Patients can chew gum immediately before surgery I guess

A study presented at the American Society of Anesthesiologists (ASA) meeting in October of this year found that patients who chew gum in the immediate preoperative period may safely undergo surgery.

The authors, based at the University of Pennsylvania, found that gum chewing increases saliva production and the volume of fluid in the stomach, but stomach acidity was equivalent to that of non-gum chewers. An article about the study said The mean gastric volume, or total amount of liquid in the stomach, was statistically higher in patients who chewed gum before their procedure (13ml) versus those who did not (6ml). A 7 mL difference might be statistically significant, but surely is not clinically important.

The research differed from previous studies because it involved patients who underwent upper gastrointestinal endoscopy, which enabled the investigators to recover all of the fluid in the stomach for testing. Prior studies had been done using nasogastric tubes, and it was impossible to determine whether all gastric fluid was recovered when the tubes were suctioned.

The study involved 34 gum chewers who were allowed to chew any type or any amount of gum compared to 33 patients who did not chew gum.

Another article quoted its lead author.

"We found that although chewing gum before surgery increases the production of saliva and therefore the volume of stomach liquids, it does not affect the level of stomach acidity in a way that would elevate complication risks," explains Dr. Goudra.

He says patients shouldnt be encouraged to chew gum before procedures involving anesthesia, but the habit shouldnt necessitate the cancellation or delay of scheduled cases if other aspiration risk factors arent present.

There has been long-standing debate about the subject of whether using gum and hard candy should be treated the same as ingesting a regular meal.

I wrote about this on my blog back in January 2014 and pointed out that the ASA guidelines do not address the issue.

In an effort to do due diligence, I was able to locate the abstract of this paper on the ASA website. Im glad I did because the abstract came to the opposite conclusion.

When the abstract was submitted, it included fewer patients—24 who chewed gum and 23 who did not.

The average gastric volumes were 9.78 mL for the gum chewers and 24.08 mL for the non-gum chewers (p = 0.027), and pH values were not significantly different (p = 0.094). It looks like regression to the mean occurred as the number of subjects increased.

In the original abstract, the authors concluded the following: Chewing gum in the preoperative fasting period leads to significant increase in the residual gastric volumes, with no difference in pH. We recommend that patients who have inadvertently chewed gum in the fasting period should be treated as full stomach and management modified accordingly. [Emphasis added]

So what is going on here? This would not be the first time that an abstract differed from the final paper. Actually, this sort of thing happens quite frequently. However in this case, the conclusions of the two versions are diametrically opposed to each other.

The study was presented at a meeting. Lets see what happens when it is submitted to a journal for peer review.

The correct way to have done the study would have been to calculate the number of patients needed to be studied (power analysis) beforehand.

Since this was not done, I recommend we go with the conclusion of the larger number of patients studied because it agrees with my bias that chewing gum is not potentially harmful.

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Its All About That Bass featuring Kate Davis

Greetings:

You gotta hear this......

Its All About the Bass featuring Kate Davis....

Amazing stuff...


http://youtu.be/iyTTX6Wlf1Y


Enjoy


Marc

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Amazicon Proves Unprofessionalism At Its Finest

Ever find yourself dealing with someone who labels themselves a "professional" only to discover that their behavior is anything but professional? Its certainly sad indeed when a grown adult acts like a toddler who is in desperate need of a diaper change. Harsh but true. Take the Amazicon Convention, taking place April 4th, 5th and 6th at the Clarion Hotel in Essington, PA. I met the owner of the show this past January at the Philadelphia Comic-Con at the Clarion Hotel where I was a guest. I was summoned to the Amazicon table. Someone was sent over and told me the owner of the convention  wanted to meet me. I was escorted to him and the owner made his pitch and said he wanted to me attend his show. I offered to help with the Costume Contest and we were booked.




Flash forward to late March with a little over a week prior to the convention. After returning from Orlando, Florida I wrote on my personal Facebook Page how I had many charity events, birthday bookings and trips coming up and life was good. Almost immediately I received a scathing email from the owner of Amazicon ripping me apart because I did not mention his show in my Facebook status. Well, read for yourself friends:

Now is this anyway to conduct a business? What gives him the right to tell me what I should be posting on my personal Facebook account, which is not public but private? Why get upset that I referred to his show as a local con when that is in fact, what it is? Why on earth is he saying that Awesomecon does not care about their attendees and doesnt want me there (when in fact, they do want me there as a member of the press)? Mike and Connie you have a lot to learn about running a business but furthermore, you have a lot to learn about communication. This is not how you talk to people. This is not how you treat others. I hope you both take this as a valuable lesson and learn from it particularly if you want your show to survive. I have been attending conventions all over the country for 11 years as a simple con goer, a member of the press, a cosplay guest and working for vendors. I have never in my 11 years seen such outlandish behavior. The Amazicon show should be embarrassed. 

A source reported to me that Amazicon has been getting emails regarding this manner from people scrutinizing them saying they are now refusing to attend, thus stressing the owners out. 

After removing Amazicon from my friends list, they continued to message me and I had to block them. They seemed particularly peeved that I said I was going to show everyone  what they said and then resorted to saying that I was in fact, the unprofessional one. Well as you said, Facebook is public, the internet in public. So let the internet see what you did, shall we?

http://amazicon.net/

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Recognition

The following is based on an actual case that occurred a long time ago in a galaxy far, far away.

A 65-year-old man arrived in the emergency department by ambulance after being found unresponsive. His respiratory rate was 40/minute, heart rate was 170/minute, and temperature was 102.2°. He did not respond to Narcan or an ampule of 50% dextrose. Blood sugar was 600 mg/dL. The diagnosis of diabetic ketoacidosis was made. IV fluids and an insulin drip were given. After some hydration he became more alert and complained of abdominal pain. On examination, his abdomen was tender to palpation. Four hours after arrival, a surgical consultant was called and diagnosed an incarcerated inguinal hernia. Before the patient could be taken to surgery, he suffered a cardiac arrest and could not be resuscitated. Review of the case revealed that although blood cultures were drawn and were eventually positive, antibiotics had not been ordered.

What happened? The possibility that this patient was septic never occurred to the doctors managing the case. I am sure that if a scenario like this appeared on a test, those doctors would have immediately chosen the right antibiotics. Some doctors are "book smart" but cant deal with a real live patient.

Although the doctors didnt do a very thorough abdominal exam at first, the real problem here was recognition.

I was reminded of this case by a recent article about a 2013 paper that appeared in a journal called Human Factors. The paper, "The Effectiveness Of Airline Pilot Training for Abnormal Events," pointed out that pilots doing their periodic training know that certain crises—stalls, low-level wind shear, engine failures on takeoff—are part of every simulator session and will occur in predictable ways.

The authors presented those situations in unexpected ways, measured pilots reactions, and found that experienced pilots responded less skillfully.

From the paper: Our control conditions demonstrate that pilots’ abilities to respond to the “schoolhouse” versions of each abnormal event were in fine fettle. The problems that arose when the abnormal events were presented outside of the familiar contexts used in training demonstrate a failure of these skills to generalize to other situations.

They suggested four ways to improve training and testing.

1) Change it up. In other words, dont practice things the same way every time.

2) Train for surprise.

3) Turn off the automation. Dont let the pilots depend on automated systems to help them recognize what is going on because if those systems fail, pilots will have trouble dealing with the situation.

4) Reevaluate the idea of teaching to the test which can "present the illusion that real learning has taken place when in fact it has not."

Item #3 is particularly relevant because of some recent interest in the negative effects that automation is having on pilots and possibly society in general. The 2009 crash of an Air France plane into the South Atlantic Ocean has been analyzed in several recent publications. (Here and here)

The cockpit voice recorder transcript is chilling. In a storm, the autopilot failed, and the plane stalled. Three pilots failed to recognize what happened and did all the wrong things.

I have been saying for years that we need to teach med students and residents how to think. Recognition of rare events would be a good area to focus on.

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2015 Match Review

Continuing grim news for international med school grads and some US grads too

There were a lot of happy faces on March 20th as depicted in this brief video of the excitement on the campus of the University of Rochester School of Medicine. Similar scenes took place at every US medical school because 93.9% of the 18,025 graduates of US allopathic medical schools matched in a specialty.

But for the 1093 (6.1%) US graduates who didnt match things were not so bright. These applicants had to go through the Supplemental Offer and Acceptance Program (SOAP) which connects unfilled programs with unmatched students.

Because there were over 8600 unmatched graduates from schools all over the world vying for about 1200 unfilled first-year residency positions, even some US med school grads did not secure a position. One of these unfortunate souls tells her story in this blog.

The 7400 or so new MDs left out in the cold will not be able to pursue their careers. They will not progress into any specialty, nor will they be able to obtain licenses to practice medicine anywhere in this country. Those with substantial tuition debt will have no way to pay off their loans.

The percentage of unmatched US graduates has been relatively stable over the last five years, ranging from 4.9% to 6.3% while the number of first-year residency positions offered has steadily increased by nearly 4000 from 23,420 in 2011 to 27,293 this year.

Graduates of osteopathic medical schools didnt fare quite as well. Of the 2949 osteopathic school applicants, 610 (20.7%) went unmatched, but this percentage has steadily declined from a high of 28.3% in 2011.

International med school grads were much worse off; 2354 (46.9%) US citizens and 3725 (50.6%) non-US citizen graduates of international medical schools did not match. Both of these groups also had declining percentages of unmatched applicants. In addition, about 1900 US citizen graduates of offshore schools either withdrew or did not submit a rank list compared to almost 2700 non-US citizen international graduates who did likewise.

Reentering the match next year is an option, but spending a year outside of clinical medicine greatly reduces ones chances of finding an accredited position.

If you factor in the number of applicants who either withdrew from the match for did not submit a rank list. graduates of international medical schools have well below a 50% chance of matching.

In previous posts here and here, I have warned about the risks involved with attending an offshore medical school. If you are considering attending such a school, I urge you to look at the numbers and think long and hard about your decision.

Source: Advance Data Tables 2015 Residency Match

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Work hours limits in Sweden Its complicated

A physician in training from Sweden emailed me some questions, and the topic of work hours came up. To protect his identity, I have slightly altered a some of his responses, but I have not altered his message.

It´s quite interesting as physician work hours, or rather productivity, are debated a lot in Sweden right now.

The work hour restriction [50 hours/week in Sweden] is not enforced at all. This summer I was working as a junior house officer in a surgical specialty at a county hospital, and I can´t say I noticed anyone trying to cap my work hours, on my first day I was encouraged to work as much as I could.

On the other hand I was not put on the on call schedule, as that involved covering the ED (outside of academia EM-physicians are scarce) and all surgical services. It is hard to get to work 50 hours a week covering only a 12-bed service, when the nurses do all the blood tests (except blood gases), urinary catheters, do all patient transporting, and such. I did get some OR time though.

I think there is no enforcement of the 50 hours/week restriction because doctors here don´t get paid as fee-for-service. There is zero difference if you do 5 or 10 cases during your shift. There is no incentive to work more than 50 hours/week, and doctors don´t.

A problem that is more particular for surgery is the limited capacity of operating theaters, in many hospitals productivity is low, case turnover time is long, and you can only do elective cases between 8:30-16:00 (and God forbid you operate past 16:00). In the hospital I worked, we were not allowed to start elective cases after 14:30, and we only had 2.5 days/week when we could operate.

If you want to make money, you take a leave, go to Norway, work 80-100 hours/week in some rural hospital there for a few months, and earn three times as much. [I was also told about this by some Swedish surgical residents I met while attending a conference there last year.]

We do a lot of administration. A study published in a Swedish medical journal, in Swedish sadly, found that Swedish surgical residents spend 40% of their time on administration and 40% of their time taking care of patients. Their British counterparts did 15% admin and 66% patient care. An average work day was 8.2 hours in Sweden and 12.2 hours in England.

Because of this, few physician hours are "productive" and Swedish doctors see very few patients compared to most Organization for Economic Co-operation and Development (OECD) countries. Queues build up and the hospitals don´t want that. So I guess they want us to work.

There was however a government crackdown on a rural hospital in northern Sweden where the county (which is the governmental body running hospitals in Sweden) was fined for imposing too long work hours. So there may be change, but rural northern hospitals are not in an ideal position to recruit more doctors.

Right now work hours are restricted formally but in practice it is hard to get that amount of meaningful work done. It has some perks however, as residents can pick up their children from day care. [Emphasis added]

Is this where we are heading in the United States?

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Antibiotics vs surgery for appendicitis Its time for a randomized trial

Maybe youve heard that there is a growing debate about whether antibiotics are as good or better than surgery for treating appendicitis.

So far there have been several studies from Europe showing that antibiotics may be safely used to treat appendicitis in many cases. However, the studies have involved small numbers of patients and have exhibited some flaws in their methods. A few studies from the US have been published, but they were not randomized or prospective.

I have blogged about some of these studies on three occasions. If you would like to read these posts, click on their titles.

Antibiotics instead of surgery for appendicitis? Im still not convinced

Antibiotics instead of surgery for appendicitis? No way

Antibiotics instead of surgery for appendicitis? I don’t think so.

A group of surgeons in Washington State are putting together what will be the first randomized prospective trial of antibiotics vs. surgery for appendicitis in the United States. In order to obtain a grant from the Patient-Centered Outcomes Research Institute to help fund the project, the investigators must demonstrate that people in this country would be willing to participate in such a study.

To help determine the level of interest, they have written a brief explanation of why this study is being proposed. It parallels my thinking on the subject.

At the end of their post is a link to survey involving one question:

If you had appendicitis, would you be willing to join a study that would randomize you (a 50% chance, or flip of a coin) to “surgery ” or “antibiotics?”

You dont have to read the Washington researchers post to take the survey.

You may click here to answer that question. Thanks.

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Cosplay Spotlight JAZE Cosplay

Husband and wife team Aime and Lance aka JAZE Cosplay have rocked the costuming world with their movie quality costumes and props. The talented couple have been guests at shows all over the country and have wowed the crowd with their highly detailed and first class craftmanship. Aime and Lance took some time to talk to the Confessions of a Cosplay Girl Blog about their art, how they met and a memorable encounter with Thor actress Jamie Alexander.

Victoria: How long have the two of you been in the hobby of costuming?

Aime and Lance: If by standard definition of costuming, wed have to say all our lives! lol Ever since we were young we both have always loved celebrating Halloween because we get to dress up and become anything we want.  However, it wasnt until two years ago that we both made the decision to seriously begin to challenge our creative minds and take our costuming to the next level!

Victoria: What was the first costumes you created?

Aime and Lance: For me (Aime) my first cosplay was Xena: Warrior Princess and for Lance it was Marvels Daredevil (movie version). Two strong characters that each of us admired and loved emulating!

Victoria: What is the most difficult costume you have ever constructed?

Aime and Lance: The most challenging costumes for both of us were our Thor and Sif from Thor: The Dark World. They werent so much difficult per say, its just that we had such little time before the debuting convention to construct both suits of armor as well as props (and a full ODIN costume in addition), that it was a challenge to get them all completed both quickly and efficiently. Nevertheless we pushed ourselves to the limit, supported each other through every step of the way, and success was achieved!

Victoria: Are you currently working on anything new?

Aime and Lance: We have a few surprise projects in the works (will be able to reveal more as they progress!).

Victoria: How did the two of you meet?

Aime and Lance: We met through a mutual friend and have been inseparable ever since! We love sharing every waking moment together, it truly is as if we are one soul.

Victoria:  Thats so beautiful! Do you have a favorite "couples" costume?

Aime and Lance: Astronema and Psycho Silver! We love the story behind their relationship, the challenges they faced when falling in love, the inner-duality that both characters had to experience, and overcoming all odds for each other!

Victoria: What conventions will you be attending for the remainder of 2014?

Aime and Lance: Currently our convention line-up for the remainder of 2014 consists of PowerMorphicon in Pasadena, CA August 22nd-24th and Comic Media Expo in Mesa, AZ October 17th-19th and possibly a few others which well know more within the next month.

Victoria: You have met many celebrities in your travels. Do you have a favorite celebrity encounter?

Aime and Lance: Weve met quite a few celebrities, many of whom we are now happy to call friends. One of the most memorable encounters has to be with Jaimie Alexander (who is just as sweet as can be) at the Comikaze Expo last November. We stepped away from our booth for a minute to check out the AMC Movie panel she was on, and as soon as she noticed us she interrupted her own interview to point us out and have her handler request a photograph with us when she was done.

Victoria:  Where can people contact you for bookings and view a portfolio of your work?

Aime and Lance: For bookings and events we can be contacted via email:JazeCosplay@gmail.com Our portfolio and event galleries can be seen via our website: www.JazeCosplay.comAnd our other social media sites are: www.facebook.com/JazeCosplay      www.twitter.com/JazeCosplaywww.instagram.com/JazeCosplay    www.pinterest.com/JazeCosplay    www.youtube.com/user/JazeCosplay

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Readmissions Sometimes its the patients

My Twitter friend Dan Diamond (@ddiamond) posted a picture of a slide that said a hospitalized patient was taught to inject insulin using an orange to practice on. When he was readmitted to the hospital with a very high blood sugar, it turned out that instead of injecting himself at home, the patient was injecting his insulin dose into an orange, and then eating it.

Weve all heard stories about patients who took suppositories by mouth instead of the way they were intended.

Since doctors get blamed for just about everything, some would say that patients who take suppositories by mouth or eat an orange filled with insulin do so because they were not properly taught by their doctors (or nurses).

I have blogged before about the problem of who is at fault if patients do not follow up. Although I feel that much of the time its the patient who decides not to return for follow-up, it seems prevailing sentiment and possibly even the courts say its the physician who should be held responsible.

But how do you explain this? A study in Heart, a BMJ journal, found that of 208 hypertensive patients referred to a clinic for suboptimal blood pressure control, 52 (25%) were either completely or partially non-adherent [aka non-compliant] with their antihypertensive medications as determined by urine mass spectrometry.

The authors concluded that urine testing for medications or their metabolites would help doctors avoid ordering unnecessary investigations for patients whose blood pressures were not well-controlled.

The reasons for patient non-adherence were not mentioned. Could all 52 patients not have been told about the importance of taking their medications? I doubt it.

You might think the 15% who were partially non-adherent may have forgotten to take the drugs occasionally, but it turns out that most of those in this group took adequate doses of most of other their prescribed medications. This suggests that they selectively omitted some doses of one or more drugs.

The only explanation I can fathom for the 10% who had no traces of any BP meds in their urine is that they just said "to hell with it" and didnt take their meds at all.

I know someone with type 2 diabetes who doesnt watch her weight or what she eats and doesnt check her blood sugars. She says, "Youve got to die of something. Id rather live my life the way I want to."

Is it that doctors and nurses arent educating the patients or are the patients at fault?

The answer to this question has important implications because of the newly established financial penalties for hospitals with high readmission rates.

Older methods that may improve adherence are tracking prescription refills and having pharmacists or nurses specifically assigned to explain medications to patients in detail.

Heres something that might help.

A recent meta-analysis showed that adherence to HIV/AIDS antiretroviral therapy was modestly improved when patients were sent reminders to take their medications by text message. Those who were more adherent had lower viral loads and better CD4 counts.

Of course, such an intervention assumes that patients have mobile phones or pagers capable of receiving texts, will check for messages, and will act upon the advice. Compared to patients with HIV/AIDS, those with hypertension might tend to be much older and possibly not as technologically savvy.

So what is the solution? I dont know, but sometimes the problem is the patients.

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Its that time of year again

Hopes are high; everyone is prepared; all the talk is over. The big day is finally here.

No, its not about the Super Bowl. Its about the American Board of Surgery In-Training Examination (ABSITE).

Every year at the end of January, all surgical residents take a five-hour, 250 question multiple-choice test. For many, it can be a watershed moment because their careers may be on the line.

I have written about the use of the ABSITE as a criterion for resident promotion. Whether you think it should be or not, it is used that way—sometimes as the only criterion. You can bet that in a few weeks, some residency programs will post notices saying they are looking for a categorical PGY-2 or 3 due to an "unexpected" vacancy for July 2015.

Another attending surgeon and I used to take in-house call the night before the examination so that all of the residents could take the test after a decent nights sleep.

Now the test may be given on different days so that the entire group does not have to take it at once.

One difficult situation I faced as a program director was when I had a good clinical resident who just could not do well on a multiple-choice examination. I had to decide whether keeping a resident who scored at the 10th percentile was worth the gamble. Scoring in the 10th percentile or less on a regular basis means that the resident has a good chance of failing the written board examination.

Of course, the very nature of percentiles is that 10% of those who take the test will finish in the 10th percentile or below. Also, the failure rate of the written board examination has hovered around 25% for many years.

The problem for programs is that the Residency Review Committee for Surgery mandates that 65% of a programs graduating residents must pass both parts of the board examination on the first attempt.

Of the many things I do not miss about practicing medicine during this turbulent era, the palpable level of anxiety surrounding the buildup to the exam and waiting for the dreaded results to come back rank high on the list.

I wish all residents who are taking the test the best of luck. I hope you were reading all along and not trying to cram a years worth of studying into the week before the test.

May you all score above the 50th percentile.

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More ratings—this time its residency programs

Can you really decide which surgical residency program is right for you using Doximitys Residency Navigator?

I dont think so, and heres why.

The rankings of residency programs were obtained by surveying surgeon members of Doximity. They were asked name the five top programs for clinical surgery training. When the survey was announced in June, I predicted that most respondents would probably overlook the word "clinical" and focus on the usual famous academic institutions.

I also pointed out that anyone not intimately familiar with a program would be unable to judge whether it is good or not and suggested that reputation would be the main driver of results.

In fact, that is exactly what happened. Of the top 40 programs listed, all are based at university hospitals, as are 66 of the top 70. Back in June, I speculated about the top five programs and got the first two correct but in the wrong order.

A 2012 survey of surgical residents with over 4200 responders (an 80% response rate) found that community hospital trainees were significantly more satisfied with their operative experience and less likely to worry about practicing independently after graduation. Wouldnt you then expect a few community hospital programs to be among the top 40 hospitals for clinical surgery training?

Proof that the surveys findings are not reliable is that every one of the 253 surgical residency programs in the country was mentioned by one or more of those who responded. This included one program that has been terminated by the Residency Review Committee for Surgery. At least it appears near the bottom of the list.

The number of voters who cited the lower ranking programs must have been very few, meaning the difference between the 200th and 240th program ranks is probably not statistically significant.

Some programs that were rated are so new that very few or no residents have graduated yet. How could anyone know if they are turning out competent clinical surgeons?

Board passage rates for programs, which are available online, were omitted for some and were not clearly identified as the percentage of residents who passed both parts of the boards on the first attempt only.

The percentile rankings of alumni peer-reviewed articles, grants, and clinical trials are displayed prominently. What do those data have to do with the research question—which residency programs "offer the best clinical training"?

So whats the bottom line?

You can put the Doximity Resident Navigator in with the other misleading ratings of hospitals and doctors. Applicants considering surgical residencies should not rely on it for guidance.

It has warmed the hearts of faculty and residents at highly rated programs, but I wonder how the OR lounge discussions are going at places where programs ranked lower than expected.

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