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Published / by Harry Bigwood

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Cardiology from my point of view

Published / by Harry Bigwood

Applying the surgical precept of complete coronary revascularization to percutaneous coronary intervention has led to the common belief that optimal results of PCI in patients with multivessel disease require revascularization of all stenotic lesions. However, little evidence supports this belief. In fact, revascularization of only the culprit lesions (those causing ischemia) might well be the most effective strategy for most contemporary PCI procedures.

Fractional flow reserve (FFR) measurement is an invasive method for identifying a culprit lesion: A pressure guidewire is placed distally to the stenosis to calculate the pressure gradient during hyperemic stress produced by adenosine-induced dilation of the microvasculature. Investigators for the manufacturer-sponsored FAME (FFR vs. Angiography for Multivessel Evaluation) study randomly assigned 1005 patients with multivessel coronary disease (mean age, 64; one quarter, women) to FFR-based PCI (revascularization only of vessels with FFR le-386852180%) or to conventional PCI (guided by angiography alone).

At 1 year, the rate of death, MI, or repeat revascularization was lower in the FFR-based group than in the conventional group (13.2% vs. 18.3%; P=0.02). The mean number of coronary lesions per patient was similar in both groups (2.8 vs. 2.7), but 37% of lesions in FFR-based group were considered nonischemic (FFR >80%). Consequently, significantly fewer drug-eluting stents were used in the FFR-based group than in the conventional group (1.9 vs. 2.7, P

jficm fellowship preparation

Published / by Harry Bigwood

This site is a work in progress. It is meant for educational purposes only and should not be used to aid clinical decision making. It contains ‘mindmaps’ designed in preparation for the Joint Faculty of Intensive Care Medicine Fellowship exam. The source materials for these notes include

Textbook of Critical Care 5ed 

 Oh’s Intensive Care Manual

…(I will provide specific links to additional references shortly)

The mindmaps are best reviewed by printing them out and enlarging them to A3 size.

Knee Surgery

Published / by Harry Bigwood

Sep 28 2008

The instruments sets of all the knee prosthesis currently available permit the surgeon to position the cutting guide, for the femoral resection, with between 0 and 3 degrees of external rotation. The position itself is decided by the surgeon based on his experience and without any clear reference and as a result can be innacurate. Taking into account this problem we sought to design a new device that avoid the aformentioned problem. Our Trans Epicondilor alignment guide permits the surgeon to trace, in an accurate fashion, the trans-epicondilar line and guide therefore the femoral rescection and a better positioning of the femoral component.

Research Methods

We have gathered the data from the first 90 cases of patients who were operated on using this new instrument. From December 2007 to February 2008 (75 Females, 15 Males, 60 Left & 30 Right) the average patient age was 68 years. We used Knee Replacements from various different companies and in all cases the surgical access was through a medial mini-incision. The parameters taken into consideration for the evaluation of the results were, an X-Ray evaluation of the knee post-op, anterior knee pain, the number of lateral releases performed, the Q angle, the stability of the knee after the implant, the range of flexion and the satisfaction of the patient.

Results

The use of the alignment guid reduced significantly the percentage of the cases of incorrect patella tracking and anterior knee pain. In none of the 90 cases was it necessary to perform soft tissue releases in order to obtain the correct patella tracking, the Q angle was always correct, it was never necessary to perform ligament balancing of the knee and both the stability and flexion of the knee were improved.

Tags: Abstract, knee

Shoulder Surgery

Published / by Harry Bigwood

Oct 17 2008

I’ve wrote this article as a result of some questions received as a result of my initial post on transfer of the Latissimus Dorsi for regaining external rotation when implanting a reverse shoulder prosthesis. As the video I included didn’t have any audio included I have wrote this overview/paper of the surgical technique to aid anyone that’s thinking of trying out this very interesting operation.

Seen initially with apprehension the reverse prosthesis of Grammont showed itself to be very effective in the treatment of Gleno-Humeral arthropathies associated with lesions of the Rotator Cuff.

The biomechanical principle of this system is based on the fact that the medialisation and lowering of the center of rotation of the humeral head, obtained through the inversion of the geometry of the shoulder joint, creates and increase lever arm for the deltoid muscle that is able, therefore, to actively elevate the limb even in the absence of the rotator cuff.

The usage of a semi-constrained system creates a situation where the shear forces that are created as a result of the highering of the humeral head become transformed into pression forces that tend to stabilise the joint and prevent loosening of the glenoid component.

Another contribution to the working of this system is the fact that the CCD angle of the humeral component is markedly more valgus (155) with respect to the anatomic CCD (130). Which, theoretically, increases the risk for dislocation but is surely beneficial to reducing the stresses on both of the components.

The validation of this principle was totally obtained clinically with increments in active elevation more than three times those obtained with an anatomic prosthesis ( + 65° versus + 20° ).

Before

After

In the presence of these spectacular results certain limits of the system came out that need to be very clear to the surgeon to properly inform the patient about the operation and the rehabilitative program, which must take into account these limits post-op.

One of these limits consists in the poor recovery of active external rotation in the case of a Pre-Op tear of the Teres Minor, which in the series of Sirveaux, accounted for 17.8% of the cases. The external rotation deficit negatively affects the result of the operation if one considers that in the case history of Sirveaux a 9 point lower Constant Score was noted in the cases where the Teres Minor was not present.

In other series of implants where the group of patients with Teres Minor tears was removed (Bolieau et al) the difference is even greater (46 points with respect to 66) even if it must be taken into account the fact that, included in this last case history were cases of Eccentric Arthropathy, Post Traumatic Arthropathy and revisions of previous prosthesis.

In the clinical examination the tear of the Teres Minor is seen through the Hornblower’s Sign:  To elevate the hand to the mouth or on their head the patient must elevate the shoulder bringing the shoulder to the height of the hand.

In patients with a serious deficit of elevation the Hornblower’s Sign is obviously not easy to carry out in this manner, but the conditions of the Teres Minor can be evaluated through the Patte test while the examiner holds the elbow in 90 (or less in the presence of a rigid shoulder) of abduction.

Under normal conditions the force in the RE 2 position is due to the combined action of the infra-scapularus and the Teres Minor and to a lesser degree the protective fascia of the Deltoid. In an eccentric arthropathy the Infra Spinosa is almost always torn and the addition of the protective fascia of the Deltoid has a insignificant effect in the reduction of the lever arm given the medialisation of the joint’s center of rotation.

The possability to carry out active external rotation in abduction will therefore be the measure of the presence of the Teres Minor. For further confirmation we carry out the tests with the patient standing up and sitting down, to reduce the effects of gravity.

Even if active external rotation, with the elbow held against the body (RE1) is principally tied to the working of the Infra Spinosa (Walsh et al) we asked ourselves if even in this position the Teres Minor can be clinically studied.

In fact the active RE1 in the absence of the Teres Minor is constantly negative.

Our consideration is therefore the following: In the case of a full tear of Infra Spinatus, undergoing a passive rotation in RE1 results in an automatic rotation back to neutral (lag sign) as demonstrated by Walsh. An also present lesion of the Teres Minor makes the arm behave like this in internal rotation, probably because the Teres Minor, although not an external rotator, is the last brake on the internal rotation in this position.

The certainty of the lesion of the Teres Minor obviously is obtained from the examination of the scans of axial MRI or TC that should be studied in distal cuts (fig…). It should be noted that in the presence of serious atrophy and/or fat infiltration the Teres Minor may lose its function even if it is still inserted.

On the functional level the deficit of active external rotation in abduction has a negative impact on the possibility of making daily gestures such as eating, drinking, combing, to wash the face and put an object on a shelf placed above the level of the head.

With the implantation of a reverse prosthesis, external rotation does not improve significantly in fact it can even worsen in adduction (Boileau 7°-11°, Sirveaux 3, 5°-11, 2°, Gilbart 17°-12°) while there are marked improvements in abduction (Sirveaux 17°-40°). Obviously the reason for this is the tensioning of the Teres Minor and of the distal part of Infra Spinatus, in the rare cases where this is retained, by the lowering effect of the Centre of rotation of the head cut which compensates the reduction of their lever arm linked to medialisation of the center of rotation.

In case of total absence of Infra Spinatus and the Teres Minor with the Horn Blowers sign external rotation in abduction cannot improve after reverse prosthesis and the sign of the Horn Blower’s  sign can obviously get worse. (Sirveaux).

The question remains that, with the deltoid particularly strong, once can recuperate post-op a certain amount of extra-rotation, even in the absence of the posterior Cuff in the case in which the deficit pre-op of mobility is linked to the articular rigidity, that the prosthetic implant can at least partially solve.

In an attempt to overcome this limit we introduced the technique, which requires the usage of a reverse prosthesis with the transfer of the Latissimus Dorsi and Teres Major for the Teres Minor carrying out the whole procedure through a single Delta-Pec access.

In practice the Latissimus Dorsi and the Teres Major are seperated by the medial lip of the bicepital groove, passed posteriorly to the humorous and attached on the proximal metafisis just distal to the insertion of the Teres Minor in an attempt to partly restore active Extra Rotation.

Surgical Technique

The patient is placed in beach chair position and performs a Delta-Pec access extended distally down to the lower border of the Pectoralis Major that is cut totally at about 1, 5 cm from the humeral insertion point. The Sub-Scap tendon, if present, can be removed from the humorous to then be reinserted at the end of the operation.

With the humerous in maximum external rotation the tendon of the Latissimus Dorsi is isolated immediately below the Pectoralis Major and detached from the medial lip of the bicepital groove with a no. 11 scalpel. The tendon has the appearance of a thin blade often attached to the Teres Major and has an insertion point that is both wider and more “meaty” that the latter.

Sometimes this can be a difficult moment both for the presence of adhesions between the two tendons and an important tendinitis of the Latissimus Dorsi and for the partial fusion between the two, which constitutes an anatomical variant.

The underlying plain is represented by the Teres Major, more voluminous and fleshy, which is also detached. Both tendons get sutured with two unbroken high resistance, permanent sutures (Fibre Wire, Arthrex) in a “Baseball Stitch” manner taking care not to penetrate, with the needle, the same muscle fibres because since the muscle is thin doing so could separate the fibres and weaken the strength of the new attachment. The “Baseball Stitch” technique gives us the possibility to roll the muscle in a tube like form that makes it easier to pass it behind the humorous and gives, at the same time more mechanical stability.

At this point one carries out a detachment, with a blunt instrument, of the tendon from the muscle tissue that distally is situated in close contact with the plexus and with the auxiliary vessels.

The next step provides for the preparation of the transition behind the humorous below the inferior border of the Sub-Scap and Teres Major which must be carried out in close contact with the humeral metafisis and with the arm in external rotation in order to not put the auxiliary nerve in danger. This nerve runs proximally on the superior border of the Latissimus Dorsi at a distance of 27.1 ± 8.9 mm from the humeral insertion point. To create the necessary tunnel must some fibres of the triceps muscle will have to be detached.

After having completed the posterior humeral tunnel we introduce a suture passer or a needle free with a thread to transport in a latero medial direction the suture. The suture is taken from its medial exit point and if used to drag the transfer anteriorly and laterally on the humorous.

The humeral cortical bone is prepared for the insertion by crudely chipping at it with a chisel, a little below connection of the Teres Minor. If the length is not enough it’s ok to reinsert the two muscles just laterally of the external lip of the bicepital groove at the same height, or a little higher, with respect to the Pec-Major.  put the two sides of the muscles just lip outside the shower bicep the same height or just above the insertion of the large pectoral.

One proceeds then to the implantation of the metaglene and Glenosphere of the reverse prosthesis and the preparation of the diafisi before the passage of the sutures, to avoid damaging them during the perpetration of the canal. The sutures prepared previously on transfer are then passed in couples through the humeral holes in a lateral medial direction using a needle and knotted definitively taking into account that the fibre wire requires at least eight alternating knots.

The humeral stem is then implanted with the usage of cement as, again a prosthesis without cement could damage the tran-osseous sutures. The Pec-Major is the sutured to its previous humeral insertion point with 3 or 4 permanent X sutures (ethibond n 5 Ethicon, J&J )

During post-op the limb is rested for 4 weeks in a sling in slight abduction and in neutral rotation. Some slight passive movement can be permitted 4 weeks after the operation avoiding internal rotation and elevation over 120° for another 3 weeks in order to not put the transfer in tension. Even the external rotation should be avoided for weeks in order to not put the suture of the Pec-Major under pressure.

Tags: Latissimus Dorsi, Prosthesis, Reverse, Shoulder

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Published / by Harry Bigwood

Bread and butter

The “bread and butter” medical conditions at SFH are malaria, tuberculosis, other respiratory tract infections, diarrhoeal disease, AIDS (and its myriad manifestations and complications), parasitic infestations (such as hookworm), and other bacterial infections (such as cellulitis and abscesses). Accidents and injuries account for many of the surgical admissions.

Some examples that were not “bread and butter” cases are described in the sections that follow.

Paralysed by a mad dog

A 52-year-old man, Mr Z, was admitted to SFH in mid-April with confusion and paralysis. In early February a dog bit both him and a small child at his village. The dog was believed to have rabies because of its strange behaviour. It was also said to have been (take a guess…) “foaming at the mouth”. The other villagers subsequently destroyed the dog. The small child was urgently taken to SFH for treatment. Mr Z, a peasant farmer, chose not to make the considerable journey to the hospital and remained at the village to work on the land.

Mr Z began to develop weakness in his right leg in early April, starting at the site of the dog bite. Two weeks later, at the time of admission, all of his limbs were flaccidly hypotonic (i.e. floppy like a rag doll) with absent reflexes and marked weakness. He was also disorientated. Sensation was difficult to assess, but Mr Z showed no response to painful stimuli in his limbs. Mr Z also had loss of anal sphincter tone and was doubly incontinent. As is typical of Zambians, his plantar reflexes were neither up nor down (*).

* There is a memorable quote in “Manson’s Tropical Diseases” on the subject of the toughness of African feet. It says that if Babinski had been African, he would never have become famous for his eponymous neurological sign. Usually the noxious stimulus of a metal bar running the length of a bare African sole shows no neurological response.

According to one of the nurses on the ward, Mr Z started to “bark like a dog” during the night. The next morning, on ward round, I was greeted by his lifeless body and his grief-stricken wife. Thankfully Mr Z’s torment was not prolonged. Mr Z’s illness was notified as a case of paralytic rabies, as well as a case of acute flaccid paralysis.

Hard as nails

One of the first patients I had the privilege of looking after at SFH was Mr P, a man in his fifties. He originally had a seizure and fell into a blazing fire, badly burning his left foot. The wound became infected, and sometime later Mr P developed stiffness in his neck. Within three or four days the rigidity encompassed his whole body and he began to experience agonising muscle spasms. Back in New Zealand, tetanus has almost “bogey man” status – in Zambia it was very real.

I first met Mr P almost two weeks after he was admitted to SFH. He had already been treated with antibiotics and tetanus antitoxin. Still, the slightest environmental disturbance could trigger a cascade of painful muscle spasms. He also had terrible trismus (“lockjaw”) – he could barely open his mouth wide enough to admit a straw. By this time his muscle mass had dissolved to almost nothing. As well as experiencing bursts of severe pain he was in danger of dying from aspiration pneumonia secondary to choking, or from infection of his burn or bed sores, or even from simply wasting away.

I gave his daily dose of diazepam a substantial boost to try to control the spasms that had now persisted for a couple of weeks. The next day he greeted me with a “thumb’s up” sign and said “Doctor, those medicines you gave me – they were super!”. Miraculously, Mr P steadily recovered from that point onwards. With the close attention of his wife at his bedside, Mr P survived tetanus without parenteral nutrition, intubation, mechanical ventilation, or the many other high-tech interventions that he would certainly have received in the West. His rigid jaw transformed into a rapid-fire set of lips. Soon he was pestering me for walking sticks and asking for more food.

I bumped into him a few weeks later when he was returning to clinic for review, so he could be gradually weaned off diazepam. His wife smiled and shook my hand and said, “thank you, Doctor Neek-sorn”, while Mr P, still riding in a wheelchair, vowed to track me down when he was stronger – so that he could be my “garden boy”!

“Lockjaw” – Mr P a few days after Paul and I arrived at St. Francis’ Hospital. For the photo Mr. P was asked to open his mouth as wide as possible. (Photo by Paul Young).

Running on empty

Anyone who has experienced medicine in Africa will be amazed at the haemoglobin levels that walk in through the door. The risks associated with blood transfusion are many (not to mention the expense), so the only indication for the administration of blood is to save someone’s life.

A 23 year old man, Mr N presented to SFH with malaria. He had tried taking chloroquine at home, having had symptoms of fever and headache for over a week. When I saw him he kept trying to sit up, despite experiencing obviously severe dizziness. Finally, the nurse and I were able to convince him to lie still on his bed. Looking at his conjunctivae in the afternoon darkness of the ward was like seeing a pair of crescent moons on a clear night. His blood slide showed heavy malarial parasitaemia (4+), and his haemoglobin concentration was measured at 2.5 g/dL. The “Oxford Handbook of Clinical Medicine” includes a page of laboratory values that can be rapidly fatal – included are haemoglobin concentrations less than 7.0 g/dL (#). Needless, to say Mr N was given a blood transfusion. He went on to make a remarkably rapid recovery after treatment with quinine.

# …when accompanied by a low mean cell volume or a history of bleeding. The presence of Plasmodium falciparum on a blood film is also on the “dangerous” list.

Sugar and alcohol

Mr L, a teacher in his early forties, was admitted in a confused, but rousable, state. He was jabbering loudly and incomprehensibly. The brief history obtained indicated that Mr L had been on a heavy drinking binge the day before. On the morning of his admission, his wife found him in the state described above. Mr L was administered a hefty bolus of glucose, along with a dose of thiamine. Later his random blood glucose returned the incredible value of 0.2 mM (less than about 2.5 mM is considered low) – thus he was diagnosed with alcohol-induced hypoglycaemia. His blood slide also showed a malarial parasitaemia of 1+; the significance of this was unclear given the likely background levels of parasitaemia in the Zambian population. Nevertheless, treatment with quinine (and lots more glucose) was also initiated.

A few days later Mr L was back to his normal self and ready to go home. Later I learnt from another teacher at the same school that Mr L had been depressed following his suspension from teaching duties. He was suspected of sexual misconduct with some of his female students.

The shrinking feet of the man from Malawi

Mr J had travelled to SFH from Malawi. He was admitted overnight. The brief admission note showed that he was in his thirties and had three presenting complaints: (1) “hungry”, (2) “shrinking feet”, and (3) “does not want to answer anymore questions”.  A blood slide showed the presence of malarial parasites, and anti-malarial treatment was started. By the time I saw him the next day he was handcuffed to his bed – he had apparently been “scaring the nurses” during the night. A “psychiatric” referral was arranged. The psychiatric assessment was summarised by a list of three “impressions” at the bottom of the page: (1) “psychopath – aggressive type”, (2) “Ganser syndrome” (**), and (3) “Criminal”. He was given the universal treatment for psychiatric illness in Zambia, big doses of chlorpromazine. The next day he again had three complaints, this time they were: (1) “dry mouth”, (2) “sleepiness”, and (3) “too many drugs, and not enough food”.

** “Ganser syndrome –what the @#$% is that?”, I hear you cry in despair. The “Oxford Handbook of Clinical Specialties” has the following entry in the section “Some unusual eponymous syndromes”: “Disorientation plus pseudodementia with ‘approximate answering’, e.g. an answer to ‘What is the colour of the chair in the corner?’ might be: ‘What corner? I don’t know what a corner is. I don’t see a chair…’ … Often there is a preceding head injury.”…

I think that Mr J’s main problem was hunger, a problem shared by many people in Malawi during my time in Africa, a consequence of poor crop yields. He also seemed to have a well developed sense of humour, which led him towards a fate resembling something out of “One Flew Over The Cuckoo’s Nest”. Ultimately, Mr J agreed to continue taking his medicines when he was told he would be discharged in a few days. Soon after his discharge he returned begging for money to allow him to travel back to Malawi. He was told he might be able to hitch a ride on an ambulance returning to Chipata and was sent on his way.

Excerpts from the original case notes of Mr J’s psychiatric assessment (photo by Paul Young).

A poisoning

Organophosphates appear to be the favourite means of poisoning in Katete – whether the target is animal or human.  Typically, a person’s dog will be poisoned and their crops will be raided the following night. Sometimes people are accidentally poisoned by drinking from a container that previously contained a pesticidal substance. Mr C, a 23 year old man, poisoned himself.

Mr C was admitted unconscious with a bradycardia (slow heart rate) of 48 beats per minute. His mouth was dripping with saliva and tears were streaming down his cheeks. His pupils were tightly constricted and his muscles were twitching rapidly. He was also incontinent of urine. His presentation was a textbook description of organophosphate poisoning.

Mr C was given frequent doses of atropine to keep his heart rate up, until his pupils were no longer constricted and his secretions decreased. He was also treated with diazepam. One of the nurses noticed blood in the urine after putting a condom catheter in place. Subsequent urinalysis showed the presence of Schistosoma haematobium, for which he was treated with a stat dose of praziquantel.

After a few days Mr C was ready to go home. What made Mr C poison himself? He attempted suicide after being accused of “impregnating” a girl.

“A Midsummer Night’s Dream”

One day I walked through the gates of SFH to be greeted by the “eeyore-ing” voice of what sounded like a demonic donkey. I scanned the courtyard and corridors with my eyes but could not find the source of this bizarre noise. Soon after starting the ward round the source found me – he was admitted to Saint Augustine.

Mr D was a young, healthy looking man in his twenties. He had a history of intractable hiccups that had been tormenting him (and everyone else within earshot of him) for over two months. The hiccups were quite violent, rapidly repetitive, and associated with a great deal of belching and tic-like facial movements. Interestingly, the hiccups subsided whenever Mr D had food in his mouth, and when he slept at night. Full clinical examination yielded no other abnormalities. A psychogenic cause was suspected.

It turned out that Mr D had been cursed by a local village woman. The purpose of the curse was to prevent Mr D from working on his father’s farm, and to ruin his marriage prospects (it was clearly working…). An attempt was made to reassure Mr D that there was nothing physically wrong with him and that the curse would only be effective as long as he believed in it’s power over him. Unfortunately, his conviction in the power of the curse was strong, and thus the curse was powerful. Mr D did concede, however, that the curse would wear off eventually. I tried (for his and everyone else’s benefit) to convince him that it might wear off sooner rather than later. He was also encouraged to keep working despite the hiccups, and even to try walking around with food in his mouth. The next day he was discharged, hiccups and all – his ultimate fate remains unknown.

Something other than pus

Medicine at SFH is not all weird and wonderful signs and symptoms. Many of the problems people face in Zambia are similar to those of people back home.

KS was a boy aged about twelve years old. He was admitted to St. Augustine with a vague history of palpitations and fevers. After a thorough history and examination, a physical basis for these symptoms was deemed unlikely. We suggested to him that sometimes people get palpitations when they are worried about something. Eventually, he said that he had just started studying at a new boarding school where he was being bullied and that he was missing his mother. His parents were contacted and they made the journey to SFH. KS’s parents showed great concern and thanked me for bringing their son’s problems to light. They said they would find a place for him at a day school closer to home.

“No problems, Doctor…”

Mr P was a 26 year old male patient at Saint Augustine. He had recently made an excellent recovery from a left lower lobe pneumonia after treatment with amoxicillin. However, in typical Zambian fashion, a new set of problems emerged. He now complained of urinary urgency (having to rush to the toilet), polyuria (passing large volumes of urine), polyphagia (even the patient in the bed beside him said that he ate like a hippo), and polydipsia (excessive thirst). The list grew even longer as he finally divulged what his most troubling problems were – pain and weakness in both lower limbs that prevented him from walking. He also said he was numb from the thighs down.

The mystery began to unravel when Mr P admitted that, although he has since stopped drinking alcohol (as many patients do when they are admitted to hospital…), for nearly three years he gulped down about two-and-a-half bottles of kachasu (think Zambian rocket fuel brewed from maize) each day. It turned out that he had decided to give up alcohol as he was now engaged to be married (I neglected to ask how many cows he paid for his bride-to-be).

Mr P was examined thoroughly, but no significant clinical findings were made until  his neurological assessment. He had a wide-based gait, unsteadiness on Romberg’s test (standing with your feet together and eyes closed), mild lower limb weakness (equal distally and proximally), normal tone, brisk-normal deep tendon reflexes, and loss of pin-prick and proprioceptive sensation in a stocking distribution below the thighs.

I suspected a peripheral neuropathy resulting from alcohol misuse, vitamin deficiency (such as dry beriberi), or diabetes mellitus. He was started on B multivitamin tablets, and a fasting blood glucose concentration was measured – it was normal, effectively ruling out diabetes mellitus (despite the suggestive history).

Mr P was always the last patient I saw on ward round. I would stand scratching my head wondering what else I could do for him. Prophetically, after a couple of days a big box of thiamine arrived at SFH. Previously the only thiamine that could be given was in the tiny B multivitamin tablets, each tablet containing only 1 mg of thiamine. Unsure of the appropriate dose for treating dry beriberi, I started Mr P on 200 mg of thiamine daily, and gave him some pyridoxine as well just in case.

The weekend passed and on the Monday I came to the end of my ward round ready to find the best spot on my head to scratch. I asked Mr P if there were any problems, he said, “No problems, doctor…”. I stared at him in disbelief, and checked that I had heard him correctly. He smiled, hopped out of bed and quickly walked a short way up and down the ward. He was happily sent home – after being warned not to start drinking alcohol again.

Peripheral neuropathy-like symptoms are commonplace at SFH. Often they are attributed to the effects of HIV infection, and it is assumed that nothing can be done. However, I learnt from Mr P that all avenues must be exhausted before making such an assumption – or you might just miss a case of dry beriberi (thiamine deficiency) associated with excessive alcohol consumption…

Medicine for a Mzungu

Mr N was a medical student from a far off land in the South Pacific. After a few weeks at SFH he was finally convinced to join the SFH football team. After a few near-death experiences at training and a couple of comical cameos on match day, he was charitably given a place in the starting line-up for the big game against a team from a rival hospital. A large, typically enthusiastic crowd assembled as the livestock cleared the pitch and the referee signalled the start of the match.

Filling the right back position Mr N struggled against a fleet-footed winger who had the added bonus of football boots. Mr N quickly learnt that there are two types of footballers in Zambia – those with boots and those without. The SFH side struggled against their flamboyant opponents and were in disarray after conceding two rapid-fire first-half goals (sadly the referee failed to notice that three of the visitor’s forwards were off-side when he awarded first goal…).

After a rousing half-time talk – all of which was unintelligible to Mr N – the SFH team were rejuvenated. Roared on by the home crowd, a new-found enthusiasm and the will to win surged through the team. Miraculously, a valiant fight back brought the score level at two goals apiece. Then the real drama began to unfold.

The SFH team were awarded a corner after being camped in the opposition goal mouth for some time. Chaos ensued in the six-yard box as the ball was delivered in from the right. Somehow the ball was driven goal-ward by a SFH striker, only to be deflected wide by a defender’s fist. The referee courageously steeped forward and pointed to the penalty spot. The visiting players swarmed around him, vigorously pleading their case. A few minutes passed. Finally, the referee’s resolve broke down. Leaving the SFH boys dumbfounded, the referee reversed his decision and bizarrely awarded a free kick to the visitors. The show went on.

In the dying minutes of the match, the SFH team pushed all available men forward. The visitors cleared out of their penalty area and launched a counter-attack. Mr N, finding himself out of position, began to scurry back towards his own goal. However, an SFH midfielder, battling in defence, stole the ball from the visitors as they surged forward. Thinking quickly, he unleashed a long ball downfield. Mr N sharply turned as the ball soared overhead. Somehow he evaded the offside trap and found himself 30 meters from the opposition line, hurtling goal-ward with the ball at his feet.

Time stood still (as it tends to on such occasions). The crowd hushed (or perhaps they roared – one of the two…). The visitor’s keeper, sensing danger, rushed off his line. As Mr N met the pouncing keeper he instinctively pushed the ball to the keeper’s left with the outside of his right foot. The ball  slipped past the stranded keeper and glided inside the near post.

Pandemonium followed in the form of a massive pitch invasion. Acrobatic Zambian children cartwheeled and back-flipped across the surface of the pitch, while the adults jumped for joy and sang loudly. Met with dissent by the visiting team, the referee signalled the end of the match. SFH were victorious, three goals to two.

For the rest of the week, Mr N was called upon by countless supporters who insisted on reliving the match-winning goal. Mr N however had other concerns, having sustained a bloodied and grazed knee during the match. As expected the wound became infected. Pus oozed from every crack in the skin. Mr N was left hobbling around with a painful golf-ball sized lymph node in his right groin. Reluctantly he started a course of antibiotics as the infection progressively worsened. Magically the medicine did it’s job and Mr N was walking freely again four days later.

NB. Anyone who doubts the verity of this story can write to Charles “Coach” Chupa at St. Francis Hospital. He will gladly provide you with a written deposition confirming the truth of the events I have described…

The St. Francis boys – nervous before the big game.

Opposing right backs. Note my soon to be infected right knee – I wish I had shin pads like my Zambian colleague…

Please note that this was originally written in 2002.

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The Beauty of Motion

Published / by Harry Bigwood

Dec 13 2008

A recently published book caused me to examine what some of my colleagues have done in their orthopedic practices in terms of adopting a team approach to health care in an effort to offer higher quality and efficiency. In Redefining Health Care, Michael E. Porter and Elizabeth Olmsted Teisberg propose that the nation’s health care system is using “21st-century technology delivered with a 19th-century system” and that our sector of the economy is one of the last to have significant reconfiguring.

Porter and Teisberg emphasize that hospitals should closely follow cases, track survival rates, recovery times, and patient satisfaction, etc. They note that someone needs to consider the different visits, different buildings, different times and ensure the doctors and studies are available within a reasonable and efficient time period for the patient.

One stumbling block in this transformation will be, “Physicians no longer should see themselves as isolated,” Porter writes. “They need to see themselves as part of a team.” To me, this means the solo fighter-pilot mentality of many orthopedic surgeons (including yours truly) will have to change to flying more in formation. That will mean more oversight with standardization, documentation and regimentation in our practices. This change is proposed to benefit patients and increase efficiencies for all.

Personal experience

This year I came to appreciate the potential for the team approach to medical care when members of my family were evaluated and treated at two different centers using this method. They had a head physician of international stature and a center approach to the diagnosis as well as numerous supporting physicians, physician assistants and other dedicated professional staff. The laboratory studies and data collections were not that intrusive on our time. We could do much of the data entry in advance on the Internet, during the visit and/or with a research assistant. The centers provided their specific outcomes on proposed treatments as well as their failure and complications rates, which we found helpful in the decision-making process.

Our visits and treatments were coordinated so they could usually be completed in 1 day or less when possible and our appointment was dedicated to individual care. While I was pleased with the medical care, it involved travel, staying in an adjacent hotel the night before, and in some cases arguing with the insurers as the treatment was considered not being the standard of the community — lacking peer-reviewed, published articles with 2 year follow-up.

The treatment was more expensive then what is available locally, but it was worth the slightly higher costs to my family. The alternative would have required more of our time and frustration trying to get all the results and recommendations in one place at one time. I realize all community hospitals cannot have the volume, physician specialization, donations and grants to support the impressive team approaches, research documentation and follow-up we experienced. However, all can start applying some of the techniques to those specific areas where they do have the most volume.

Time-saving approach

As orthopedic surgeons in the outpatient environment, we can more easily achieve (and most of you have) the benefits of the team approach to the practice of orthopedics. This involves a streamlined approach from the preoperative setting through treatment and follow-up. Many individual orthopedic outpatient practices have made restructuring adjustments to allow the patient to obtain an expert opinion, have necessary imaging done on site and a treatment decision in one visit.

Compare this approach to having multiple visits to various locations and follow-up visits. For example, having a MRI and/or ultrasound immediately available is something I appreciate. This saves the patient time, by allowing him or her to only miss a half day of work and leave that appointment with a recommendation(s).

Think of yourself and the value of your time. Patients need to be treated the same way. It even has the potential to save in overall costs. One of the current stumbling blocks is obtaining pre-authorizations. This may delay this whole process of minimizing visits for consultations and tests. Most current systems are not concerned about the patient’s hours missed from work and the time they spent traveling back and forth for care, tests, consultations, return visits and waiting for results.

Hospital support

Orthopedic success with the team approach when it involves inpatient care is dependent on mutual cooperation, buy-in and support from hospitals. The hospital becomes a partner and facilitates the approach through its administration and professional staff. Some institutions have utilized well-established team approaches for some time. Emulating aspects of these existing programs can be easily done.

Most of the institutions with successful team approaches have strong physician leadership, a progressive administrative staff, and innovative nurses and therapists in common. Additionally, they often benefit from significant yearly philanthropic donations (nonpatient-generated revenue). In some cases these funds enabled new bricks-and-mortar to establish centers of excellence, supported establishing specialization in areas of new treatment options, and supported innovative programs for nonrevenue-generating professional staff.

Many programs receive grants to help fund their research arms and programs for the needy. The hospital’s demographics and payer mix certainly impacts the availability of this potential additional support to ensure these innovative programs are financially maintainable.

There are examples of team approaches to orthopedic care that do function well and efficiently and strictly within the patient revenue stream. The more organized and efficient they are, the more likely they can reduce overall costs and benefit from volunteerism and the support of patients and family members who have benefited from the higher standard of care.

Orthopedic example

In many institutions, joint replacement is one example of a treatment that has benefited greatly from the team approach. Strong institutions and dedicated physicians have developed this team approach and have viable functional programs currently from which we can all learn.

My personal experience trying to implement many aspects of the team approach to ACL and knee replacement has increased my patients’ quality of care over the past few years. It has included an experienced and trained nurse who coordinates the admission process, collates necessary studies and consultations, plans and coordinates discharge and anticipates after-care needs and conveniences.

We have a dedicated orthopedic nursing service and section of the hospital performing joint replacements. We have excellent therapists and established a new and effective pain control program with the anesthesia department.

In the future, hospitals will be forced to become “team players” with physicians as there will be more pay-for-performance initiatives and “bundling experiments” in which Medicare will make one payment to cover a treatment or procedure and the physicians and hospital will decide how it is distributed. That may or may not be good news, however, the bad news is the proposed bundled reimbursement to be divided with the hospital and the physicians will be less then the current sums paid individually.

Tags: Costs, Organisation, Orthopaedics

Healthcare Compliance » Blog Archive » Tuberculosis

Published / by Harry Bigwood

A brief overview of OSHA/tuberculosis relevancy in heathcare settings:

Tuberculosis (TB) – An infectious bacterial disease transmitted through the air that mainly affects the lungs.

With rare exceptions, TB is infectious only when it occurs in the lungs or larynx. TB that occurs elsewhere in the body is usually not infectious, unless the person also has TB in the lungs or larynx at the same time.

According to the Centers for Disease Control and Prevention (CDC), an estimated 2 billion persons (i.e., one third of the world’s population) are infected with M. tuberculosis. Tuberculosis kills almost 1.6 million people per year.Although the 2007 TB rate (4.4 cases per 100,000 population) was the lowest recorded in the United States since national reporting began in 1953, the average annual decline has slowed since 2000. TB is now the second most common cause of death from infectious disease in the world after human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS).

Characteristics of persons exposed to M. tuberculosis that might affect the risk for infection are not well defined. The probability that a person who is exposed to M. tuberculosis will become infected depends primarily on the concentration of infectious droplet nuclei in the air and the duration of exposure to a person with infectious TB disease. The closer the proximity and the longer the duration of exposure, the higher the risk is for being infected. Additional hazards are now present because of multidrug-resistant (MDR) TB. MDR organisms are resistant to the drugs that are normally used to treat TB, such as Isoniazid and Rifampin. The course of treatment when treating MDR TB increases from 6 months to 18-24 months, and the cure rate decreases from nearly 100% to less than 60%. Mortality among patients with MDR-TB can be high.

TB disease in persons over the age of 65 constitutes a large proportion of TB cases in the United States. Many of these individuals have latent TB infection; however, with aging these individuals’ immune function starts to decline, placing them at increased risk of developing active TB disease, and employees in long-term care facilities at risk of occupational exposure to TB. Nursing homes or long-term care facilities for the elderly have been identified as having a high-risk situation for the transmission of TB. The degree of risk of occupational exposure of a worker to TB will vary based on a number of factors.

OSHA withdrew its 1997 proposed standard on Occupational Exposure to Tuberculosis because it is unlikely to result in a meaningful reduction of disease transmission caused by contact with the most significant remaining source of occupational risk: exposure to individuals with undiagnosed and unsuspected TB.

Although OSHA has no standard for TB Infection Control, it will enforce the “General Duty Clause” in situations where employers’ failure to implement available precautions exposes workers to the hazard of TB infection. Created under the Occupational Safety & Health Act of 1970, the General Duty Clause can be thought as an employer’s general responsibility to ensure the safety of all its employees and states: “Each employer shall furnish to each employee a place of employment which is free from recognized hazards that cause or are likely to cause death or serious physical harm & each employee shall comply with the occupational safety & health standards and all rules, regulations and orders issued pursuant to this Act which are applicable to his own actions and conduct.” Additionally, OSHA requires employers with employee exposure to TB must comply with certain requirements including: 1910.134 – Respiratory Protection, 1910.145 – Accident Prevention Signs and Tags, and 1904 – Recordkeeping.

Under the General Duty Clause, OSHA will issue citations to employers with employees working in one of the workplaces where the CDC has identified workers as having a higher incidence of TB infection than the general population, when the employees are not provided appropriate protection and who have exposure as defined below:

Exposure to the exhaled air of an individual with suspected or confirmed pulmonary TB disease,

Or

Employee exposure without appropriate protection to a high hazard procedure performed on an individual with suspected or confirmed infectious TB disease and which has the potential to generate infectious airborne droplet nuclei.

Furthermore: OSHA will issue citations under the “General Duty Clause” in cases where the following procedures are not followed:

Periodic Evaluations: TB skin testing shall be conducted every three (3) months for workers in high risk categories, every six (6) months for workers in intermediate risk categories, and annually for low risk personnel.  The CDC has defined the criteria for high, intermediate, and low risk categories.

When working with TB potential hazards, OSHA recommends the prompt implementation of early screening procedures, and staff training to help them identify potentially infectious individuals, which will allow for early identification of patients with infectious TB and the initiations of appropriate controls before occupational exposure occurs to staff and other patients.

OSHA encourages employers to follow the guidelines established by the Centers for Disease Control and Prevention (CDC), Division of Tuberculosis Elimination (DTBE) to minimize the potential of TB transmission.

Should TB exposure occur, OSHA Directive CPL 2.106 states individuals with suspected or confirmed infectious TB disease must be placed in a respiratory acid-fast bacilli (AFB) isolation room. High hazard procedures on individuals with suspected or confirmed infectious TB disease must be performed in AFB treatment rooms, AFB isolation rooms, booths, and/or hoods. (AFB isolation refers to a negative pressure room or an area that exhausts room air directly outside or through HEPA filters if recirculation is unavoidable).

OSHA requires all healthcare settings establish a TB infection control program designed to ensure prompt detection, airborne precautions, and treatment of persons who have suspected or confirmed TB disease.

Fundamentals of Effective TB Infection Control:

Administrative Controls

Environmental Controls

Respiratory-Protection Controls

For more information on Tuberculosis & OSHA feel free to email OSHA Optics, LLC at:

[email protected]HAOptics.com

For information on OSHA’s mandated annual training requirements for healthcare workers, we encourage you to visit OSHA Optics, LLC’s website at:

www.OSHAOptics.com

Category: Healthcare, Healthcare Compliance, Healthcare Regulations, Healthcare Standards, Hospital Acquired, Hospital Acquired Disease, Hospital Acquired Diseases, Hospital Acquired Infection, Hospital Acquired Infections, Hospital Disease, Hospital Diseases, Hospital Infection, Hospital Infections, Infection, Infection Control, Infections, Infectious Disease, Mycobacterium Tuberculosis, Nosocomial, Nosocomial Diseases, Nosocomial Infections, OSHA, OSHA Compliance, OSHA Compliance Healthcare, OSHA Healthcare, OSHA Healthcare Compliance, TB, Tuberculosis, Tuberculosis Infection Control, Tuberculosis Vaccination, Tuberculosis Vaccine

Healthcare Compliance » Blog Archive » Bloodborne Pathogens and OSHA: “Hepatitis B Vaccination and Post-Exposure Evaluation and Follow Up”

Published / by Harry Bigwood

Bloodborne Pathogens means pathogenic microorganisms that may be present in human blood and can cause disease in humans. These pathogens include, but are not limited to, hepatitis B virus (HBV), hepatitis C virus (HCV), and human immunodeficiency virus (HIV). This article will address HBV exclusively.

Hepatitis B is a potentially serious form of liver inflammation due to infection by the hepatitis B virus (HBV). It occurs in both rapidly developing (acute) and long-lasting (chronic) forms, and is one of the commonest chronic infectious diseases worldwide.

The Hepatitis B vaccine is administered intramuscularly in three doses usually given on a schedule of 0, 1, and 6 months, but there can be flexibility in this schedule. More than 95 percent of children and adolescents and more than 90 percent of young, healthy adults develop adequate immunity following the recommended three doses. Persons who respond to the vaccine are protected from both acute hepatitis B infections as well as chronic infection.

OSHA mandates employers make available the hepatitis B vaccine and vaccination series to all employees who have occupational exposure, and post-exposure evaluation and follow-up to all employees who have had an exposure incident. OSHA further requires employers are to ensure that all medical evaluations and procedures including the hepatitis B vaccine and vaccination series and post-exposure evaluation and follow-up, including prophylaxis are:

1. Made available at no cost to the employee

2. Made available to the employee at a reasonable time and place

3. Performed by or under the supervision of a licensed physician or by or under the supervision of another licensed healthcare professional

Following a report of an exposure incident, OSHA mandates that the employer shall make immediately available to the exposed employee a confidential medical evaluation and follow-up, including at least the following elements:

1. Documentation of the route(s) of exposure

2. The circumstances under which the exposure incident occurred

3. Identification and documentation of the source individual, unless the employer can establish that identification is infeasible or prohibited by state or local law

Hepatitis B Post-Vaccination Titer Notes:

· All healthcare workers should have serologic testing 1–2 months following the final dose of the hepatitis B vaccine series.

  • If adequate anti-HBs is present (>10mIU/mL), nothing more needs to be done. An anti-HBs serologic test result of >10mIU/mL indicates immunity. Periodic testing or boosting is not needed. If the post-vaccination test result is less than 10mIU/mL, the vaccine series should be repeated and testing done 1–2 months after the second series.

Hepatitis B Vaccine Notes:

· Brand Names: Engerix-B, Recombivax HB

· The hepatitis B vaccine has been available since 1982.

· The hepatitis B vaccine causes the body to produce protective levels of hepatitis B antibodies which will protect against infection from hepatitis B virus.

· The Advisory Committee on Immunization Practices (ACIP) recommends hepatitis B vaccination for everyone 18 years of age and younger, and for adults over 18 years of age who are at risk for HBV infection.

· There is no known cure for hepatitis B. Thus, prevention is the best option to dealing with this disease. Currently, the only Food and Drug Administration (FDA) approved medicines for treatment of hepatitis B are Interferon Alpha and Lamivudine.

o Interferon Alpha is usually used only for persons whose liver enzyme tests are abnormal.

o The FDA recently approved Lamivudine in December 1998 for the treatment of chronic hepatitis.

For more information on Bloodborne Pathogens & OSHA feel free to email OSHA Optics, LLC at:

[email protected]

For information on OSHA’s mandated annual training requirements for healthcare workers, we encourage you to visit OSHA Optics, LLC’s website at:

www.OSHAOptics.com

Category: Bloodborne Pathogens, Bloodborne Pathogens Training, HBV, Healthcare Compliance, Healthcare Regulations, Healthcare Standards, Hepatitis, Hepatitis B, Hepatitis Vaccination, Hepatitis Vaccine, Hospital Acquired, Hospital Acquired Disease, Hospital Acquired Diseases, Hospital Acquired Infection, Hospital Acquired Infections, Hospital Disease, Hospital Diseases, Hospital Infection, Hospital Infections, Infection, Infection Control, Infections, Infectious Disease, Nosocomial, Nosocomial Diseases, Nosocomial Infections, OSHA, OSHA Compliance, OSHA Compliance Healthcare, OSHA Healthcare, OSHA Healthcare Compliance

Anesthesiology

Published / by Harry Bigwood

I have pens, piles and piles of pens. My operating room locker is crammed with them, flashing logos of anesthetics, muscle relaxants, narcotics, β-blockers, painkillers and antacids in bright primary colors. I also have scrub caps, sticky pads, calculators, clips for my hospital ID tags and some odd gizmos that I can’t even figure out, all proclaiming my presumed loyalty to a brand of something or other that an… read more

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