To use an analogy, a bowling ball under a mattress may not necessarily be obvious, but if you lay on the bed, would become painfully obvious.

Physicians also use the hands/fingers to examine areas that may not be visible... such as the unpleasant digital rectal exam (inserting a finger up a bung-hole) which is done to detect blood in the stool, rectal/anal cancers, anal muscular incompetence, etc.

However, I find it odd that the mouth is a body area that is not often "felt" around... physicians included.

A finger can appreciate unusual mouth pathology that may not necessarily be appreciated by looking alone. Furthermore, just like the rectal exam, a finger can appreciate base of tongue pathology that cannot be visualized by having a patient go "ah".

I truly feel that actor Michael Douglas would have been diagnosed with his base of tongue cancer much earlier if only a doctor stuck a finger and swept that back area of the tongue. One can "feel" cancer as it is rock hard and very tender. True... it may cause a person to gag, but for a cancer test, it's dirt cheap, fast, and reliable.

However, it does not just have to be areas of the mouth that can not be seen. Even for those ulcerations and bumps of the mouth that one can clearly visualize (or not), it does help to touch it. Is it hard? Soft? Ulcerated? Tender? Grooved? Papillated? Fungating? Rubber-like? Blottable?

Each characteristic provides information to achieve a more accurate diagnosis.

To an ENT way of thinking, if a doctor regularly performs a digital rectal exam, than one can certainly do the same thing at the other end. It's less invasive and provides just as much information.

Say "ah"!!!

September 24, 2011

United Kingdom Ends $17 Billion Electronic Medical Records Initiative

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The Wall Street Journal on Sept 23, 2011 reported that the United Kingdom will scrap the entire electronic medical records (EMR) initiative that has been 9 years in the making with nearly 6.4 billion pounds already spent.

That action was hinted at back in August 2011 after a scathing parliamentary report stating the initiative to be wasteful and incapable of delivery.

I'm not surprised...

It's hard enough to get a group of doctors in one hospital to agree with a treatment plan let alone agree to a medical records system. The problem is exponentially more difficult when applying it to an entire country.

Physicians practice medicine differently... just like teachers have their own unique way of teaching kids. A method that may work for one doctor or teacher will not work for another. Even the method may change depending on how "busy" things are (teacher with a class of 5 kids versus 30 kids) so a doctor in a busy inner-city emergency room will have different flows and needs from an electronic medical records than a rural family practice with a sedate pace. Furthermore, the needs of a dermatologist is very different from a pediatrician. One can't expect a single EMR system to meet the needs of both perfectly just like one cannot expect a math teacher to use the same teaching methods as a singing teacher.

Forcing physicians to use a single standard electronic medical records without adapting to these realities is bound to fail no matter how much time, training, software, and hardware you throw at it.

A better alternative (my opinion), is to treat electronic medical records like the computers they reside on. There should be many different types of EMR systems just like there are MANY different types of computer models, speeds, makes, cost, sizes, etc.

However, unlike current EMR systems, in spite of who makes a computer and what operating system software it runs, it has standardized components... USB, Firewire, HDMI, VGA, BlueTooth, etc. as well as a universal communication medium called the "internet" that works with phones, computers, laptops, etc regardless of who makes it and what software it is on.

You would think that an EMR system given its digital essence would be able to easily communicate with other systems... but no... they don't communicate at all... which is why paper reports still exist... which are than scanned into the EMR.

Rather than the government (whether the United Kingdom or the United States) dictating what physicians must do and mandating EMR initiatives, I believe the money would be much better spent on mandating inter-operability and communication standards. The free market will create the best EMR systems and physicians will pick the one that best meets their need.

The other more insidious side of EMR is the over-reaching health goal mandates which means well, but runs into the same problem of applying standards to all physicians. Take "meaningful use" set by the Centers of Medicare and Medicaid Services (CMS). One of the core measures of meaningful use is adult weight-screening and follow-up.

Now as an ENT specialist, I see patients specifically for earwax. Why in the world would I want to perform a weight-screening when all I want to do (and what the patient only wants me to do) is get earwax out???

Makes no sense.

Does it to you???

Reference:
U.K. Scrapping National Health IT Network. InformationWeek Healthcare. Aug 4, 2011
U.K. Ends Health-Service IT Upgrade. Wall Street Journal. Sept 23, 2011

September 22, 2011

New Webpage on Vocal Cord Granuloma

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Given the sudden interest patients have expressed in vocal cord granulomas ever since singer John Mayer announced a hiatus in concerts due to his voicebox granuloma, a new webpage has been developed to describe this unusual mass as well as treatment options.

Read all about it here!

September 21, 2011

Singer John Mayer Diagnosed with Vocal Cord Granuloma

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On Sept 19, 2011, media reported that singer John Mayer has been forced to cancel all upcoming concert plans and delay release of a new album due to a voicebox growth.

This growth was described as a "granuloma."

What exactly is a granuloma?

It is a benign mass commonly due to repetitive mild vocal trauma resulting in exuberant growth of a specific region of the voicebox lining.

To be more precise, rather than the vocal cord itself, granulomas are most commonly found on the vocal process which is the "hinge" that allows for vocal cord movement. It is located in the back area of the voicebox.

An imprecise analogy of what a granuloma is would be a keloid of the skin.

Symptoms include mild (if any) hoarseness, mild intermittent pain on the side of the voicebox where the granuloma is located with talking/singing, rarely coughing up blood, and if large, shortness of breath.

Just like keloids of the skin, surgical removal alone is almost certainly going to fail with recurrence of the granuloma within weeks to months. All repetitive trauma to the area must be addressed to minimize risk of recurrence which is why restricted voice use must be pursued for several months (no loud talking/singing, talking ONLY when you must). Voice therapy helps to "teach" a person how to talk when they talk without causing further injury to the area. As such, botox injection to the vocal cord has been found helpful to semi-paralyze the vocal cords from coming together (chemically induced vocal cord paralysis). Reflux medications are necessary even if a patient has no symptoms as ANY acid exposure to the area is just as bad a trauma due to yelling.

Steroid injections are helpful to minimize the underlying exuberant inflammatory reaction that leads to granuloma recurrence and may need to be performed several times for effect.

To summarize, the steps followed when a granuloma-like mass is discovered on exam is as follows:

1) Trial restricted voice use and reflux medications. Voice therapy also strongly recommended.
2) If no improvement after a period of time, surgical excision to ensure it truly is a granuloma and not cancer or some other pathology
3) Follow-up with steroid injections to the granuloma site. Watch video below.
4) Botox injection can be considered which chemically prevents complete vocal cord adduction preventing the repetitive trauma to the granuloma site.

Read a Rolling Stone report here.

Read more about voicebox granulomas.

September 18, 2011

Tongue Acrobatics

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Impressive tongue acrobatics... Not much more to say! Watch the video here.

World's Longest Human Tongue

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The longest human tongue ever recorded is that of Stephen Taylor and measures 9.8 centimetres (3.86 in). Apparently, his tongue has not stopped growing even though he is a grown adult.

The longest tongue for a female is that of Los Angeles resident Chanel Tapper whose tongue measures 3.8 inches! Her tongue is also quite acrobatic as shown in this YouTube video.


Another Rock Singer With Injured Voice

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On Sept 16, 2011, the Stone Temple Pilots had to cancel their tour because their lead singer Scott Weiland was placed on voice rest due to damaged vocal cords at risk for permanent damage. Specifically, the doctors at University of Cincinnati Voice Health Center determined that he had scarring on his left vocal cord and a tremendously inflamed right vocal cord.

The left vocal cord scarring is likely from past vocal trauma that did not heal properly and is now permanently damaged whereas the right vocal cord is at risk of also becoming permanently damaged if not aggressively managed. The picture shown here is an example with inflammation involving both vocal cords. Compare this with the picture below which shows one normal vocal cord and one inflamed vocal cord.


Without further information, beyond voice rest to allow the vocal cord inflammation to resolve without further injury, treatment may also include steroids as well as reflux medication.

It seems to be a continuing trend for singers of all genres to be pushed to the point where their vocal cords get injured resulting in show cancellations and at worst, become a one-hit wonder.

Other singers THIS YEAR alone who have cancelled tours due to voice injury include Kings of Leon, Duran Duran, Adele, The Vaccines, etc

And it's not just rockers, but also opera singers.

If you are a singer and you don't have a voice coach and supportive management, you need to remedy this immediately or you risk having a career that's a one-hit wonder.

September 17, 2011

World Record Large Ears

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On September 2011, the Guinness Book of World Records announced the longest ears of any dog belongs to a Coonhound named Harbor. His magnificent ears measured 12.25 inches and 13.5 inches long (left and right respectively).

I wonder how much earwax he produces!

September 10, 2011

Keychain Emergency Airway Device (Video)

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Health professionals who know how to perform cricothyroidotomy to obtain an emergency airway in someone who is obstructing can appreciate a nifty keychain device called LifeStat.

LifeStat can be carried around and immediately utilized to perform emergency cricothyroidotomy in any setting.

Watch a video here to see how it works.

It can be purchase from Shippert Medical for $145 here.

Reference:
Utilization of the LifeStat emergency airway device. Ann Otol Rhinol Laryngol. 2008 Jan;117(1):1-4.


September 09, 2011

Smoker's Kids Have More Ear Infections

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Although not entirely new news... a new review paper which collated the results of 61 past studies has reaffirmed that smoking around kids increases their risk of ear infections dramatically.

Just how much?

Kids living with a smoker had a:

  • 37 percent higher risk of ear infections and hearing problems
  • 62 percent higher risk of ear problems if the household smoker was their mom
  • 86 percent more likely to undergo ear surgery than kids without secondhand smoke exposure

Read a MSNBC story on this here.

So don't smoke for your own health as well as your kids' health!!!

Reference:
Parental Smoking and the Risk of Middle Ear Disease in Children. Arch Pediatr Adolesc Med. Published online September 5, 2011. doi:10.1001/archpediatrics.2011.158

September 08, 2011

100 Years of Style and Dance

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A random post for those who appreciate dance and fashion...

Carbon Dioxide Helps with Nasal Allergies

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MSNBC reported recently that a shot of carbon dioxide gas into the nose can help with allergies based on preliminary findings funded by Capnia, a company that makes the product.

Upside:
Symptoms of nasal allergies improved within 30 minutes.
No liquid is involved... just carbon dioxide gas.

Downside:
Lasts only 4 hours
80% has nasal discomfort after use
25% became teary eyed
14-20% developed headaches

My take?
I'll pass on this drug... There are already good drugs with minimal side effects that lasts up to 24 hours already on the market .

Read the story here.

Of note, some readers may point out that there is an older study that had better results. With two one-minute carbon dioxide treatments into the nose resulted in symptom relief within 10 minutes and lasted for 24 hours. Even with these results, I'll still pass... not sure how many people will go with 2 one-minute treatments when a 1 second swallow with an allergy pill or nasal spray use works just as good.

Reference:
Nasal carbon dioxide for the symptomatic treatment of perennial allergic rhinitis. Annals of Allergy, Asthma & Immunology - 19 August 2011 (10.1016/j.anai.2011.07.014)

Intranasal noninhaled carbon dioxide for the symptomatic relief treatment of seasonal allergic rhinitis. J Allergy Clin Immunol. Volume 121, Issue 1, Pages 105-109 (January 2008).

September 07, 2011

Intranasal Treatment for Clogged Ears

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A common cause of clogged ears with inability to pop them easily is due to eustachian tube dysfunction. There are a number of ways to address this annoying problem, but one of the first steps to try is intranasal medications whether in nasal spray form or nasal drop form.

The whole idea behind intranasal treatment is the fact that the ears are connected to the back of the nose via a tunnel called the eustachian tube. Watch video explanation.


Normally, when the ears are popped (also known as valsalva), the individual is opening up the eustachian tube to allow pressure and/or fluid in the ears to drain/escape out into the back of the nose. That's why when you blow your nose, you often hear a popping noise in the ears. Read more about how/why this happens here.

Patients suffering from eustachian tube dysfunction are unable to get the tunnel to open up. In this scenario, the pressure or fluid remains trapped in the ear. It's a plumbing problem in its essence.

Given the problem is the eustachian tube, intranasal medications are used to try and open up the tunnel and make it easier for the individual to pop the ears open.

Trick is... how to get the intranasal medications to where the eustachian tube is located in the very back of the nose.

There are a few ways to accomplish this... some which work better than others.

Method 1:
Use a nasal spray medication and aim the bottle to the back of the neck while keeping the head down (looking at the floor). The spray bottle MUST be perpendicular to the face. Why? Take a look at the diagram below:


If you aim the bottle towards the eye or top of the head, the medication is hitting areas of the nose where the sinus cavities are... not where the eustachian tube is located.

You have to look down and point the nasal spray bottle up towards the ceiling because all nasal spray medications use a straw that requires vertical orientation (same reason why when you drink Pepsi from a cup, the cup is upright).



Anatomically, the nasal spray "shoots" the medication straight up to where the eustachian tube is located.
Method 2:
Use an eye dropper and place a drop of the medication into the nose and have it "drain" to where the eustachian tube is located. Practically, this means filling a prescription of the nasal spray medication, opening up the bottle, and pouring the contents into an eye dropper.

This method requires positioning the head such that gravity will ensure proper movement of the medication to where the eustachian tube is located.

There are two ways to achieve this. This first way is the "Head-Tipped-Back Position".

In this position, the nasal drop will "fall" down to where the eustachian tube is located:
Mygind's Position is the alternative position which accomplishes the same thing, but the person is laying down looking up. For some people, this position is more comfortable than bending the head back.

Studies have shown that Method 2 (nasal drops) works better than Method 1 (nasal spray). However based on my personal experience in my patient population, Method 2 is not as well tolerated as Method 1. People often feel like drowning or suffocating when performing this maneuver (mini water-boarding so to speak). Also, it seems to be more irritating to the mucosal lining of the nose and throat.

And as we all know, if it is not comfortable or user-friendly, patients will not do it.

As such, I usually recommend Method 1 (nasal spray) which works "good enough". For patients who are ambitious and are willing, go with Method 2 (nasal drop).

Reference:
Techniques of Intranasal Steroid Use. Otolaryngol Head Neck Surg 130(1):5-24.
Intranasal delivery of drugs to eustachian tube orifice. The Journal of Laryngology & Otology (2011), 125: 934-939

Images taken from Techniques of Intranasal Steroid Use and Wikipedia.

September 05, 2011

Best Ballpoint Pen for Emergency Cricothyroidotomy?

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I recently blogged about a man who choked to death on an airplane and the impossibility of saving this man's life with a surgical airway like a cricothyroidotomy without a sharp object around inside the plane (ie, knife or scalpel).

I also stated that "Some surgeons would argue a strong, stiff ball-point pen could have been used to perform the cricothyroidotomy, but as someone who has performed a dozen emergency cricothyroidotomies and tracheotomies in the past, even under the best of circumstances with a knife and being on a hospital floor with help around, it is hard. Furthermore, skin and the windpipe is made of tough 'fabric' and trying to punch a ball-point pen through is laughable. Try doing it yourself on a chicken with the skin on."

Well... it got me thinking... Let's assume for argument's sake that it IS possible to perform a cricothyroidotomy by literally punching through with a stiff ball-point pen into the airway. Would it actually work???

Believe it or not, there are two studies (listed below) I was able to find that tried to answer that very question. Contrary to popular belief... even IF a ball-point pen is able to secure an airway, the majority were found to be unsuitable due to inadequate internal diameter with too high an airway resistance for breathing.

In fact, the only TWO pens that might work (from a breathing standpoint) are the:

Baron retractable ballpoint
BIC soft feel Jumbo

I can't even find these items on Amazon.com.

A sports bottle straw apparently works better than a pen.

Reference:
Bystander cricothyroidotomy performed with an improvised airway. Mil Med. 2002 Jan;167(1):76-8.

Airflow efficacy of ballpoint pen tubes: a consideration for use in bystander cricothyrotomy. Emerg Med J. 2010 Apr;27(4):317-20.

Beating Heart in a Box

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With heart and lung transplants, the current standard is to transport the heart (or any other organ to be transplanted) inside an icebox cooler on ice. It's the same kind of icebox cooler you would use to take on a picnic. Think about it... You can buy a human organ transportation container off of Amazon.com for $39. In fact, I would not be surprised if some medical centers purchased such icebox coolers from Amazon.com.

Well, a company called TransMedics is aiming to elevate organ transportation technology from the icebox cooler to a cyborg-like container where the heart is warm, alive, and still-beating from donor to recipient. Same goes for the lung. Others soon to follow!

Check out these videos!




The Healthcare Dilemma Simplified

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As an otolaryngologist in private practice, I have observed from the sidelines the healthcare crisis that is brewing in our nation, being debated in Congress, and bemoaned by fellow colleagues.

Being a simple man, I see the essence of the healthcare problem being summarized in one sentence:

"How to deliver low-cost, high-quality healthcare cheaply."

Being a simple man, I also realize that this statement is nearly impossible to accomplish for something as complex as healthcare delivery.

It's also a concept engineers have struggled with for way longer than medicine has. It is summarized by a great graphic known as the "Engineering Project Triangle". What is achievable is only where the colors overlap.




Design something quickly and to a high standard, but then it will not be cheap. 

Design something quickly and cheaply, but it will not be of high quality.

Design something with high quality and cheaply, but it will take a long time.

In other words, you can only pick two.

In terms of healthcare, the triangle could be known as the "Healthcare Project Triangle."



Design healthcare that is able to provide quality care at low-cost, than not everyone can have it. It's also known as "rationed" care which is what Canada and Great Britain have to some degree.

Design healthcare that is able to provide quality care to everybody, it will be expensive. This is where our healthcare model is currently situated.

Design healthcare this is able to provide low-cost care to everybody, it will suffer in terms of quality. Some would argue this is the HMO model. It's also what we could consider the kind of healthcare that is provided in free clinics.

In essence, you can't have healthcare with all three characteristics. You can only pick two.

Engineers know that and are probably wondering why doesn't everybody else.

"You can only pick two" is what the great debate is all about. Nobody can decide on which two and there are FANTASTIC arguments for the given two a Senator or presidential candidate will promote.

However, in the end, either quality, quantity, or low cost will suffer no matter which healthcare policy is chosen.

So the great debate has been identified...

The great question is what will be sacrificed?

Because unfortunately, there is no great answer.

Reference:
When Nurses Wear "Do Not Disturb" Signs. Dr. Wes.

Man Chokes to Death During Air Flight... Preventable?

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Image courtesy of digitalart / FreeDigitalPhotos.net
News media reported on Sept 5, 2011 about Robert Rippingale who choked to death during a flight from Singapore to New Zealand. He was with his girlfriend who noted he was shaking and turning blue after eating an in-flight meal. A doctor and two nurses attempted to save him though unsuccessfully.

The article reports that CPR was performed to try and save the man, but the obvious question is whether a Heimlich maneuver was done. Obviously, as long as an obstruction is present, doing CPR is bound to fail.

Assuming a Heimlich maneuver was performed and failed to remove the airway obstruction... what could have been done to save this man's life?

Let's assume best case scenario of having an experienced ENT surgeon was on board.

The surgeon could try to relieve the obstruction manually by looking down the throat using a laryngoscope and using instruments to remove the food obstruction from the airway.

If that fails, an emergency cricothyroidotomy would have saved this man's life. This emergency life-saving procedure is in essence making a hole in the neck directly into the airway. It is slightly different from a tracheostomy in terms of where anatomically this hole is made, but the end-result is the same.

Question is, EVEN if you had an experienced ENT on board, would an airplane even have a laryngoscope as well as instruments to remove a food impaction? Would an emergency cricothyroidotomy even be possible due to prohibition of sharp objects in airplanes? After all, you still need a knife of some sort to make the incision and to dissect down to the airway. Without a sharp instrument, this step would be impossible even if you have someone who knows what to do.

According to Appendix A to Part 121 of Title 14 of the Code of Federal Regulations (14 CFR 121), the specific requirements for US carriers regarding first aid and emergency aid kits are as follows:

For 0-50 seats, one kit is required; 51-150 seats, two kits are required; 151-250 seats require three; and more than 250 seats require 4 kits.

These kits must include, at a minimum:
  • 16 Adhesive bandage compresses, 1-inch
  • 20 Antiseptic swabs
  • 10 Ammonia inhalants
  • 8 Bandage compresses, 4-inch
  • 5 Triangular bandage compresses, 40-inch
  • 1 Arm splint, noninflatable
  • 1 Leg splint, noninflatable
  • 4 Roller bandage, 4-inch
  • 2 Adhesive tape, 1-inch standard roll
  • 1 Bandage scissors
Also, at least one approved medical kit must be on board that includes at a minimum:
  • 1 Sphygmonanometer
  • 1 Stethoscope
  • 3 Airways, oropharyngeal (3 sizes): 1 pediatric, 1 small adult, 1 large adult or equivalent.
  • Self-inflating manual resuscitation device with 3 masks (1 pediatric, 1 small adult, 1 large adult or equivalent).
  • CPR mask (3 sizes), 1 pediatric, 1 small adult, 1 large adult, or equivalent.
  • 1 IV Admin Set: Tubing w/ 2 Y connectors
  • 2 Alcohol sponges
  • 1 Adhesive tape, 1-inch standard roll adhesive.
  • 1 pair Tape scissors
  • 1 Tourniquet
  • 1 Saline solution, 500 cc
  • 1 pair Protective nonpermeable gloves or equivalent
  • 6 Needles (2-18 ga., 2-20 ga., 2-22 ga., or sizes necessary to administer required medications).
  • 4 Syringes (1-5 cc, 2-10 cc, or sizes necessary to administer required medications).
  • 4 Analgesic, non-narcotic, tablets, 325 mg
  • 4 Antihistamine tablets, 25 mg
  • 2 Antihistamine injectable, 50 mg, (single dose ampule or equivalent).
  • 2 Atropine, 0.5 mg, 5 cc (single dose ampule or equivalent).
  • 4 Aspirin tablets, 325 mg
  • 1 Bronchodilator, inhaled (metered dose inhaler or equivalent).
  • 1 Dextrose, 50%/50 cc injectable, (single dose ampule or equivalent).
  • 2 Epinephrine 1:1000, 1 cc, injectable, (single dose ampule or equivalent).
  • 2 Epinephrine 1:10,000, 2 cc, injectable, (single dose ampule or equivalent).
  • 2 Lidocaine, 5 cc, 20 mg/ml, injectable (single dose ampule or equivalent).
  • 10 Nitroglycerin tablets, 0.4 mg
  • 1 Basic instructions for use of the drugs in the kit.
It seems that there are airways of different sizes available, but no laryngoscope or other instruments to remove airway foreign objects.

Nowhere is a scalpel or knife listed either. You have needles and syringes which theoretically can be used to "poke" into the airway. However, though an 18 gauge needle might work for a chipmunk's airway, it is not sufficient for a full-grown man. It would be like breathing through a straw, but 50 times smaller and even more difficult to breath thru.

So it appears that in the event of an airway obstruction during an air-flight for which Heimlich fails, you can have the world's best surgeon present, and the man still would have died.

Some surgeons would argue a strong, stiff ball-point pen could have been used to perform the cricothyroidotomy, but as someone who has performed a dozen emergency cricothyroidotomies and tracheotomies in the past, even under the best of circumstances with a knife and being on a hospital floor with help around, it is hard. Furthermore, skin and the windpipe is made of tough "fabric" and trying to punch a ball-point pen through is laughable. Try doing it yourself on a chicken with the skin on.

Read the news article here.

September 03, 2011

Best Medication for Dizziness

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So how would one go about figuring out the best medication for dizziness due to motion-sickness leading to nausea and even vomiting?

Well, step 1... Put a bunch of people in a machine and figure out the necessary motions that will cause dizziness.

Step 2... Do the same thing, but this time, put people on different medications and figure out what works the best.

Sound crazy?

Well it has been done by the friendly folks at NASA. Why would they perform such unpleasant experiments? It's for the fighter pilots and astronauts who may encounter motion sickness where dizziness may mean the difference between life and death and have no alternative other than medications.

So what medication did they find works the best?

Through trial and error, they have found that a combination of oral scopolamine (not the patch), to suppress vomiting, and dextroamphetamine, to counteract scopolamine's potential to induce drowsiness, reduced the incidence of motion sickness from 70 percent to about 12 percent among passengers in the "Vomit Comet"—a DC-9 aircraft used to achieve brief periods of zero gravity as part of NASA's Reduced Gravity Program.

They have also found that conditioning (repeating movements that induce dizziness) over and over again does result in the development of tolerance to a motion environment in 95% of individuals.

Read more about this here.

Surgery Without Wires

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Surgery is messy... and I don't mean in terms of blood and guts...

What I mean are wires, cables, tubing, etc.

Let's take a routine tonsillectomy and adenoidectomy for example...

  1. Electric cord for the operating table
  2. Electric cord for the anesthesia machine
  3. Electric cord for the surgeon's headlight
  4. Light cord from the surgeon's headlight to the lightbox
  5. Breathing circuit tube from the patient to the anesthesia machine
  6. Carbon dioxide outflow tube from the patient to the anesthesia machine
  7. Suction tubing from the surgical table to the vacuum canister
  8. Vacuum cable from the vacuum canister to the wall socket
  9. Electrocautery cable (along with electric cord to power the machine)
  10. Coblation cable (along with electric cord to power the machine)
  11. IV fluids lines from patient to IV bags
  12. EKG lines
  13. Grounding pad cable
  14. All the wires and cables that go with running a computer
  15. etc etc etc
It's an "organized" chaos of cords, tubes, electric wires, etc all emanating away from the patient like a Man-of-Wars jellyfish.

Pictures shown on the internet as well as movies are "staged" and appear to be neat and orderly, but believe me (as someone who has had pictures taken), surgeons and nurses take the time to "tidy" things up before the picture or video is recorded giving a false impression of neatness.

99% of the time, everyone knows where everything is, so it's not a problem. However, when an unanticipated emergency happens, things get confusing and in fact dangerous to not only the patient, but the staff (I recall one incidence of a nurse running to get a surgical tray, tripping on one of the numerous cords mentioned above, falling, and breaking her hand).

When something stops working... we literally have to trace the cord from source to origin to figure out why something stopped working. With all the cords present, this tracing needs to be done by hand and eye (analogous to an entertainment system with all the wires in the back, one would trace out the cords by hand and eye).

IS there a better way???

Of course the operating room staff takes the time to bundle and organize the various cords, but the fact remains that the cords are there.

What about wireless technology to power instruments or relay information?

Well, NPR reported on August 23, a young 22 year-old entrepreneur Meredith Perry, who has invented and patented a way to transmit power over the air without the need for wires using ultrasound. Yup... the same ultrasound used to look at a human fetus in the womb.

Her ingenious idea is to use ultrasound to "vibrate" the air which than vibrates a piezoelectric transducer contained within nearby devices. The vibration of the piezoelectric transducer will than generate an electric current which can be stored in a battery and used to power anything that requires energy.

I acknowledge that it may take time before such wireless power is available to power large surgical devices, but one can always hope!

Read the NPR story here.

September 02, 2011

Movie Sets are Dangerous to Ears!

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First it was Maggie Q, and now I learn that there are other celebrities with hearing loss due to movie set loud noise exposure.

Leonard Nimoy (Spock of Star Trek fame) suffers from right ear tinnitus due to hearing damage from a special effects explosion during filming of Star Trek episode "Arena".

Similarly, Steve Martin suffers from tinnitus due to hearing damage sustained during filming of a pistol-shooting scene for "¡Three Amigos!" in 1986.

Here is a full list of celebrities with hearing problems.

September 01, 2011

Hearing Loss Can Can Accelerate Brain Volume Loss

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Everyone has heard of the saying "If you don't use it, you will lose it."

Well, when it comes to hearing loss, that seems to apply to not just hearing per se, but the actual structure of the brain!

Researchers studied MRI scans of older individuals (ages 60-77) with hearing loss, they found less brain volume in the auditory cortex of the brain which is not entirely surprising. What was surprising was that there was less brain activity on functional MRI scans when these individuals listened to complex sentences (it is just not "hearing" that is lost, but higher level brain function of "comprehension" being lost too).

These results suggest that hearing loss can lead to a systematic decrease in neural activity of speech comprehension and may also contribute to loss of brain volume especially in the primary auditory cortex.

This finding also implies that by wearing hearing aids, such loss can be prevented.

The next step would be to do the same research on patients WITH known hearing loss, but hearing aids have been used. What would be also interesting would be to see if such brain changes can be reversed if hearing aids are used after such brain loss is seen on MRI.

Reference:
Hearing Loss in Older Adults Affects Neural Systems Supporting Speech Comprehension. The Journal of Neuroscience, 31 August 2011, 31(35): 12638-12643; doi: 10.1523/​JNEUROSCI.2559-11.2011
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