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February 29, 2012

Surgical Time-Out, circa Year 2050

In the year 2050, surgical time-outs have reached a new level of safety to ensure the utmost care and risk reduction for patients.

Unlike the primitive time-outs performed in the the first decade of the 21st century (2000-2012) which involved one designated individual to confirm prior to incision (Basic9), the patient name, surgical site, performing surgeon, allergies, antibiotic administration, positioning, x-ray name confirmation, fire hazards, and fall risk, significant additional safety checklists have been implemented to create a new state-of-the-art culture of safety both in and out of the operating room.

In 2015, surgical time-outs extended to also include electrical and air quality checks (Environ2) along with separate mandatory time-outs of the Basic9 before, during, and at conclusion of surgery.  To ensure minimal air contaminants as well as maintain the highest performance of all electrical equipment in the operating room, the Environ2 requires a separate electrical and environmental engineer to certify all equipment and confirm air quality at a level of no more than one contaminant part per trillion to the 10th power in 35 separate locations within the operating theater. The Environ2 checks are double-confirmed by the circulating nurse who has been granted broad powers to cancel surgery for any reason without consequence if there are any concerns with the operating room environment that may increase infection risk for the patient as well as sub-optimal performance of any and all equipment used to perform the surgery.

In 2020, the Total5 was added to Basic9 and Environ2 which truly heralded the onset of state-of-the-art surgical time-outs. Total5, developed jointly by the Harvard School of Public Health and National Institute of Medicine, involves a comprehensive time-out of any and all individuals entering into the operating room in the knowledge that surgical outcomes are affected by personnel movement into and out of the operating room whether from contaminants on the skin or clothing of staff to infections that they may or may not be harboring. In rare cases, given the recent terrorist attacks both biological as well as chemical, the Total5 would additionally eliminate such threats.

As such, Total5 involves for each and every staff member that enters the operating room to undergo "individual time-outs":

1) Geiger counter check
2) Body pat-down by TSA (whose duties have tremendously expanded from initial airport security)
3) Metal detector check
4) Chemical check (specifically looking for arsenic, mercury, formaldehyde, etc as well as drug screen)
5) Biohazard check (routine organisms include MRSA, VRSA, C dif, HIV, hepatitis, etc as well as more exotic organisms like Ebola, Swine Flu, Anthrax, etc).

A separate consent must be in the chart for each and every individual who is present for the patient's surgery with their Total5 report.

The Basic9, Environ2, and Total5 surgical time-outs collectively have ensured a 360 degree safety net for the patient.

But... it is not until now in the year 2050 that the surgical time-out has reached a penultimate state with the expansion of the Total5 to Total10. In addition to the original Total5 for surgical staff, 5 additional time-out checks of surgical staff is now required. Continuing with #6...

6) Retina scan (to confirm staff identity)
7) Fingerprint scan (to double-check staff identity)
8) Malpractice insurance check (if positive, consent must be in chart to ensure patient was aware of any malpractice committed by any surgical personnel doctor or nurse)
9) EKG to ensure peak cardiac health of staff member
10) EEG to ensure a rested mind at peak performance of staff member

As with the Total5, Total10 report for each staff member must be included in the patient consent in the patient's chart.

There was some confusion whether each staff member can undergo just one Total10 per day, but with new regulation acknowledging possibility of patient infection contaminating personnel as well as staff member fatigue that may progress throughout the day, a Total10 MUST be performed before each and every surgical case.

For any further questions on surgical time-outs, please contact your local hospital JCAHO executive liaison.

February 26, 2012

Dr. Chang a Washingtonian Top Doctor for 2012

For 2012, Dr. Chang was selected as a Washingtonian Top Doctor in the field of otolaryngology (page 120). This year's list was published in the March 2012 issue of the magazine.

February 25, 2012

Hiccups and Laryngospasm

So one day I was having some bad hiccups... you know, the obnoxious kind complete with strangled noise and chest jerks.

However, this experience unlike the numerous prior episodes of hiccups triggered an intellectual brainstorm about breathing and stridor in general.

Hiccups (aka singultus) are due to brief, intermittent, and involuntary diaphragm contractions against a closed glottis. For the layperson, this means during a hiccup:
  • Your body takes a quick breath inwards (inhalation)
  • Your body brings the vocal cords together
  • Both above actions occur simultaneously, involuntarily, and briefly 
Which brought me to consider another disorder called laryngospasm which is the most severe form of vocal cord dysfunction. In this particular condition, the vocal cords come together involuntarily just as in hiccups... BUT, it may last for seconds to minutes while the breathing is still voluntary. At worst, it results in complete airway obstruction causing a loud high-pitched squeal called stridor (check out this movie below). Click here for more information about this condition.

Laryngospasm is due to sustained and involuntary vocal cord closure WHILE the person voluntarily tries to breath. For the layperson, this means during a laryngospasm attack:
  • Your body tries to breath voluntarily
  • Your vocal cords involuntarily closes for a sustained period of time
  • The above actions occur simultaneously
So... when you get down to it, the only difference between hiccups which is common and afflicts many people and laryngospasm which is rare is: 1) how long it lasts for and 2) whether the diaphragmatic movement is voluntary or involuntary.

Which got me thinking... is there actually a medical condition that is BOTH a hiccup and laryngospasm at the same time?

In fact, there is... though I must preface by saying there has been only one case report (that I'm aware of) of this super-rare condition called "Diaphragmatic Flutter with Stridor."

Reported back in 1995, the journal Chest reported a 13 years old girl who presented with rapid stridulous panting that occurred only during inspiration while awake (symptoms disappeared while asleep). Laryngoscopy showed an abnormal closed glottis. ECG noted noncardiac electrical activity due to involuntary diaphragmatic contractions occurring at a rate of 200/min. Fluoroscopy of her diaphragm revealed rapid myoclonic contractions of the left hemidiaphragm.

In essence, she was "hiccuping" 200 times per minute while having a sustained laryngospasm attack. The suffering this child and her family must have gone through must have been unbelievable and I'm sure tracheostomy must have been entertained at some point.

Treatment (cure) ultimately was achieved by crushing the patient's left phrenic nerve.

So let's take a look at all three conditions in table format:

Diaphragm Contraction
Vocal Cord Closure
Diaphragmatic Flutter

The common theme between all three disorders is the involuntary vocal cord closure resulting in airway obstruction. The variation in presentation is utterly dependent on whether the diaphragm contraction is involuntary or not and how long the "attack" lasts for.

Diaphragmatic Flutter Presenting as Inspiratory Stridor. 10.1378/chest.107.3.872 CHEST March 1995 vol. 107 no. 3

Laryngospasm and Other Forms of Vocal Cord Dysfunction. Fauquier ENT.

February 21, 2012

Allergy Shots in the Leg? Abdomen?

It is not uncommon that we have patients that ask if allergy shots can be administered in the leg (or other part of the body) rather than the usual behind the upper arm.

Before we answer that question, let's ask why we given it in the upper arm in the first place!

1) Easy to access
2) Easy to monitor for any adverse reaction
3) All the good studies done are based on injections administered to the upper arm
4) No good studies performed determining whether injections done at other body sites has equal efficacy to the arm.
5) If anaphylaxis occurs, a tourniquet can be easily applied to the arm proximal to the injection site which theoretically would decrease allergen traveling systemically

Given these answers, is it possible to give allergy shots in other body locations other than the arm?

Yes... BUT...

1) No good studies performed determining whether injections done at other body sites has equal efficacy to the arm.
2) If anaphylaxis occurs, may not be possible to apply a tourniquet easily (if given in the abdomen for example)
3) May not be as easy to monitor for a reaction (if given in the buttocks for example)


It is recommended that allergy shots be given in the upper arm and not other locations.

Ask the expert. AAAAI 2/6/12

February 19, 2012

Greater Patient Satisfaction At Expense of Better Care?

Much has been made about improving patient satisfaction in the healthcare industry in the belief that greater patient satisfaction equates with better health. To this end, patients are routinely asked to complete a survey based on their impressions on the care they received.

BUT... does greater patient satisfaction actually result in or is the result of better care???

According to a recent study... higher patient satisfaction actually resulted in:

• Greater inpatient hospitalization
• Higher overall healthcare utilization
• Higher prescription usage

The one and only measured benefit of higher patient satisfaction scores was decreased ER use.

Why would there be an increased risk of death with higher patient satisfaction scores?

Well, if a doctor always does what the patient wants, that would tend to lead towards higher patient satisfaction... EVEN if it's the wrong thing to do.

For example... when a patient sees a doctor for a perceived sinus infection, it is not uncommon for a patient to expect to leave with an antibiotic.

Unfortunately, many sinus infections are actually viral URI for which antibiotics is the WRONG course of action.

Inappropriate antibiotics lead to drug-resistant infections which lead to deaths. They can also cause side effects that may require additional healthcare intervention.

However, if a doctor resists a patient's desire for an antibiotic, that would lead to a decrease in patient satisfaction.

Also, the more testing and treatment that is performed, the higher the risk of downstream adverse effects. For example, a patient may desire a CT scan of the chest to rule out lung cancer even though the chest x-ray is normal. Unfortunately, the CT scan picks up a small liver nodule. Needle biopsies are performed which unfortunately resulted in excessive bleeding requiring surgical correction and several days in the hospital. In the end, it was just a benign cyst that never required any treatment.

These examples may oversimplify a very complex issue, but it does suggest that one interpretation of higher patient satisfaction scores are that doctors and hospital systems may choose to do the wrong thing in order to get a better score.

The Cost of Satisfaction: A National Study of Patient Satisfaction, Health Care Utilization, Expenditures, and Mortality. Arch Intern Med. Published online February 13, 2012. doi:10.1001/archinternmed.2011.1662

Why Rating Your Doctor Is Bad For Your Health. Forbes 1/2/13.

February 18, 2012

Skin Patch Immunotherapy for Allergy Cure

Over the years, there have been a variety of systems via which physicians and researchers have attempted to cure patients of their inhalant allergies.

These include (click here for a description of each):

Allergy shots
Under the tongue allergy drops (SLIT)
• Intra-Lymphatic Injections (ILIT)
• Allergy Tablets
• Epicutaneous Immunotherapy (EPIT)
• Intra-Nasal Spray
• Bronchial Inhalers

Well... we can now add skin patches to the list.

European researchers conducted a placebo-controlled, double-blinded trial involving 132 patients with grass pollen allergies. The patients were randomly divided into one of four groups: placebo, low-dose, medium-dose or high-dose patches. Patients applied six weekly patches prepared with grass allergens prior to and during the 2008 grass season and ALL reported improvement in their symptoms (30% in 2008) though one year later, there was a dose-dependent improvement with essentially no improvement in low-dose and placebo groups.

Unfortunately, higher-dose patches had higher rates of adverse events including pruritus, erythema, wheal, or eczema leading to an overall drop-out rate of 8.3% from the study.

This all may sound good and promising, but two of the study's authors hold patents on patch-based immunotherapy which may lead to study bias.

My take? More study is needed...

Epicutaneous allergen-specific immunotherapy ameliorates grass pollen–induced rhinoconjunctivitis: A double-blind, placebo-controlled dose escalation study. The Journal of Allergy and Clinical Immunology Volume 129, Issue 1 , Pages 128-135, January 2012

February 15, 2012

New Video on Newborn Hearing Testing

Given how often we see newborns in need of hearing testing, we have produced a video showing how the two main types of non-verbal hearing tests are performed today: Auditory Brainstem Response (ABR) and Otoacoustic Emission (OAE).

Given newborns can not communicate whether they can hear or not, such hearing tests depend on the ability to detect nerve signals transmitting sound information from the ear all the way to the brain. This type of test is much like an EKG which can detect the electrical activity of the heart.

Watch the video to see how ABR and OAE hearing testing works in infants (as well as adults)!

February 12, 2012

Adele Speaks About her Vocal Cord Surgery on 60 Minutes

When it was first reported that Adele was undergoing vocal cord surgery in October 2011, there was much speculation regarding what exact vocal cord pathology she suffered from (hemorrhage? polyp?) and what type of vocal cord surgery she underwent for correction (laser? cutting?).

During her 60 Minutes interview with Anderson Cooper which aired on February 12, 2012, many details regarding her vocal cord problems have clarified.

She apparently suffered from a vocal cord polyp with hemorrhage.

Typically, this problem is normally treated with strict voice rest followed by extensive voice therapy prior to surgical consideration. However, this (safe) course of action takes time and as such, she pursued a much more aggressive approach in order to recover her voice as quickly as possible.

To explain, a lesson in some basic anatomy first...

Normally, the vocal cords are pearly white without any vasculature. Watch a video of how this exam is performed.

However, when a blood vessel is present in the vocal cords, they may look something like this:

When there is a hemorrhagic polyp with a blood vessel as in Adele's case, her vocal cords may have looked like this where the blue arrowhead is pointing to a hemorrhagic polyp. The green arrow is pointing towards a feeding blood vessel.

The issue with a blood vessel within the vocal cord itself is that it fluctuates in size due to whether it is irritated from phono-trauma or even hormones. When a polyp is present, the vocal changes are even more dramatic. Such fluctuation in size causes the voice to change in pitch and quality on an hour to hour basis depending on how much swelling occurs. For a singer, it makes the voice very unpredictable.

When the blood vessel becomes engorged and traumatized, it may even rupture leading to a vocal cord hemorrhage. Especially in a woman, the blood vessel may be more prone to hemorrhage during her menstrual cycle.

This is a dangerous situation for a singer because of their regular voice use and need to use it forcefully. However with too much force, the blood vessel may suddenly rupture (even in the middle of a performance) resulting in a hemorrhage into the vocal lining itself causing a sudden and complete loss of voice. There may even be mild pain associated with this occurrence.

In Adele's case, she remembers the very moment this occurred during a radio interview when she "felt a pop" and her vocal pitch suddenly dropped into the bass range.

This makes perfect sense... To use the analogy of a violin string, the thicker the violin string the deeper the pitch. When hemorrhage occurs, the vocal cord becomes thicker due to blood pooling resulting in a deeper voice instantly.

To the right is a picture of a vocal cord hemorrhage. Note the entire vocal cord on one side (which is the patient's right side for those in the know) is brilliant red indicative of the presence of blood throughout the cord.

How is this treated?

Initially, during an acute vocal cord hemorrhage, STRICT VOICE REST is mandatory. With continued voice use, the patient risks abnormal healing that may result in the development or exacerbation of a vocal cord polyp. With repetitive cycles of healing and trauma, vocal cord scarring may even develop. Along with strict voice rest, steroids are often prescribed to help reduce the inflammatory swelling that often occurs as well as minimize risk of scarring.

Unfortunately, though such treatment may resolve the hemorrhage, it will typically not get rid of the culprit blood vessel and associated polyp.

For that, surgical intervention is required.

One option is to precisely cut out the polyp and cauterize the feeding blood vessel at the same time. This approach was the course that Adele pursued. Watch a video on this approach (video shows a generic vocal cord mass removal, but the approach is identical).

The other option is use of a laser first to extinguish blood vessels present which may also significantly resolve the polyp followed by excision of the residual polyp at a later date. This latter approach is typically what I recommend. Why? It is relatively non-invasive and I feel the risk of scarring to be less compared with excision and vessel obliteration with a laser at the same time (though not zero). Furthermore, a smaller polyp also means a smaller wound that needs to heal.

Shown at end of this blog article is a video of a vascular polyp being obliterated using a pulsed-dye laser (courtesy of Dr. Chandra Marie-Ivey). Another type of laser that may be used is a KTP laser. Read more about laser treatment of vocal cord pathology here.

Regardless of how or in what order the surgery is performed, strict voice rest is mandatory for a period of time post-operatively. For Adele, that was strict voice rest for nearly two months (Nov and Dec 2011). Why? Because with talking or any other vocal activity, the vocal cords come together. After surgical removal of a polyp, there is a raw surface present which won't heal as well if the other vocal cord is banging against it. Talking after vocal cord surgery is analogous to jogging right after foot surgery.

The vocal cord surgical wound MUST heal prior to talking let alone singing for normal recovery. That means strict voice rest. Strict voice rest means no talking, no singing, no whispering, no mouthing words, no throat-clearing, no humming, etc.

Read more about vocal cord polyps here.

Read the 60 Minutes interview here.

Of note, she later went on to sing a stellar performance at the Grammy Awards debuting her new voice for the first time after her surgery.

February 01, 2012

What is the Voicebox Doing When You Scream? Yodel?

In the same spirit of a recent TEDMED talk by Nate Bell and re-published on CNN Jan 12, 2012 whereby he performed various beatboxing noises while stroboscopy was performed, I decided to record a similar video with a person performing various unusual human vocalizations to see what happens.

For those who don't know what stroboscopy is, click here.

Such vocalizations recorded included various types of human screams and a yodel.

Check it out here...

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VIDEO: How Does the Human Voicebox Work?


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