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May 30, 2012

Waking Up to NOT Just Major Colonoscopy Bills...

The New York Times published an article on May 28, 2012 regarding the high anesthesia charges associated with colonoscopy.

What people need to realize is that anesthesia charges apply not just to colonoscopy, but ANY procedure that requires general anesthesia... tonsillectomy, appendectomy, gallbladder surgery, ear tube placement in kids, etc.

With any procedure requiring general anesthesia, a patient is going to receive THREE bills... not just one which is what most reasonable people think.

1) A bill from the surgeon

2) A bill from anesthesia

3) A bill from the hospital

Sometimes the hospital and anesthesia charges are bundled into a single bill.

Often, patients mistakenly focus on the surgeon's charges thinking that's where their largest out-of-pocket cost is going to lie. However, the surgeon's fee is almost always the lowest of the charges.

Let's take a look at the New York Time's article...

The GI doctors actually performing the colonoscopy procedure got paid around $200. The anesthesia charges were around $2000 or 10x more (note that insurance coverage was an issue in this article and IF insurance did cover, out-of-pocket charges would have been significantly lower).

And than... if the procedure is done in the hospital, the hospital charges will often be around $5000 or 25x more.

These charges are similar to that found for many ENT procedures as well including tonsillectomy. (Of note, all insurances that we participate with... the anesthesia group I work with also participates with.)

On a more personal note, I recently underwent a general surgical procedure myself performed under general anesthesia in the hospital and got the following charges (3 different bills):

1) Surgeon's charge of $425 of which I owed $148.54 (difference covered by insurance)
2) Anesthesia charge of $1,400 of which I owed $140 (difference covered by insurance)
3) Hospital charge of $3,710.25 of which I owed $559.05 (difference covered by insurance)

Now if anesthesia did not participate with my insurance company, than I would have been fully responsible for anesthesia's full charge of $1,400. This situation is what the New York Time's article mainly focused on.

SO what is a cost-conscious patient to do?

Rather than focusing on the surgeon doing the procedure, the biggest cost-savings will occur negotiating with the hospital followed by anesthesia.

OR... avoid having procedures done in the hospital altogether to avoid hospital charges followed by avoid general anesthesia if at all possible and stick with local anesthesia alone. You will than ONLY have to deal with surgical charges which the surgeon should be able to inform up-front.

WHY do surgeons do procedures in the hospital rather than the office?

Beyond patient and procedural factors which may require general anesthesia, procedures may preferentially be performed in the hospital due to money. No big surprise there, but it may not be for the reasons people may suspect.

Let's take a real life example... balloon sinuplasty.

Balloon sinuplasty is an innovative minimally invasive surgical procedure to treat chronic sinusitis. Prior to 2011, this procedure was almost always performed in the operating room in the hospital though it could have been performed in the office.


The balloon used for this procedure costs around $2000 and is not reusable.

The reimbursement for the surgeon to perform this procedure was around $200+ depending on the number of sinuses addressed and insurance company.

SO... if balloon sinuplasty was performed in the office prior to 2011, the surgeon would have spent $2000 to do the procedure and than would have gotten paid only $200+ meaning a loss of ~$1800.

Why not charge the patient for the balloon device? Because it is called balance-billing and it is illegal.

So what is a surgeon to do if a patient desires balloon sinuplasty and yet the surgeon doesn't want to lose money?

You do it in the hospital... where the hospital eats the $2000 cost of purchasing the balloon device... and the surgeon still gets paid $200.

However, starting in 2012, insurance companies started reimbursing surgeons for the cost of the device which is why all of a sudden, balloon sinuplasty is now being performed in the office.

This type of financial calculation occurs all the time in medical offices.

Even a pediatrician's office where gardasil vaccination is often not offered... Why? Because the vaccine costs more than what the pediatrician will get reimbursed to give it.

Waking up to Major Colonoscopy Bills. New York Times 5/28/12

May 27, 2012

Homemade Sorbet Ice Cream for those Suffering from the Flu!

My wife loves to make homemade ice cream and came across this recipe called "Influenza Rx Sorbet" by Jeni Britton Bauer in her homemade ice cream cookbook.

The recipe includes lemon and orange juice for Vitamin C.

Ginger and cayenne to help clear nasal passages as well as antiseptic properties.

Humectants, honey, and liquid pectin to help a dry, itchy throat retain moisture.

Sorbet in and of itself helps calm an inflamed sore throat.

Though I would love to regurgitate the recipe, you will have to buy her New York Times bestselling homemade ice cream cookbook. It's on page 180-181.

Oh... and by the way... the other ice cream recipes are quite yummey!

Synthetic Vocal Cords [video]

Synthetic vocal cords being under development at MIT and Harvard... Very good video!

What are some of the vocal cord problems that may benefit from such a synthetic gel? Vocal cord paralysis, vocal cord surgery to address polyps, cysts, nodules, granulomas, etc.

As an FYI... the synthetic vocal cord gel portrayed in the video is still under development and not available for patient use yet...

Why Do Humans Have Weak Sense of Smell

Compared to nearly all other animals, humans have the weakest sense of smell. You would think that humans and our closest evolutionary cousins (chimpanzees, apes, etc) would have similar sense of smell, but humans still have a much weaker olfactory sense.

Why might that be?

Well, research from Karolinska Institutet have discovered that humans are the ONLY mammals whereby no new neurons are formed in the olfactory bulb after birth. Or if there is any, it is VERY little.

In all other mammals including apes, new neurons are constantly being formed in the olfactory bulb which might explain why all mammals with the exception of humans have a superb sense of smell.

How did scientists figure out the absence of neuron growth in humans?

They looked at Carbon-14 levels within the DNA of the olfactory bulb. Carbon-14 levels in the atmosphere increased significantly due to nuclear bomb testing during the Cold War.

As such, IF new neurons were being formed, one would expect Carbon-14 levels which gets incorporated into developing DNA, to be similar to current atmospheric levels. Or at least find a certain turn-over percentage of both "old" and "new" neurons reflective of the Carbon-14 atmospheric levels at time of neuron development.

However, what researchers have found was Carbon 14 concentrations that corresponded to the atmospheric levels at the time of birth of the individuals establishing that there is very limited, if any, postnatal neuron development in the human olfactory bulb.

Although human sense of smell may be weak compared to other animals, it is still the most sensitive sense humans have given it can discriminate more than 1 trillion olfactory stimuli whereas the eye can discriminate several million different colors and the ear only half a million different tones.

The age of olfactory bulb neurons in humans. Neuron. May 24, 2012, 10.1016/j.neuron.2012.03.030

Humans Can Discriminate More than 1 Trillion Olfactory Stimuli. Science 21 March 2014: Vol. 343 no. 6177 pp. 1370-1372. DOI: 10.1126/science.1249168

May 26, 2012

Movie Director John Woo Has Throat Cancer?

Famed movie director John Woo apparently is being treated for throat cancer. The director of such movies including Mission: Impossible II is apparently undergoing treatment in the United States.

Details are sparse.

However, he apparently "has been admitted into a hospital for 4 months" which leads me to think that his throat cancer is late-stage which usually requires both radiation and chemotherapy for definitive treatment. Surgery may or may not be required, though hard to say without more information.

Woo reportedly suffers from throat cancer. 5/26/12

How Does Nasal Packing Stop Nosebleeds?

It is not unusual for an ENT or an Emergency Room physician to see a patient with a very bad nosebleed... the kind that can potentially be life-threatening given how much active bleeding is occurring.

In these situations, nasal packing is the fastest and best way of stopping the nosebleed.

For any type of active bleeding, direct pressure tamponades the bleeding thereby stopping it... whether it be a stab wound to the leg or a bad nosebleed. In essence, direct pressure exerts a certain amount of pressure that exceeds the blood pressure preventing blood flow. The corollary being if the amount of direct pressure being exerted is LESS than the blood pressure, bleeding will still occur.

With nasal packing, pressure is exerted by the packing material and pressed against whatever the bleeding source is within the nose.

My personal favorite packing material is called the rapid rhino made by Arthrocare (I have no financial ties to the company). It is in essence a balloon covered by a bio-compatible self-lubricating fabric. This device is inserted into the nose in a deflated state. 
Once fully inserted into the nose, it is than inflated using a standard syringe. Enough air is inflated into the device such that the pressure exerted by the balloon exceeds the blood pressure of the vessels within the nose.

The key point here is that enough pressure must be exerted by the balloon device. If the patient's blood pressure exceeds the balloon pressure, bleeding will still occur and MORE air must be pushed in. As such, in patients with high blood pressure, more air must be inflated into the balloon device to stop a nosebleed compared to a patient with low blood pressure.

So, here is what it looks like to insert a rapid rhino nasal packing.

Step 1: After hydrating the fabric, the nasal packing is placed at entrance of nose.

Step 2: Nasal packing is fully inserted into the nasal cavity.

Step 3: The nasal packing balloon is than inflated with enough air pressure to stop the nosebleed.

Obviously, blood pressure must also be controlled and the nasal packing can be removed in about 3 days for patients not taking any blood thinners or anti-coagulants (coumadin, plavix, ticlid, pradaxa, aspirin, ibuprofen, etc). For those on such medications, packing may need to be kept in place longer.

For more information about nosebleeds.

Watch a video regarding how cauterization can stop nosebleeds.

May 22, 2012

Name an ENT Who Has Won an Olympic Gold Medal

He not only won one Olympic Gold Medal, but two in men's platform diving in 1948 and 1952.

Dr. Sammy Lee also won bronze medal in the 3 meter springboard and coached Bob Webster and Greg Louganis to their Olympic medals.

In terms of his medical career, he studied pre-med at Occidental College followed his MD from University of Southern California (USC) Medical School in 1947. He than went on to become an ear, nose and throat specialist.


TV Show HOUSE Exploring ENT Problems

I must clarify that I never really like TV show House for reasons explained here... but patients who love watching House have alerted me to some episodes this season that touched on ENT problems.

So... here goes...

Episode 21 (Season 8): Holding On
Diagnosis: Persistent Stapedial Artery

19 years old cheerleader was admitted after suffering from dizziness, massive nosebleed, and auditory hallucinations. It was ultimately determined that he was suffering from a persistent stapedial artery.

This artery is a congenital defect of the inner ear that should have obliterated during fetal development. However, if persistent, is typically found going through the stapes bone of the middle ear.

It CAN cause symptoms of dizziness as the pulsations of the artery can transmit through the stapes footplate and into the vestibule via the oval window. It can also cause auditory hallucinations by pressing against the nearby temporal lobe as well as a nosebleed. If the artery ruptures, it can only drain through the eustachian tube and out the nose.

However, if the patient presented to the ER with nosebleed and dizziness, a complete physical exam would have been performed and a clearly seen blood-filled middle ear cavity (hemotympanum) would have been seen that even a medical student would have found. That would have indicated an ear issue causing both the dizziness and nosebleed. Also, the patient would have complained of hearing loss with blood in the ear.

From that point, the differential diagnosis is actually quite small and would have been obtained relatively easily.

Diagnosis: Amoebic Meningitis

35 years old man admitted to House’s service after he is discovered crying blood. He later develops light sensitivity, vomiting, and a stiff neck.

After suspecting meningitis, it was discovered that he was using a Neti Pot and was using tap water rather than distilled or sterilized water in order to perform saline flushes. The water happened to contain an amoeba (likely Naegleria fowleri) which caused an amoebic infection of the brain.  The culprit organism Naegleria fowleri causes a life-threatening encephalitis after passing thru the nose and up into the brain where the organism eats neurons for food.

Such brain infections have been recently reported in the news and can be prevented by using water that is boiled, distilled, or filtered.

Fortunately, it is rare.

May 21, 2012

Noise Charts as It Relates to Hearing Damage

Fun hearing facts collected from a variety of sources...

Environmental Noise
Weakest sound heard0dB
Whisper Quiet Library at 6'30dB
Normal conversation at 3'60-65dB
Telephone dial tone80dB
City Traffic (inside car)85dB
Train whistle at 500', Truck Traffic90dB
Jackhammer at 50'95dB
Subway train at 200'95dB
Level at which sustained exposure may result in hearing loss90 - 95dB
Hand Drill98dB
Power mower at 3'107dB
Snowmobile, Motorcycle100dB
Power saw at 3'110dB
Sandblasting, Loud Rock Concert115dB
Pain begins125dB
Pneumatic riveter at 4'125dB
Even short term exposure can cause permanent damage - Loudest recommended exposure WITH hearing protection140dB
Jet engine at 100'140dB
12 Gauge Shotgun Blast165dB
Death of hearing tissue180dB
Loudest sound possible194dB

OSHA Daily Permissible Noise Level Exposure
Hours per daySound level
.25 or less115dB

Perceptions of Increases in Decibel Level
Imperceptible Change1dB
 Barely Perceptible Change3dB
Clearly Noticeable Change5dB
About Twice as Loud10dB
About Four Times as Loud20dB

Sound Levels Found in Music
Normal piano practice60 -70dB
Fortissimo Singer, 3'70dB
Chamber music, small auditorium75 - 85dB
Piano Fortissimo84 - 103dB
Violin82 - 92dB
Cello85 -111dB
Flute 92 -103dB
Piccolo90 -106dB
Clarinet85 - 114dB
French horn90 - 106dB
Trombone85 - 114dB
Tympani and bass drum106dB
Walkman on 5/1094dB
Symphonic music peak120 - 137dB
Amplifier, rock, 4-6'120dB
Rock music peak150dB

The National Institute for Occupational Safety and Health (NIOSH)

Binge Listening: Is exposure to leisure noise causing hearing loss in young Australians? [pdf] – Australian Hearing, National Acoustic Laboratories

Occupational Noise Exposure. OSHA

People DO Suffer Hearing Loss After a Loud Concert

Almost everybody at some point in their lives have attended a loud concert or loud nightclub.

Almost everybody will also recall a temporary reduction in their hearing with or without ringing afterwards for a short period of time.

This phenomenon is called temporary threshold shift (TTS) whereby the affected person has a temporary hearing loss that may last hours to days due to temporary damage of the outer hair cells of the cochlea.

If loud nose exposure happens enough times, permanent hearing loss can occur.

For some, permanent hearing loss may occur after attending numerous loud concerts whereas in other more "susceptible" individuals, it can happen after a single loud concert.

It doesn't even have to be a loud music concert. ANY loud noise exposure can do including shooting guns, listening to a portable music player like the iPod, fireworks, playing in an orchestra/band, etc.

However, loud concerts are of particular interest given how many individuals are exposed all at once and provided a unique research opportunity which was presented on May 21, 2012 at the American Otologic Society Meeting in Los Angeles.

The researchers (led by Dr. Jennifer Derebery of the House Ear Institute) essentially took hearing test before and after the concert of 29 teenagers.

72% suffered objective hearing loss after the concert though only 53% reported subjective hearing loss. 25% reported new onset tinnitus after the concert.

Of note, hearing ear plugs were offered to the study subjects, but only 3 accepted them.

Adult researchers who sat with the teenagers under investigation measured sound levels throughout the concert. During the 26 songs played during the three hour concert, sound levels ranged from 82 to 110 decibels with an average of 98.5 decibels. The mean level was greater than 100 decibels for 10 of the 26 songs.

As a reference, ear pain occurs at 125dB. Jet engine noise is at 140dB. Sustained loud noise exposure of 90-95dB can result in permanent hearing loss.

OSHA (Office of Safety and Health Administration) mandates workers to never be exposed to sound levels of 100dB for more than 2 hours per day (no more than 4 hours per day at 95dB).

Clearly something more needs to be done to protect teenagers' hearing, especially given how few accepted hearing ear plugs. A fundamental cultural shift would most likely have to occur with encouragement from not only the musicians but also parents and teachers...

OR, the music volume at concerts should be turned down... No boos please.

Teenagers Hear Worse After Attending Concert. LiveScience 5/21/12

May 20, 2012

Azithromycin Increases Risk of Death Slightly... Well, So Does Tylenol and Ibuprofen

The media has made much fuss about a NEJM study suggesting a slight increased risk of death from taking azithromycin or z-pack. The more unhealthy you are, the higher the risk... no duh... (I would think the sicker you are, the greater the risk of death PERIOD... a sick person by definition is closer to death than a healthy person).

How slight? Compared to amoxicillin, about 47 additional cardiovascular deaths per one million courses of therapy.

Never mind the blatant biases found in the study nicely espoused on by cardiologist Dr. Wes in his blog. I should also point out that there's another study that did NOT find an increased risk of death with azithromycin.

Thinking you should never take a z-pack again due to this slight increased risk of death?

Well, good luck finding an alternative medication (of any kind) because they ALL have a potential risk of death.

Similar to z-pack, these other antibiotics also have an increased risk of sudden cardiac death:

• Avelox
• Bactrim
• Biaxin
• Cipro
• Diflucan
• Erythromycin
• Factive
• Floxin
• Foscavir
• Ketek
• Levaquin
• Sporanox
• Sulfa
• Tequin

It's not just antibiotics. These other common medications (not all-inclusive) also have an increased risk of sudden cardiac death:

• Benadryl (allergy)
• Pepcid (reflux)
• Albuterol (asthma)
• Prozac (depression)
• Serevent (asthma)
• Sudafed (decongestant)

The complete list can be found here.

Let's consider other popular drugs that also has an increased risk of death, though not necessarily from a cardiac trigger.

• ALL antibiotics due to a severe anaphylactic allergic reaction - Take Penicillin for example... about 300 die annually from penicillin allergic reaction in the US
Tylenol causes liver failure - About 400 deaths per year in the US
Ibuprofen causes internal bleeding - About 15,000 - 20,000 die per year in the US
Alcohol related deaths - 75,000 deaths per year in the US
Smoking related deaths - 443,000 deaths per year (one in five deaths) in the US

Never mind deaths from driving a car, accidental gunfire, drowning in a swimming pool, etc.

Life in general in the United States has a risk of death.

Azithromycin may up chance of sudden cardiac death. Heartwire 5/16/12
Popular Antibiotic May Raise Risk of Sudden Death. NYT 5/16/12
Azithromycin and the Risk of Cardiovascular Death. New England Journal of Medicine 2012; 366:1881-1890May 17, 2012
Use of Azithromycin and Death from Cardiovascular Causes. N Engl J Med 2013; 368:1704-1712May 2, 2013DOI: 10.1056/NEJMoa1300799

Australia Ends $500 Million Electronic Medical Records Initiative

First United Kingdom ends their $17 billion electronic medical records initiative in 2011 and now Australia follows suit after 6 years of trying to fund their HealthSMART health information technology project and projected costs went from $318 million to $557 million.

This Australian project was to have provided hospitals with software from Cerner, iSoft (now CSC) and InterSystems... the same system which also failed to be implemented by United Kingdom.

I said it before and I'll say it again... I'm not surprised.

And I would wager that the United State's own electronic medical records initiative HITECH signed into law in 2009 by President Obama will also fail similarly though perhaps not as spectacularly.

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, Australia, 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???

Government dumps hospital IT system. ABC News 5/18/12
Victoria kills HealthSMART IT project. IT News. 5/18/12

May 19, 2012

Fauquier ENT Reaches 5 Million Web Visits

It is with some amazement that a certain milestone was reached this past week...

Fauquier ENT's online presence received over 5,000,000 web visits since first coming into existence in 2004. This number includes practice website and blog.

There has been exponential growth year over year with daily web visits now averaging close to 8,000 hits per day with some occasional peak days exceeding 10,000 views.

Our YouTube channel has done even better on its own with over a QUARTER BILLION VIEWS since we first established it in 2007. As of today, our videos have collectively received over 228 million views, averaging 45,000 views per day.

Thanks for all the online support!

May 17, 2012

Can Eye Drop Medications be Used in the Ear?

Can EYE drop medications be used in the EAR for ear problems like ear infections?

For the most part, absolutely, but not vice-versa.

For pretty much any EAR drop preparation, there is an equivalent EYE drop preparation which can be used safely in the ear.

Why does this matter?

For some patients, the ear drops may burn when placed. Given eye drops uses a much "gentler" solution, such patients find that eye drops doesn't burn in the ear nearly as much compared to ear drops.

Also, it may be cheaper for the patient if the EYE drop medication is prescribed rather than the EAR drop medication. Often, it is not unusual for a brand name ear drop medication to be available in generic eye drop form.

NOW... EAR drop medications should NOT be used in the EYE because preservatives used in eye drop preparations are much gentler than those used in ear drops due to the eyeball being much more sensitive compared to the ear. As such, it may burn if ear drops are used in the eye... but not vice-versa.

• Floxin (Ear) equivalent to Ocuflox (Eye)
• Ciprodex (Ear) equivalent to Ciloxan (Eye) without the steroid dexamethasone
• Cipro HC (Ear) equivalent to Ciloxan (Eye) without the steroid hydrocortisone
• Cortisporin (neomycin-polymyxin-hydrocortisone) is available in both eye and ear preparations
• Tobradex (Eye) can be used in the ear and is imprecisely similar to Cortisporin (Eye/Ear).
• Dexamethasone 0.1%, Fluocinonide 0.05%, as well as Prednisolone 1% (Eye) can all be used in the ear and is imprecisely similar to Dermotic
• Vasocidin (Eye) which contains sulfacetamide and prednisolone has no ear equivalent

May 11, 2012

Actress Reese Witherspoon's Dad is an Otolaryngologist!

It has recently come to my attention that actress Reese Witherspoon's dad is an eminent otolaryngologist!

John Witherspoon, MD has practiced with a Nashville, TN otolaryngology group for over 30 years and is an instructor in this specialty at Vanderbilt University Medical Center.

He went to medical school at University of Tennessee Health Science Center College of Medicine and completed his residency at Tulane University Hospitals and Clinics.

He unfortunately has come under recent scrutiny from the media which hopefully will pass over quickly!

I wonder if Reese Witherspoon used her dad as a role model in the romantic comedy movie "Just Like Heaven when she played Elizabeth, a workaholic doctor.

May 07, 2012

Chronic Cough Could be Due to Lung Cancer

BBC News recently reported that chronic cough may be due to lung cancer.

Here are my two cents on this condition in support of this assertion.

I often seen patients for chronic cough... not the kind that has been going on for only a few weeks, but the kind of cough that has gone on for over 1 or more years. Even 10-20 years.

It is not unusual for such patients to have seen an ENT, GI, pulmonary, and allergy specialists to try and stop their cough.

In particular, such patients may be informed their cough is not due to the lungs after getting a chest x-ray and pulmonary function tests which all come back normal along with lack of response to inhaler medications.

Unfortunately, some patients' chronic cough is due to lung cancer which is only discovered on additional studies including bronchoscopy and CT scan of the chest. Obtaining only a chest X-ray and breathing tests are not sufficient enough.

Now, it certainly is not necessary to perform these additional specialized studies in every patient who has been coughing for a few weeks... but when somebody has been coughing for over 1 year, a more intensive search for abnormalities is required.

In my clinic, it is not uncommon that a patient who has been coughing for over 1+ years ends up being found to have lung cancer.

Of course, there are other causes of chronic cough including reflux, allergies, post-nasal drip, medication side effect, etc that also needs to be looked into.

For more info on chronic cough.

Persistent cough 'could be lung cancer warning' BBC News 5/6/12

May 04, 2012

Beastie Boys Adam Yauch Dies of Parotid Cancer

Image by Patrick Lynch from Wikipedia
On May 4, 2012, Adam Yauch, one of the founding members of the Beastie Boys, died of a "rare parotid gland cancer" that he had been battling since its diagnosis in 2009. For those who do not know what a parotid gland is... it is one of the major glands that produce saliva or spit and is located immediately in front of the ear (looks like fish eggs in the picture taken from Wikipedia). It is about the size of the palm of the hand.

It is unclear exactly what type of parotid gland cancer Adam Yauch had, but here's a list of what it could have been:

• Acinic Cell Carcinoma
• Adenocarcinoma
• Squamous Cell Carcinoma
• Mucoepidermoid Carcinoma
• Carcinoma ex-pleomorphic adenoma

Thankfully, the vast majority of parotid tumors are benign growths such a pleomorphic adenoma or Warthin's tumor.

Typically, with any type of parotid mass, the sequence of events to diagnose and treat such masses occur in a standard fashion:

1) Mass appreciated by patient or primary care doctor
2) Patient sees ENT who confirms mass localized to parotid gland
3) CT scan of the neck with contrast ordered to further evaluate the mass
4) Fine needle biopsy obtained of the mass for pathologic diagnosis
5) Surgical excision performed... an operation called "parotidectomy"
6) If needle biopsy indicated cancer, neck dissection is also performed to remove all lymph nodes that may contain cancer followed by radiation therapy to the whole area.

Parotidectomy surgery is a "difficult" surgery mainly in the sense that one of the main risks of surgery is permanent facial paralysis. Why? It is because the nerve that allows facial movement goes right through this gland (in yellow in the picture above).

As such, the vast amount of time dedicated to this surgery which may last anywhere from one to several hours is identifying and isolating all involved branches of the facial nerve. The actual parotid gland mass removal takes less than 15 minutes.

Read more about this surgery here.

Adam Yauch Dead: Beastie Boys' MCA Dies After Battling Cancer. Huffington Post 5/4/12.

5 Years Old Child Dies After Tonsillectomy from Narcotic Overdose?

The Story

On April 7, 2011, 5 years old child underwent tonsillectomy in Delaware for obstructive sleep apnea.

Post-operatively, he was given a narcotic nubain (nalbuphine) twice, IV morphine once, and lortab once over the next hour. Lortab was the last narcotic given shortly before 3PM.

The child was discharged home at 3:50PM in an "unresponsive" state. He was put to bed once he arrived at home.

At 6PM, parents called 911 when the child was found unresponsive and not breathing. He was shortly thereafter pronounced dead.

According to the death certificate, the cause of death was "respiratory arrest associated with opioid analgesia status post tonsillectomy."

The Analysis

This story is tragic, but underscores the importance of how dangerous narcotics are at any age including adults, but especially children.

It is unusual that a young child receive 4 doses of narcotics within a 60 minute period of time for pain control. Pain control is important, but giving this much narcotics risk respiratory depression and ultimately complete breathing cessation as it did here.

What I suspect happened is as follows... to be clear, this is what I GUESS to have happened based on what has been written so far about this case.

Post-op orders included 3 different narcotics for pain control depending on how severe the pain. Post-op orders between the ENT and anesthesiologist probably included:

Nubain every 4 hours as needed for moderate pain
Morphine every 1 hour as needed for severe pain
Lortab every 4 hours as needed for moderate pain

As such, from a nursing standpoint, they have 3 narcotic choices: nubain, morphine, and lortab.

Nubain was initially given.

Apparently, this did not control the child's pain.

As such, another dose of nubain was given, perhaps by a different nurse (not sure how/why this happened as nubain dosing typically is every 3-6 hours as needed for pain). Perhaps a miscommunication occurred such that the nurse giving nubain a second time was unaware that this medication was already given.

Another (short) period of time passed and child was still in pain and as such, the nurse looks at the orders and realizes she can't prescribe nubain anymore, but morphine and lortab still can be prescribed as neither has been given yet.

SO... morphine was given.

Another (short) period of time passed and I suspect the child still showed signs of being in pain. So the nurse looks at the orders and sees that nubain and morphine have already been given and as per orders, is not due for another dose for several hours...

BUT... lortab hasn't been given yet... so lortab was provided.

So in the end, a child in pain received 2 doses of nubain, 1 dose of morphine, and 1 dose of lortab in a short period of time.

Many things clearly went wrong here, but the main issues can be as follows:

1) It takes time for a narcotic to take effect so expecting pain relief in a short period of time is not an indication that the narcotic medication did not work. More time should have been given prior to considering additional pain control measures.

2) Though nubain, morphine, and lortab are all different medications, they are all STILL narcotics and some common sense judgement should have been used prior to giving all 3 within a one hour period of time.

3) THREE different narcotic choices should never have been written with discretion left to nurse. Ideally 1, but not more than two narcotic choices should have been ordered. It is also debatable whether nubain, morphine, and lortab were appropriate choices for children this age.

4) An unresponsive child should not have been discharged. If the child was observed longer, oxygen desaturations may have been noted with appropriate medical interventions that would have prevented death. Just as an aside, there is an "antidote" to narcotic overdose called narcan.

Did Early Discharge Cause Child's Death After Tonsillectomy? Outpatient Surgery 5/4/12

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