Archive for November 2007

The Weekly Roundup…

Stuff this week that caught my eye: Does medical tourism harm the natives? Are all those CT scans destroying more than our budgets? Are nocturnalists at risk for more than decubs? Will Medicare need to cut hospital payments to fuel P4P? Answers: yes, yes, probably, and duh.Yesterday, NPR’s All Things Considered described the dark side of medical tourism: some Thai patients are now having a hard time finding docs. This is an old complaint, of course – docs (and nurses) leaving their native lands to come to the US or Western Europe for more lucrative practices in more modern facilities. What’s new? The Thai docs aren’t leaving Bangkok; they’re leaving the public hospitals to go across town to the hospitals that cater to foreigners. Some of these places, like the iconic Bumrungrad Hospital with its sushi bar and VIP suites, are the Thai version of the Cleveland Clinic. But even…

Rapid Response Teams: Ready for Prime Time?

Last year, I (with Peter Pronovost) wrote the toughest paper of my life – one that critiqued the Institute for Healthcare Improvement’s 100,000 Lives Campaign. This is the healthcare equivalent of criticizing both Mother Teresa and your local food bank in a single sitting (you can also read Don Berwick and his team’s response here). Although some of our concerns were over IHI’s methodologically suspect “122,300 Lives Saved” estimate, we also criticized the Campaign’s decision to include the establishment of a Rapid Response Team as a national standard.Don’t get me wrong. The concept of a Rapid Response Team is attractive. It isn’t hard to find patients who die in hospitals or require emergent transfer to the ICU in whom evidence of deterioration was present for hours – sometimes days – before the crash. In some of these cases, nurses failed to recognize the early signs of deterioration (tachycardia, tachypnea), or,…

Dennis Quaid’s Kids: Are VIPs Safer?

The Entertainment Blogosphere was atwitter yesterday with the story of actor Dennis Quaid’s twin newborns, who reportedly received a 1000-fold heparin overdose at Cedars-Sinai Medical Center in La La Land. Cedars’ Chief Medical Officer Michael Langberg may win this year’s Oscar for fastest public apology – having learned the lesson from the 2003 Duke transplant error, where the hospital stonewalled for a week or so, adding chum to the media feeding frenzy.The error came during heparin line flushes, when a 10,000 units/ml solution of heparin was mistakenly substituted for the intended 10 units/ml solution. Although the cases required pharmacologic reversal of the anticoagulant effect, thankfully there were no bleeding complications.These cases come on the heels of last week’s report out of Dallas that the state-supported UT-Southwestern kept an “A-list” of potential donors and assorted bigwigs. Apparently, when these folks come to the hospital or clinic, they may get a personal…

The Surgical Hospitalist

In an article in this month’s Journal of the American College of Surgeons (with a companion cover piece in the ACS’s Bulletin), four of my surgical colleagues – and this internist, perhaps to add a “cognitive” spin – describe UCSF’s “surgical hospitalist” program. It is an impressive story.When Dr. John Maa and his friends speak of a “surgical hospitalist,” they are referring to real-live surgeons – you know, the “sometimes wrong but never in doubt” types – taking on the role of inpatient generalists. They are not referring to another type of surgical hospitalist, the internist-hospitalist co-managing hospitalized surgical patients. That model, which I believe will be the source of much of the hospitalist field’s growth in the coming decade, will be the subject of a future posting. [We’re going to have to clean up this nomenclature; for now, you’ll be able to tell the two models of care apart…

Perioperative Beta Blockers, Redux

Earlier this week, I discussed the preliminary results of the POISE trial, the blockbuster that showed that perioperative beta blockers may cause more harm than good. I've asked my UCSF colleague Andy Auerbach, one of the nation's experts on this intervention, to help us understand these truly surprising results. Andy's comments follow:"The POISE trial vividly demonstrates that giving beta blockers to surgical patients is not a simple intervention. That is, perioperative beta blockade (at a fairly high dose – 200 mg metoprolol/day) produces a mix of risks (stroke, significant hypotension, bradycardia, plus that pesky all-cause mortality) that outweighs the benefit (largely, fewer non-fatal MIs). In drilling a bit deeper into the POISE results, it appears the excess mortality was fueled by a far higher mortality rate in beta blocked patients who also had a non-cardiac complication (largely sepsis). Because non-cardiac post-op complications are more common than cardiac ones, it is…
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