Shout Outs

Updated 3/2017--all links removed as many no longer active. 

Gina (@geeners), Code Blog: Tales of a Nurse, is this week’s host of Grand Rounds. You can read this week’s twitter edition here.

How’d we get to Volume 8 already?! I think hosting this Grand Rounds finally ties me up with GruntDoc, who has hosted 7 times. Grand Rounds is the weekly round-up of blog posts by medical bloggers.

Whereas in the past the host would post nearly every link they received, it appears that we are now moving towards more curated content. I said in my previous post that I wasn’t going to institute a theme, but I was definitely more drawn to the personal-story type posts. Thanks to everyone that submitted! ……..

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Dr Rob is finally back blogging! His recent Musings Post explains: Plugging Back In.

This post is to announce two things:

1. I am back blogging again.


2. I am not blogging on this blog. I have a new blog called More Musings (of a Distractible Kind).

I also have a new project, Llamaricks, which is a blog that will hopefully draw audience participation. It’s a place for poetry; poetry by me and poetry submitted by my readers (assuming I have any). Hopefully there are people talented and/or shameless enough to submit their prose to me on that site.

OK, so I am already being untruthful. I really had three announcements. ……..

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There’s a nice discussion going on over at doc2doc: Poll: Should doctors self prescribe? Various opinions. Here are a few:

Probably antibiotics for infections would be ok, and something like Voltaren for artritis, or celebrex, but no controlled substances, this is where the water gets muddied.

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Doctors should not self prescribe nor under any obligation prescribe any medication for a family member or friend without their own "clinical consent" in regard to the medical condition in question.

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Generally doctors should not prescribe for themselves and any narcotic prescribing for self or family is a definite No. There is a saying that 'the doctor who treats himself has a fool for a patient' ….

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Then there’s this via @skepticscalpel: “Why internists shouldn’t operate MT @hhask @writeo After-hours surgery resulted in woman's death http://bit.ly/AA2DHL”

The link is to an article in The Oregonian by Nick Budnick: Oregon Medical Board sheds light on cosmetic surgery by Northeast Portland doctor that led to woman's death

For botching an after-hours cosmetic surgery that caused her friend's death, a Northeast Portland physician faces administrative charges and could lose her license.
Soraya Abbassian committed "gross or repeated" negligence while performing the Dec. 15, 2010 surgery, including administering what an autopsy found to be a fatal overdose of local anesthesia, according to a disciplinary complaint issued by the Oregon Medical Board on Thursday. ……….

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H/T to @scanman for the link to this letter written by John Steinbeck to his eldest son, Thom: Nothing good gets away

In November of 1958, John Steinbeck — the renowned author of, most notably, The Grapes of Wrath, East of Eden, and Of Mice and Men — received a letter from his eldest son, Thom, who was attending boarding school. In it, the teenager spoke of Susan, a young girl with whom he believed he had fallen in love.

Steinbeck replied the same day. His beautiful letter of advice can be enjoyed below. …..

Dear Thom:
We had your letter this morning. I will answer it from my point of view and of course Elaine will from hers.

First—if you are in love—that’s a good thing—that’s about the best thing that can happen to anyone. Don’t let anyone make it small or light to you.…………..

And don’t worry about losing. If it is right, it happens—The main thing is not to hurry. Nothing good gets away.

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Jordan Grumet Interviews Himself on his blog In My Humble Opinion (twitter handle @jordangrumet)

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Q: Taken as a whole, what is your blog about? What are the major themes?
A: If you asked me this question a few years ago, I would have said that my blog is a love letter to my patients. As I grow wiser, I realize that it is more accurately a love letter to my father.

When my father (a prominent oncologist) died, I was seven years old. As silly as it sounds, I spent a great deal of my childhood and young adult years trying to forgive myself for his death. Even though I knew I wasn't responsible for his aneurysm, I struggled with issues of being worthy of love.

As I read my own writing, I'm struck by the parallels. I fight to be protect my patients and lead them through the dying process, much in the way I wish I could have done for my father. …………

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Via Jackie-ES blog post: Join Patternfish and HeartStrings in Supporting WomenHeart (photo credit). I purchased the pattern, now to finish the projects I have started so I can knit this beautiful scarf.

Patternfish also launched a monthly charitable support initiative starting this month where the Designer of the Month picks a favorite charity and to which Patternfish will make a contribution. And I am the first to help kick off this initiative by choosing WomenHeart, the lifeblood organization devoted to improving the quality of life and the healthcare of women living with heart disease.

Patternfish will be donating $1.00 for each Thinking of You Scarf pattern sold during January to WomenHeart and I will match that dollar for dollar.

Shout Outs

Updated 3/2017-- photos and all links (except to my own posts) removed as many no longer active. 

Grand Rounds is  taking a break this week. If you would like to host a future edition of Grand Rounds send an email to Nick Genes (you can find his contact info at here).   The most recent edition can be found here at Medgadget.  Other editions can be found here on the Grand Rounds Facebook page.

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@movinmeat  wrote a post recently, A case study in applied ethics, which lead @inwhiteink to write an educational post on decisional capacity

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“Decisional capacity” refers to a person’s ability to make a decision for a specific clinical issue. This issue is usually related to treatment. After assessment, physicians can opine whether someone possesses or lacks decisional capacity for something specific: ……

Appelbaum and Grisso published an important paper that provides a four-point rubric to assess decisional capacity. (At only four pages, it is a short, high-yield article.) Most psychiatrists apply this rubric when assessing decisional capacity in medical settings. …….

Movin Meat’s followup post:  Ethics of refusing informed consent

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From twitter:   @Mtnmd The Twitter chat that killed Sermo http://bit.ly/ipw4au

Her link is to an article by Joe Hage which I encourage you to read:  The Twitter Chat that Killed Sermo | #MedDevice

I’m not a physician. I don’t play one on TV. And I’d never heard of Sermo, the largest online physician community in the US (boasting 120,000 members) until @HJLuks mentioned them the week before.

Mine was an innocent invitation to talk during last night’s #MedDevice chat (Thursdays, 8 pm EST).

Who knew it could unravel the company.  …….

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Yesterday NPR aired this story:  Army Nurse Helps Soldiers Heal From Burn Wounds

As part of NPR's ongoing series, 'The Impact of War,' guest host Allison Keyes explores one of the tragic consequences of combat - burn wounds. Such wounds can subject victims to a painful and unpredictable recovery. Army Lt. Col. Maria Serio Melvin shares her experiences at the military's largest burn center, the Brooke Army Medical Center in San Antonio, TX, where she treated service members injured in the Iraq and Afghanistan wars …………

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Some inspiring stories of healthcare workers during the Joplin tornado

H/T @Mtnmd -- 45 Seconds: Memoirs of an ER Doctor from May 22, 2011

H/T @SeaSpray – Operating Through the Tornado

James D. "Dusty" Smith, MD, and his surgical team were midway through a routine case, the draining of a patient's infected hip, when the tornado hit St. John's Regional Medical Center in Joplin, Mo., Sunday.  ……….

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From @scutmonkey, her piece on Psychology Today:  The Radical Notion that Doctors are People, Too

Though there are few subjects as immediate to my experience as that described in Gardiner Harris's article in The New York Times, "More Doctors Say No to Endless Workdays," (April 1st, 2011), perhaps the truest indication of my opinion on the matter may be the fact that, upon first glance at the headline, I didn't feel much need to read the rest of the article.  More doctors say no to endless workdays?  Well, of course we do.  Duh.  …..

Her tweet of the article led @DarrellWhite to tweet a link to his view on the same topic:  Residency Training and the Modern Physician

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H/T to @brainpicker and @ctsinclair for the link to this:  Anatomy made of LEGO (photo credit) 

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Last Tuesday (May 24, 2011) NPR celebrated Bob Dylan Turning 70.  Near the top of the story written by Linda Fahey is a button “Visit FolkAlley.com To Hear The Mix” which links you to a wonderful mix of Dylan music sung by Joan Baez, Tim O'Brien, Rosanne Cash, Jimmy Lafave, many others — and Dylan himself.  Thanks NPR.

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Threads has a nice article by Susan Khalje on Creating Perfect Bias Fabric Loops  (photo credit)

……..we decided that loops and buttons would be a cleaner alternative.
Here are a few samples to show you what we did:
We started with strips of bias-cut fabric, making a sample or two to determine just how narrow we wanted the finished loops to be. ……….

Advertising

Updated 3/2017-- photos and all links removed as many are no longer active and it was easier than checking each one.

I am old school and find it difficult to advertise. I don’t begrudge others who do so ethically and in good taste.

There is a local cosmetic surgeon who is running a special via TV ads and on his website (the photo is a screensaver shot of the website cropped to remove his name) that for me is unethical.

For me the ad “entices” potential patients into surgery without giving them information about potential risk.   Hopefully that information is given in detail when the patient is seen in the office consultation.

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This was not an issue when I was in medical school (graduated in 1982).  I trained under surgeons who had never been allowed to advertised and frankly did not think doctors should. 

Deborah Sullivan, PhD has written a nice piece on the history of advertising in medicine, specifically cosmetic surgery:

Cosmetic surgery was re-commercialized in 1982. Before then, physicians, like other members of learned professions, were exempt from the 1890 Sherman Antitrust Act. The AMA could enforce bans on advertising because the fiduciary services physicians offered were not considered a commercial trade. Opinion changed in the deregulatory climate of the Reagan years. Hoping to bring down health care costs, the Federal Trade Commission sued the AMA for restraint of trade over their prohibition of advertising. Over the strenuous objections of the AMA and the plastic surgery specialty associations, a split Supreme Court decision let a lower court ruling in favor of the Federal Trade Commission stand [8, 9]. Advertising in medicine returned, with its ethical dilemmas, and cosmetic surgery was once again on the cutting edge.

As Dr. Sullivan notes (bold emphasis is mine)

The purpose of advertising is to persuade people to do something. The most effective ads appeal to emotions—fears and desires—and associate the subject of the advertisement with highly valued attributes. It is not difficult to persuade people to do something that will give them a more youthful, sexually attractive appearance in a culture that bestows real social and economic rewards on those who possess these traits. The lure of such rewards can make us gullible and impulsive when it comes to buying the promise of beauty.

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There are a number of physician advertising practices that are deemed inappropriate (reference 2, 3, 5).  These include

• Payment in exchange for referral of patients or media coverage
• Exaggerated claims intended to create false expectations of favorable surgical results
• Promotional inclusion of preoperative and postoperative photographs intended to misrepresent results through different lighting, expressions, or manipulated poses

I think Robert Aicher, Esq comments (reference 4)  regarding a surgeon’s web site could be extended to TV and print ads:

In this commentator’s view, ethical inferences from Web site to practitioner should be suspect. For instance, a former AMA member and Beverly Hills cosmetic surgeon, Dr. Jan Adams, surrendered his license to practice medicine on April 1, 2009, after it was suspended in 2008 for failure to pay child support, with prior alcohol-related convictions in 2003 and 2006. The November 10, 2007, death of his patient, Donda West, and his malpractice judgments of $217,337 and $250,000 in 2001 were not factors in his license surrender. Dr. Adams currently has an excellent Web site that makes no reference to any of these public records.  Accordingly, “quality” Internet advertising does not guarantee a quality practitioner, and conversely, patients routinely obtain quality results from cosmetic surgeons who do not have “quality” Web sites.

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I’m all for educating the public.  I love the segments Dr. Anonymous does with his local TV stations for just that reason. 

REFERENCES

1.  Advertising Cosmetic Surgery: The use of advertisements for cosmetic surgery has fluctuated throughout the twentieth century; Deborah A. Sullivan, PhD; Virtual Mentor. May 2010, Volume 12, Number 5: 407-411.

2.  Are Plastic Surgery Advertisements Conforming to the Ethical Codes of the American Society of Plastic Surgeons?; Spilson, Sandra V.; Chung, Kevin C.; Greenfield, Mary Lou V. H.; Walters, Madonna; Plastic & Reconstructive Surgery. 109(3):1181-1186, March 2002.

3.  The quality of Internet advertising in aesthetic surgery: an in-depth analysis; Wong WW, Camp MC, Camp JS, Gupta SC.; Aesthet Surg J. 2010 Sep 1;30(5):735-43.

4.  Commentary on "The quality of Internet advertising in aesthetic surgery: an in-depth analysis"; Aicher RH; Aesthet Surg J. 2010 Sep 1;30(5):744.
5.  ASPS Advertising Code of Ethics and Advertising 101 (in pdf form)
6.  Advertising cosmetic surgery: are doctors complying with ethical standards?; Australian Medical Association, June 2002

Know Your Surgeon

Updated 3/2017-- all links (except to my own posts) removed as many are no longer active and it was easier than checking each one.

I would caution anyone who elects to have cosmetic or plastic surgery to go to a surgeon’s office.  Meet your surgeon.  Along with learning about the procedure, ask about their training.  If your procedure is to take place outside of a hospital (for example, in a surgery center), ask if your surgeon has privileges to do the procedure in a major hospital (the hospital should have checked their training when doing the credentialing).

Treat cosmetic/plastic surgery as surgery with all the benefits AND risks of non-elective surgery.

I stumbled across this article Owner of Cosmetic Surgery Clinic Sentenced in New York for Health Care Fraud.

Arthur Kissel,a/k/a "Arthur Froom," was sentenced October 25th in Manhattan federal court to 10 years in prison for healthcare fraud offenses.  Neither Kissel nor his wife Sonia LaFontaine are doctors, but they engaged in a series of fraudulent practices out of their Manhattan cosmetic surgery clinic.  (pdf file of press release from United States Attorney Southern District of New York)

LaFONTAINE and KISSEL, along with several coconspirators including doctors who worked at LRMA, engaged in four different types of fraud at the clinic:
•  LaFONTAINE performed procedures which were billed as if they had been performed by licensed physicians.
•  LRMA billed cosmetic procedures as medically necessary procedures so that health insurance companies would be duped into paying for them.
•  KISSEL and LaFONTAINE submitted claims to health insurance companies for procedures that were never performed.
•  KISSEL and LaFONTAINE exaggerated insurance claims by increasing the number and complexity of procedures.
KISSEL and LaFONTAINE were indicted in March 1998 with conspiracy to commit health care fraud. KISSEL was extradited from Canada in 2008 and pled guilty on September 4, 2009.

Kissel and LaFontaine’s practices actually led to the death of one patient:

In imposing the maximum sentence permitted by law,Judge CHIN rejected KISSEL's claims of "ignorance and dumbness"and found that he "acted out of greed." He also stated that his crimes "led directly to the death" of JOEL CUNNINGHAM, who died on January 8, 1998, while undergoing an outpatient abdominal liposuction procedure at LRMA. CUNNINGHAM had wanted to become a NYPD police officer, but was too heavy to meet the entrance standards. He decided to have a liposuction procedure at LRMA,which used extensive advertising claiming that it was operated and supervised by a "world renowned surgeon," when in fact it was operated and supervised by KISSEL and LaFONTAINE. Evidence presented at a subsequent wrongful death suit in state court indicated that Cunningham had died of complications from anesthesia, which had been administered by an LRMA anesthesiologist who was at the time on professional probation due to drug and alcohol abuse.

Shout Outs

Updated 3/2017-- photos and all links (except to my own posts) removed as many are no longer active and it was easier than checking each one.

Dr Wes is the host for this week’s Grand Rounds! You can read this week’s edition here (photo credit).

Welcome to this week's mid-term edition of the medical blog-o-sphere's Grand Rounds! Before we begin, be SURE to get to the polls to VOTE!
This week submissions were classified by state or country of origin. Politically incorrect posts by state were colored RED whereas politically correct posts by state were colored BLUE. (States with both extremes are represented in PURPLE.)
Now what would any political post be without a POLITICAL MAP of the states represented in this week's Grand Rounds?  …………….

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Kim, Emergiblog, is the host of the latest edition of Change of Shift (Vol 5, No 9)! You can find the schedule and the COS archives at Emergiblog. (photo credit)

Welcome to Change of Shift!
After a Vegas-induced vacation, our nursing blog carnival is back!
There has been lots of activity in the blogosphere over the last four weeks, so let’s get right to the heart of it! ………..

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Check out Dr. Rob’s recent House Call Doctor podcast: When Should You Worry About a Nosebleed?

……….Doctors call nosebleeds epistaxis. I’ve mentioned before that doctors like fancy names for things; it just sounds smarter to use a Latin or Greek word. It’s especially good at parties. ……….

As someone who has had many nosebleeds within my life, you may also want to check out my old post from two years ago: Nose Bleeds. Either way, Dr. Rob and I have you covered.

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An ethical question comes up regarding the use of social media as noted by @dreamingspires

A Tweeting Hospital and Kidney Patient: The Case of the tweeting Kidney Patient has caused a small whirlpool of a ... http://bit.ly/dfsREG

The original nhssm's posterous blog post: 2nd Case Study - St George's Healthcare NHS Trust and the Tweeting Kidney Patient

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From twitter: RT @MargaretAtwood @DrSnit @kidney_boy: Hey, you're famous! http://ow.ly/30LR1. The link is to a Guardian.co.uk article by Esther Addley: Margaret Atwood creates superhero outfits for Twitter avatars

With more than a dozen novels, 17 poetry collections and countless literary awards including the 2000 Man Booker prize to her name, Margaret Atwood's credentials as one of the world's greatest living writers are not in question. ……..

in a remarkable exchange over Twitter, which saw the Canadian writer contacting two readers who had expressed admiration for her work, and offering to design "superhero comix costumes" for their avatar alter-egos, @kidney_boy and @DrSnit.

"[They] both have excellent Twitter names – suitable for superheroes – and were comix fans, and were discussing Comic.con, as I recall," she told the Guardian. ………..

This tweet links to a companion article:

@steve_lieber Some of the @PeriscopeStudio artists (incl. me) have drawn @margaretatwood's Kidney Boy and Dr. Snit. http://periscopestudio.com/?p=3638

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The Alliance for American Quilts received 118 quilts for it’s “New from Old Quilt Contest Contest.” You can see all the quilts here. My entry was “Label Me.” The quilts are now being auctioned off.

Click on an auction week below to view or download an auction guide for that week.

Week One: Monday, Oct. 25-Monday, Nov. 1

Week Two: Monday, Nov.8-Monday, Nov. 15

Week Three: Monday,Nov. 15-Monday, Nov. 22

Week Four: Monday, Nov. 29-Monday, Dec. 6

The bidding for each quilt will start at $50 and each 7-day auction week starts and ends at 9:00 pm Eastern. No Daylight Savings Time changes this year to contend with--DST changes on November 7.

All proceeds will support the AAQ and its projects.

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Dr Anonymous’ show will be follow-up to FMEC Mtg. The show begins at 9 pm EST.

Shout Outs

Updated 3/2017-- photos and all links (except to my own posts) removed as many are no longer active and it was easier than checking each one.

Medical Resident's Journey is the host for this week’s Grand Rounds!  You may recall his poem won Dr. Charles Poetry contest.  The theme this week is “uplifting moments in medicine.”  You can read this week’s edition here (photo credit).

Good morning! Thank you for all the submissions which have flooded my inbox over the past week. They kept me going through a stretch of countless overnight shifts in the emergency department, which seemed never-ending and darker than a moonless night. In the midst of stunning fall foliage this October, the vibrant colors of this week’s Grand Rounds reach towards the sky. Take a moment out of the day to live in the present. Listen to the sounds around you, whatever they may be – leaves rustling in the wind, blaring sirens, constant monitors. Sit back, relax, take a long, deep breath and a sip of your favorite morning drink. Take in the flying kites, subtle music, and silver linings of today’s indulgence: Uplifting Moments in Medicine.  ………….

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I hope you will all read Dr. Rich’s recent post:  Medical Ethics and the Amish Bus Driver Rule

Rachel Maddow, in a discussion related to the provision of abortion services, once proposed that we (society) should invoke the Amish Bus Driver Rule whenever medical professionals invoke their personal convictions in refusing to provide legal medical services.

The Amish Bus Driver Rule goes like this: If you’re Amish, and therefore have religious convictions against internal combustion engines, then you have disqualified yourself for employment as a bus driver.  …..

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From twitter:  @SusannahFox

#ACS2010 survey: Half of surgeons use FB; 20% use Twitter http://bit.ly/9XRBFt (PDF via @Sani2012)

Compare to @Pew_Internet survey: Half of all adults use FB, MySpace, LinkedIn; ~13% use Twitter http://pewrsr.ch/awb5wt

The first tweet links to this article: Time to Tweet: Session highlights importance of social networking for surgeons (page 1 and 3 of the PDF file)

………….According to Dr. Glick, 7% of the U.S. population is on Twitter, while 20% of ACS survey respondents (approximately 300 as of last week) are on Twitter. 41% of the U.S. population is on Facebook, compared with 64% of ACS survey respondents (see table, page 3). The more sobering results, according to Dr. Glick, are the number of ACS survey respondents who participate in online forums or read online health blogs – 34.5% – which is a comparatively low number.  ….

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Fellow physician, blogger, and twitterer  Jill of All Trades, MD has begun doing a podcast!  The podcast, Girlfriend M.D.,  is part of Quick and Dirty Tips family. She will be sharing the hosting duties:

Join Dr. Sanaz Majd and guest host Dr. Lissa Rankin as they answer the most common questions women have about their bodies and their health. This is a chance for you to learn about all those issues you were so curious about, but were too afraid or embarrassed to ask about. Girlfriend MD will show you that you are not alone, and that no topic is off-limits. After all, we are all girlfriends here.

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From the #hcsm twitter chat this past Sunday evening – a very helpful tip sheet to use in searching for health information online:

@pfanderson T2 My tip sheet for patients using ehealth info w/docs http://www-personal.umich.edu/~pfa/mlaguide/free/quickgd.pdf #hcsm

It is a pdf file, but I encourage you to check it out. 

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Dr Anonymous’ show will be about  DigPharm Mtg. The show begins at 9 pm EST.

Upcoming shows:
10/23 : Saturday Nite
10/28 : About FMEC Mtg
10/30 : On Location

Stem Cell Face-Lifts?

Updated 3/2017--  all links (except to my own posts) removed as many are no longer active and it was easier than checking each one.

It’s been almost a month since the LA Times ran the article by Chris Woolston:  The Healthy Skeptic: Stem cell face-lifts on unproven ground.  It’s well written and presents a fairly balanced view.  While I am a fan of stem cell research, I think the “claims” are often put ahead of the science.  This is one of those times.  I can’t find any decent articles to support the claims of the plastic surgeons doing “stem cell face-lifts.”

My view is echoed in the article (bold emphasis is mine):

Rubin says he's excited about the potential of stem cells in the cosmetic field and beyond. Still, he adds, there are many unanswered questions about the cosmetic use of stem cells, and anyone who claims to have already mastered the technique is jumping the gun. As Rubin puts it, "Claims are being made that are not supported by the evidence."

While researchers in Asia, Italy, Israel and elsewhere are reporting decent cosmetic results with injections of stem cell-enriched fat, Rubin says that nobody really knows how the stem cells themselves are behaving. He points out that fat injections alone can improve a person's appearance, no stem cells needed.

Rubin believes it's possible that injected stem cells could create new collagen and blood vessels — as they have been shown to do in animals studies — but such results have never been proved in humans. And, he adds, the long-term effects of the procedures are an open question.

Stem cell face-lifts could someday offer real advances, says Dr. Michael McGuire, president of the American Society of Plastic Surgeons and a clinical associate professor of surgery at UCLA. But he believes that scientists are still at least 10 years away from reliably harnessing stem cells to create new collagen and younger-looking skin. Until then, promises of a quick stem cell face-lift are a "scam," he says.

The American Society for Aesthetic Plastic Surgery (ASAPS) issued a statement two weeks after the article first appeared --Stem cell therapy 'could offer women natural breast enhancement from stomach fat'

“Procedures with no solid science behind them, stem cells included, give unproven hope to patients and the marketing of them brings dishonor to our entire specialty,” said Felmont Eaves, III, MD of Charlotte, NC, President of ASAPS.  The Aesthetic Society is working together with the other core societies to address this through an evidence based medicine program that will rate any procedure or device on the legitimacy of the scientific evidence behind it.  This program is in its development stage and will be available to the public within the next 12 months”.

“The use of ‘stem cells’ in advertising for cosmetic surgical applications is a global problem," says Doug Sipp, Head of the Science Policy and Ethics Study Unit at the Center for Developmental Biology of RIKEN in Kobe, Japan, who monitors supposed stem cell treatment claims worldwide in all different specialties.  "There have been many cosmetics, nutraceuticals, and device makers who claim either to use stem cells in their products, or to use ingredients that activate the customer’s own stem cells. To the best of my knowledge, none of these has a basis in scientific evidence."

Marketing.  That seems to be the issue here.  And there is much money to be made in promises that may or may not be kept with the use of stem cells.  From the LA Times article:

Stem cell face-lifts: A Sept. 13 Health section story assessing stem cell face-lifts offered by two Beverly Hills doctors said that Dr. Nathan Newman charges between $5,500 and $9,500 for the procedure and Dr. Richard Ellenbogen charges $15,000 to $25,000. The story should have noted that Ellenbogen often performs a surgical face-lift along with his injection of stem cells. —

Wish It Weren’t So

Updated 3/2017 --  all links (except to my own posts) removed as many no longer active.

I’d love to report that doctors are always ethical and have their patient’s best interest at heart, but alas even I am not that naive. 

It is important for physicians to not mislead the public as to their training or skills.  No one expects family physicians to do liposuction surgery or eye doctors to do breast augmentations. 

Here is an article in the St. Petersburg Times by Letitia Stein from August 8, 2010:  Limited training among some cosmetic surgery doctors worries state officials. 

A Tampa doctor accused of allowing unlicensed assistants to perform liposuction should have his license suspended for a year and pay a $50,000 fine, the Florida Board of Medicine decided Saturday.

The board's action was a move to address the growing concern about physicians with limited cosmetic surgery training working in medical spas.   …………

The charges stemmed from a woman who came to Dr. Yves N. Jean-Baptiste for liposuction. Jean-Baptiste had trained and received board certification in family medicine. About two years ago, he began to perform cosmetic procedures at his north Tampa practice, YJB Medical and Weight Clinics, after completing a three-day "intensive, hands-on training course" in Weston, according to his attorney.

Jean-Baptiste said he performed more than 250 liposuction procedures, his attorney noted without serious complication. But the July 2009 case illuminated his safety breaches.

State health officials said Jean-Baptiste allowed two people unlicensed to practice medicine to perform liposuction on the patient, identified as D.S. Her medical records didn't show a proper exam before the procedure, how much anesthesia was used, or the amount of fat removed. And Jean-Baptiste hadn't registered his office, then on Gunn Highway, as a surgical facility as required.   …………..

And from Dr. Rob Oliver Jr, Plastic Surgery 101, tells us about the eye doctor who had to call 911:  Ways to (nearly) ruin your life 101 - Choosing an Atlanta eye doctor to do your breast augmentation surgery

This summer there was an awful instance of medical negligence in Georgia involving an eye-doctor (opthamologist) who had major complications while attempting to perform breast augmentation surgery in his office. You can hear a frantic 911 call from the doctor explaining that he has encountered uncontrollable bleeding he created while during her breast implant surgery and has no idea how to fix it. …….

You can view 2 video news clips on the story here & here.    ………………..

The Plastic Surgeon Knows Best?

Updated 3/2017 -- all links removed as many no longer active. and it was easier than checking each one.

I tend to agree with what Dr. Robert Goldwyn had to say in this essay from his book “The Operative Note: Collected Editorials” (published in August 1992). 

The Plastic Surgeon Knows Best: 

A Hazardous Assumption

Two incidents, within four hours, seemingly disparate, were instructive nevertheless.  The first was in the barber shop, where I paid a long overdue visit.  The hair stylist – there are no more barbers left in the world – was a woman, whom I had not seen before.  She was one-half my age and a hundred times as attractive.  She was sitting in her own chair, brushing Lady Godiva length hair muttering that her friend – another “stylist” – had “ruined” her.

“She cut too much off,”  she said.

My fantasy was that her hair previously must have trailed like a bridal train.

This is a good sign, I told myself.  She will not prune me excessively, something that is easier to do with each year.  To my request for a “light trim,” she replied, “Don’t worry.  I’ll take care of it.  You’ll like the result.”

That last statement triggered an iota of apprehension but I gave myself over to her obvious charm and flying fiingers.  I must have dozed and awoke to a World War II soldier staring back at me from the mirror.  I look like an old recruit, perhaps a General Schwarzkopf but without his girth or tanks.

Then a more primal fear seized me.  Maybe my modern hair stylist was really an incarnated Delilah.  That thought sent my strength ebbing as I went to my car and then to the office – for the second incident.

This was a new patient, a twenty-eight year old writer, who was displeased with the outcome of her rhinoplasty done elsewhere.

“I told him that I wanted surgery only on the tip,” she said.  “I even wrote him a note to that effect and also specified it on the operative permit.  I couldn’t believe what I looked like when he took off the splint.  He had given me a total nose job.  When I protested and asked him what he had done to me during the operation, he got very angry and practically yelled, ‘It’s none of your business.  I was the surgeon and I know what is best for you.’ ”

Her plastic surgeon and my barber have forgotten that my hair and her nose belonged to each of us respectively and not to anyone else.  They also shared the same deficiency:  not listening.  But there is more involved:  namely, arrogance.  After they have finished with their work, we are left holding the result.  Of course, I do not equate my Marine hair cut with her new nose.  With God’s grace, in a few weeks I will regain what I had but she will not.

I believe it was Osler who advised us to listen to the patient because he or she will tell us what is wrong and if we listen longer, the patient will tell us what to do.  I am afraid that each of us occasionally ignores or forgets that verity.  The patient becomes somehow incidental to our treatment which we impose without proper regard for that person’s sensibilities and desires.

This phenomenon of not taking into meaningful account what the patient wants I have observed more among older practitioners.  Perhaps they feel that they are beyond the restrictions that usually apply to other plastic surgeons.  This kind of megalomania is not without possible severe repercussions  -- the kind that take place in a court room.

In our specialty, more crimes are of commission than omission.  fewer problems result from doing less than from attempting more.  One would think that the older plastic surgeon would appreciate doing less in order to conserve his or her strength.  Maybe the issue is one of routine:  performing “the operation” instead of the right operation.  The patient who receives more than he or she requested is about as grateful as the diner who was served Beef Wellington when he wanted a green salad.

 

When breast augmentation and reduction patients ask me what size they should “go for.”  I tell them my opinion, but also tell them they should decide “what they want.” 

I have been known to use the example of me making them a dress in a lovely green silk.  The dress fits perfectly, the color suits their skin/hair/eye coloring, BUT I find out too late they hate the color green.

So while it is my duty to listen, my patients must tell me what they want.  Then we can have a discussion about whether it is possible, etc.

More on Facial Transplantation

Updated 3/2017 -- all links (except to my own posts) removed as many no longer active. and it was easier than checking each one.

There are two related articles from Plastic Surgery Practice by Amy Di Leo who interviewed Daniel Alam, MD on the topic of facial transplantation. Dr. Alam was the primary Microvascular surgeon of the Cleveland Clinic team that performed the 22-hour face transplant procedure. I recommend both to you.

Daniel Alam, MD, on Facial Transplantation: A step-by-step discussion of the historic near-total face transplant in the United States by Amy Di Leo (January 2010)

In Part One of a two-part series of articles, Alam reviews the events that led up to the surgery, including a discussion of donor selection and preparing the patient emotionally for the procedure.

Daniel Alam, MD on Facial Transplantation Recovery and Ethics Issues by Amy Di Leo (February 2010)

Alam: There is a lot of additional recovery for a face transplant patient. That is why it is important for a patient to be local because all the people on the care team need to see her. It wouldn’t make sense for a patient to come to us from Germany for an operation like this. Connie lives about 100 miles away, and she comes for postsurgical visits at least once a month.

Related posts
Face Transplantation – First in the US Done (December 18, 2008)
Cleveland Clinic’s Connie Culp (May 6, 2009)
The Technical and Anatomical Aspects of the World's First Near-Total Human Face and Maxilla Transplant—an Article Review (December 7, 2009)

Shout Outs

 Updated 3/2017-- photos and all links (except to my own posts) removed as many no longer active. and it was easier than checking each one.

Dr. Ottematic is this week's host of Grand Rounds. You can read this week’s edition here (photo credit).

The end of the year is a time of reflection. We look forward to the years to come and look backwards, pondering our triumphs and tragedies. And, if you are anything like me, you might also look behind the dryer for that missing sock.

In late December, the tradition is also to formalize our best intentions for the future, even if we know the process is futile. Though considered nearly a pointless exercise, with failure resulting in an even worse state than before we started, we make these resolutions annually. So, onto the blogs, grouped according to some of the classic New Year’s resolution themes.

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Kim, Emergiblog, is the host of the latest edition of Change of Shift (Vol 4, No 13) !   It is the “Merry Christmas” edition.  You can find the schedule and the COS archives at Emergiblog. (photo credit)

It’s Christmas Eve and time for a new Change of Shift!
Between the hustle and bustle of the holiday rush (and the ending of fall semesters), the nurses of the blogosphere put fingers to keyboard and busted out a joyful Change of Shift!
Grab an Egg Nog (spiked, of course), and settle in for some nursing stories!

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H/T to @EvidenceMatters for the link to this WSJ article:  A Downside of Organ Donation by Laura Landro (photo credit)

Most transplants do indeed save lives. But as demand grows for donated organs and tissues, so do concerns about the risk of disease transmission, including deadly bacterial infections and viruses, tuberculosis, rabies, parasites and even cancers. Some experts are calling for better testing and tracking of organ donors in order to limit the number of infections, though others warn that this could have the effect of delaying transplants, producing false-positive results that would eliminate safe organs and adding costs to the health-care system.

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The “downside of organ donations” has prompted a re-exam of transplantation rules.  Denise Grady reviews this topic in the NY Times article:  Officials Re-examining Organ Transplant Rules

……….The case highlights the lack of a national policy on whether to bar people with poorly defined neurological disorders as donors. For now, the decision is up to individual transplant centers, said Dr. Michael G. Ison, ………..

Dr. Kuehnert said he wondered whether there should be a registry for donors who have brain inflammation, or encephalitis, from an unknown cause.

“It would be difficult to say, ‘Don’t ever recover a donor with encephalitis,’ ” he said. “Some may be O.K. But we don’t know how many times it’s a successful operation, and how many times a tragic operation.”

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H/T to @ChrisCoppola and @DrSonnyO  for the link to this CNN article which shows the good outcome of organ transplantation:  Pediatric heart transplant survivor: 'I thank God every day' by Madison Park.

"Not a day or minute goes by where I don't think about how lucky I am just to be here," said Farley of Hasbrouck Heights, New Jersey. "I thank God every day when I wake up that I woke up."

Around Christmas time, 24 years ago, Farley's heart was deteriorating.

Farley was 12 and couldn't walk without feeling exhausted. She'd stop to catch her breath after taking a few steps. During gym class, her lips and fingers turned purple from low blood oxygen levels. She often felt listless, and she had chronic bronchitis and respiratory infections…………

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Margaret Polaneczky,MD, TBTAM, has done an exception job explaining The New Mammogram Guidelines - What You Need to Know

Unless you've been living on another planet, you know that in mid-November, the US Preventive Services Task Force released new recommendations on screening mammography, in which they recommended against routine mammogram screening in women under age 50, and recommended that mammograms now be every two years in women ages 50-74.

What you may not have heard is that the Task Force has acknowledged that the mammogram guidelines were poorly worded, and have revised their original statement to clarify their intentions, mostly by removing those two little words "recommends against"…………..

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The Diane Rehm Show rebroadcasted their show on the "goat gland man” John Brinkley yesterday morning.  Brinkley was an amazing charlatan who was born in North Carolina, but much of his medical career was spent in Arkansas.  Her guest on the show is Pope Brock talking about his book on Brinkley:  Charlatan: America’s Most Dangerous Huckster, the Man Who Pursued Him, and the Age of Flimflam.   You can listen to the show here.

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The Dr Anonymous’ show this week will be New Year’s Eve, 10:30 pm ET.   

Upcoming Dr. A Shows (9pm ET)
1/2 : Saturday Night w/ Dr. A
1/5 : Maybe Tuesday Night Show
1/7 : Maybe Thursday Night Cancelled
1/9 : Saturday Night w/ Dr. A

When Does Death Start?

Updated 3/2017-- all links (except to my own posts) removed as many no longer active. and it was easier than checking each one.

H/T to @ctsinclair and @doclake  for the link to this December 16th NY Times article.  If you haven’t read it, it is worth the time, especially if you have any interest in this topic.

When does death start? from NYT http://bit.ly/8xGXjL

The article, "When does death start?",  was written by Darshak Sanghavi, the chief of pediatric cardiology at the University of Massachusetts Medical School, is Slate’s health care columnist and the author of “A Map of the Child: A Pediatrician’s Tour of the Body.”

The article uses the story of Amanda to discuss “brain death” and “death after cardiac arrest”  in conjunction with organ procurement.   No organs can be procured until a person has been declared dead (the so-called dead-donor rule). 

The question of “when does death start?” comes from the 5 minute of no heart activity after cardiac arrest.

In procuring organs from patients like Amanda, doctors have created a new class of potential organ donors who are not dead but dying. By arbitrarily drawing a line between death and life — five minutes after the heart stops — they have raised difficult ethical questions. Are they merely acknowledging death or hastening it in their zeal to save others’ lives?

The article takes the reader through the history of transplantation and the need to define “when death starts.”

Henry Beecher, a Harvard anesthesiologist and medical ethicist, convened a 13-member committee to write a definition of “irreversible coma,” or brain death, for The Journal of the American Medical Association.

President Jimmy Carter asked a blue-ribbon commission to examine the issue. The commission culminated in the Uniform Determination of Death Act in 1981, which defined death as “irreversible cessation of all functions of the entire brain, including the brainstem.”

The 1981 Uniform Determination of Death Act also defines death as the “irreversible cessation of circulatory and respiratory functions,” which left an opening for another source of donors.

In 1987, the nation’s pediatrics authorities tried to standardize the diagnosis, listing 14 different criteria to confirm brain death, like the absence of reflexes, and requiring, under certain conditions, additional X-rays and tests for brain-wave activity.

In 1997, the federal government asked the Institute of Medicine, an independent advisory body, to gather experts to determine how a dying donor might be treated. The experts ended up endorsing the procedure for donation after cardiac death, in which death occurs through a process of withdrawing life support and allowing the heart to develop “irreversible cessation.”

In 2004, pediatric cardiologist Mark Boucek at Denver Children’s Hospital, financed by a federal grant,  wrote a far more aggressive D.C.D. protocol that would save the heart, which was adopted after going through the hospital’s review process. His version …..most controversially, rejected the five-minute rule imposed by the Institute of Medicine and initially picked three minutes instead.

David Campbell, the pediatric cardiac surgeon at Denver who procured the first heart using the (Boucek) protocol, realized that even three minutes was too long. ….. In reviewing the medical literature, Boucek found the longest recorded time that a heart had ever stopped and then spontaneously restarted without medical intervention was 65 seconds.

The article goes on to discuss the current needs for organ donation.  It is estimated that at least 18 people on the transplantation list die each day before the needed organ becomes available.  This need makes the need for an answer to the question of “when does death start?’ extremely important.  The answer could increase the availability of viable organs.

The Institute of Medicine created a new class of potential organ donors: living patients with little hope of recovery who could be declared dead soon after life-support removal. Within a decade, the number of such donors increased tenfold; they now account for 8 percent of organ transplants nationwide, up to 20 percent in certain areas. Still, many hospitals were slow to adopt the practice.

Medical Spa Regulations

 Updated 3/2017-- all links (except to my own posts) removed as many are no longer active and it's easier than checking each one.

As mentioned yesterday*, the “throw away” journal, MedEsthetics, has had a couple of nice articles recently.  I looked at the first one yesterday, Medical Lasers and the Law, and today will look at the second.  I am impressed with the Massachusetts Task Force and would love to see these same findings implemented in my state.

The second article looked at how state officials are struggling to address the need for appropriate regulations governing the use of laser and light technologies in medical practices, laser centers, and medical spas.  The article reviews how the Massachusetts Legislature asked their Board of Medicine to convene a task force to study and draft some standards and regulations.  They wanted these to cover not just the use of laser and intense pulsed light devices, but also microdermabrasion, chemical peels, soft tissue fillers, sclerotherapy, BOTOX injections, etc.

Massachusetts Medical Spa Task Force represented everyone:

• Representatives from the Boards of Medicine, Nursing and Cosmetology
• Two ranking members from the state Legislature (one from the House and one from the Senate) with experience in the public health sector
• Four physicians – one internist, one plastic surgeon, and two dermatologists
• One nurse
• One registered electrologist
• One consumer

The Medical Spa Task Force gather information from their state and others on current regulations, practices, and safety concerns.  They reviewed relevant national standards.

Representative from the Boards of Medicine, Nursing, Cosmetology and Electrology provided overviews of permitted practices and related education and training requirements.  Industry representatives provided input on the medical spa marketplace and the training of estheticians.  Finally, concerns related to patient safety were identified by a physician from a leading dermatological association and a 2007 survey of American Society for Dermatologic Surgery members, which reported a steady increase in complications caused by non-physicians performing aesthetic procedures over the past five years.

Three big questions were focused  on for the proposed regulations:

• Who should perform medical spa services?
• What services should be offered and how should they be regulated?
• In what environment should these services be provided?

The Task Force developed a three-tier classification system which considered the level of risk, type of supervision needed, and training requirements.

Level I Procedures are noninvasive and demonstrate low risk.  LED therapy and microdermabrasion are examples of procedures at this level.  Since Level I procedures are not considered the practice of medicine, they are overseen solely by the Board of Cosmetology.

Level II Procedures represent a moderate level of risk and include nonablative and nonvaporizing lasers, intense pulsed light devices and radiofrequency devices.

Level III Procedures are the highest level of risk and include ablative and vaporizing devices, chemical peels, and the use of injectables.  Procedures performed using Level III devices can only be administered by a physician. 

Facilities providing Level II and III procedures would require a medical spa license.

Another goal of the Task Force was to look at the appropriate supervision of medical spa procedures.  Existing regulations often permit physicians to act as medical directors even when they know little about aesthetic procedures  and / or spend little time overseeing the spa personnel.  The Task Force proposed changes to put an end to this.

Medical directors and personnel providing medical spa services must meet certain licensure and training requirements. 

On-site supervision by a qualified healthcare provider would be required for Level II and III procedures.

While the medical director is not always required to be onsite to oversee delegated procedures, he/she must be located within four hours of the medical spa and be present on-site 10% of the time each month for each site supervised.

After grappling with the issues of ownership, the Task Force determined that anyone can own a medical spa, but they must hire appropriate medical personnel for clinical supervision.  It was determined that the Department of Health would be responsible for licensing and inspection of medical spa facilities.  It was determined that individual licensing boards would have jurisdictions over appropriate practiced by their licensees.  It was determined that a separate advisory committee should be created to provide future oversight in this constantly changing field of medical aesthetics.

The article indicated that the participants in the Task Force hope their findings will be introduced as a formal bill in the Massachusetts stat legislature sometime this year.

*Medical Lasers and the Law (March 25, 2009)

REFERENCES

Medical Spa Regulations;   MedEsthetics, Mar/April 2009, pp 14-16; Andrea Nadai, MHP

Arkansas Medical Board:  Arkansas Medical Practices Acts & Regulations (pdf file) – page 57, Regulation No. 22, Laser Surgery Guidelines

Medical Lasers and the Law

 Updated 3/2017-- all links (except to my own posts) removed as many are no longer active and it's easier than checking each one.

The “throw away” journal, MedEsthetics, has had a couple of nice articles recently.  I will look at one today and the second tomorrow.

The first one on the laws governing the use of lasers in a medical practice.   Lasers:  Aesthetic or Medical?  This one discusses and answers the question:  Who can own and operate a laser?

The Food and Drug Administration regulates all medical lasers.  Most efficacious aesthetic lasers are classified as medical devices and , as such, must be owned (or leased) by a physician.  Yes, some medical devices are legally available to other professional, but these are exceptions.

The article points out that the question of who can own a laser is more clear than who can legally operate one.  They point out that a physician can legally delegate the operation of some lasers or light devices to others.  If the physician does delegate, he/she raises a whole litany of other issues.

What is the non-physician treating?  There may be a difference between using a light-based device for hair removal and treating a medical condition.  The law is clear that only a physician or an appropriate allied health provider can make a medical diagnosis.  Diagnosis cannot be delegated by a physician.

This article also covers the “misconception that devices used to treat fat  or cellulite are not medical devices.”    The Endermologie was the original device cleared by the FDA for cellulite reduction.  It is safe to utilize it as a nonmedical device as long as one is careful with the claims made for its effectiveness. 

However, newer generation products that contain light-based components are federally classified as medical devices.

The article continues to discuss the question “Who is performing the treatment?”  This quickly can become a quagmire as the physician gets further away from medical personnel.  Estheticians are not considered medical personnel.  Estheticians are governed by a state board of cosmetology and not by the state medical board. 

While it can be argued that nonmedical staff can perform purely aesthetic procedures, such as laser hair removal or tattoo removal, bear in mind that the devices being utilized are still federally classified as medical devices and their use (and ownership) may be limited by that concept.

Another issue where care is needed is “post-procedure care.”   It should be well known by now that any of the lasers or light devices can cause problems – burns, pigmentation problems, etc.  If a nonmedical personnel is doing the treatment, it must be remembered that she/he can not make the medical diagnosis of the problem (ie burn). 

Nonmedical personnel may make an initial review and listen to the patient’s concerns, but the minute there is any irregularity or subjective complaint from the patient, a physician or appropriate medical provider should be brought in to manage patient care.

I love the last line of this article:

“Owning a laser does not give you the legal right to use it.”

It is important to check your own state’s laws.  It is also prudent to have good written protocols and to utilize medical personnel rather than simple training a “lay person” to save money.
Here  are my state’s guidelines (Regulation No 22, Laser Surgery Guidelines):

Pursuant to Ark. Code Ann. 17-95-202, the practice of medicine involves the use of surgery for the diagnosing and treatment of human disease, ailment, injury, deformity, or other physical conditions.  Surgery is further defined by this Board as any procedure in which human tissue is cut, altered, or otherwise infiltrated by mechanical means, to include the use of lasers.  The Board further finds that the use of medical lasers on human beings, for therapeutic or cosmetic purposes, constitutes the practice of medicine.

Under appropriate circumstances, that being the performing of minor procedures, a physician may delegate certain procedures and services to appropriately trained non-physician office personnel.  The physician, when delegating these minor procedures, must comply with the following protocol:

• The physician must personally diagnose the condition of the patient and prescribe the treatment and procedure to be performed.
• The physician may delegate the performance of certain tasks in the treatment only to trained non-physician personnel skilled in that procedure.
• The physician must make himself available to respond to the patient should there be any complications from the minor procedure.
• The physician should ensure and document patient records that adequately describe the condition of the patient and the procedure performed, and who performed said procedure.

A physician who does not comply with the above stated protocol when performing minor procedures will be considered as exhibiting gross negligence, subjecting the physician to a disciplinary hearing before the Board, pursuant to the Medical Practices Act and the Rules and Regulations of the Board.
History:  Adopted June 5, 1998; Amended June 2, 2005

REFERENCES
Lasers:  Aesthetic or Medical?;   MedEsthetics, Jan/Feb 2009, pp16-19; Padraic B Deighan, MBA, JD, PhD
Arkansas Medical Board:  Arkansas Medical Practices Acts & Regulations (pdf file) – page 57, Regulation No. 22, Laser Surgery Guidelines

Eight Too Many

 Updated 3/2017 -- all links removed as many no longer active and it was easier than checking each one.

I want to begin this post by basing it on “facts” reported in the news (ABCNews, Reuters, LA Times, Times Online):

• single 33 yo mother, self described “professional student”

Nadya Suleman, who describes herself as a “professional student” who lives off education grants and parental money, broke up with her boyfriend before the birth of her first child seven years ago.

• six children, ages 7 yo, 6 yo, 5 yo, 4 yo, 3 yo, and 2 yo twins
• residing with her parents in a three bedroom home 
• single mother’s own mother reports that her daughter used infertility treatments
• recently gave birth to EIGHT babies, 

  The babies were born by Caesarean section nine weeks premature and ranged from 1 pound, 8 ounces to 3 pounds, 4 ounces. The woman was carrying 24 pounds of baby.

• plans to breast feed (or more correctly use breast milk donated by other women to supplement her own)
• source of income  (see above) – education grants and parental money though recently reported

THE single mother of octuplets born in California last week is seeking $2m (£1.37m) from media interviews and commercial sponsorship to help pay the cost of raising the children.

• no mention of her insurance coverage, if there is any

I want to try to avoid the issue of fetal reduction and concentrate on some the other issues I find troubling.  
She seems (evidence is the six children she already has) to have had no need for infertility treatments.  So why did any fertility clinic take her own as a patient?  Were they more greed driven than patient driven?  That is my (outsider) view.
Human females were not made to have litters, and that is what eight babies to me is.  Sorry if I offend someone, but the risk of health issues related to such a pregnancy are multiple and serious: 

• miscarriage, pregnancy-induced hypertension/stroke, preeclampsia, gestational diabetes, acute polyhydramnios, vaginal/uterine hemorrhaging, and preterm labor & delivery.

The preterm labor and delivery is a “given”.    The length of pregnancy is usually 39 weeks for singletons, 35 weeks for twins, 33 weeks for triplets, and 29 weeks for quadruplets.  Generally, once the pregnancy reaches about 32 weeks, the complications associated with premature delivery are significantly reduced. 
Risks of complications to mother from premature delivery (incomplete list)

• Surgical and medical issues related to C-section
• Emotional issues
• Fatigue even if she has enough support

Risks of complication to each baby from premature delivery (incomplete list)

• Inability to breathe or breathe regularly on their own because of underdeveloped lungs
• Feeding and growth problems because of an immature digestive system
• Intracranial hemorrhage (bleeding into the brain)
• Hearing or vision problems related to immature nerves or treatment side effects
• Developmental delay and learning disabilities from brain damage related to immaturity
• Special problems for low birth weigh babies (less than 3.5 lbs)

Who pays for all of this and should we care?
Each one of these babies weighed less than 3.5 lbs.   Lets assume they all live (and I hope they do and that they beat the odds and don’t have any major long-term health issues). 
Median cost for NICU care (29 wk, 58 day stay in 1999) $61, 724 for each baby

The state of California is bankrupt.  The cost of each of these babies just for the first year of life is going to cost the California taxpayer more than I can imagine. 

I agree that the woman has the right to have more children, but I only agree to that IF she has the ability and resources to take care of them at the time she has them (I’m allowing for future unforeseen calamity).  I do not think she or anyone has the right to take money from my pocket that I could use to help my children (if I had any) or my nieces or nephews get their medical care or allow them to go to college.  Nor should I support her children instead of helping out my elderly parent.

Though it appears now from the Times Online that she is attempting to turn the birth of her eight babies into a source of income.  I hope she will remember to pay the hospital and doctors.  I hope she will put money into the continued health expenses these eight preemies will have. 

Although still confined to an LA hospital bed, she intends to talk to two influential television hosts this week - media mogul Oprah Winfrey, and Diane Sawyer, who presents Good Morning America.

Other Blog Posts on This Topic
Fat Doctor – Six and Eight
Medical Quack -- Obsessed with Having Babies?  Update on the Octuplets Story
Survive the Journey --Nadya Suleman's Octuplets -- How Many is too Many?
Dr Rob -- Don’t Forget the Kid(s)
NeoNurseChic – The Ethics of Octuplets
Moof -- Ooooopsie
Dr Cris – Making Babies or Saving Lives


REFERENCES
Multiple Pregnancies, Maternal Risks – Womens Health Channel
Multiple Birth Pregnancy – University of Pennslyvania
Premature Babies – Medline Plus
Premature Births – March of Dimes

The Ethical Challenge and Surgical Innovation

 Updated 3/2017 -- all links (except to my own posts) removed as many no longer active and it was easier than checking each one.

The short articles referenced below make for thoughtful, interesting reading. I had a similar discussion once during an ethics CME course I took. Most there thought that any “change” in an operation was risky and maybe unethical as the surgeon was “not trained” for it. My view point as I tried to explain it, was that like dress-making or tailoring, surgery is based on good skills. If I know how to put in a zipper or do a collar or do button-holes well, then you can put all those together to do more than just make a dress. I should be able to put those skills together to make a suit coat. That simple example opened (didn’t necessarily change) up the minds of most there.

That example is way too simple and there do need to be ways to make sure that surgeons who left their residency PRIOR to learning a technique that came along ten years later (laproscopy is a great example) have properly learned the technique prior to being given hospital privileges. What is the learning curve? Who should oversee them while they do their first six or ten or twenty cases? What if they are the first in the community to learn the skill (went to the university and took a week long course)?

Here are some short bits to entice you. This is from Dr Clayman.

The challenge for the surgeon as a creative being is that unlike all other arts, the surgical medium is sensate. Every alteration in a tried-and-true technique
exposes both the surgeon and patient to censure and unknown complication, respectively…….

The question arises, at what point along the creative continuum does a minor variation on a theme become an innovation? When does the surgeon-scientist need to ask or request a panel of peers to review an idea or concept and judge it—seeking permission prior to performance? How well equipped is the average institutional review board (IRB) panel, all too often composed of a minority of surgeons, able to pass judgment? ………….

The surgeon today, through technology, seeks to accomplish a surgical cure while lessening surgical
morbidity, hence the advent of minimally invasive surgery. However, as the incision wanes, the technology waxes and thus the surgeon must now enter a realm unfamiliar, that of the medical industrial
complex. While the surgeon is thinking less pain, quicker convalescence, better cosmesis, the industrial
side of the partnership is evaluating potential profit/loss, marketability and expense of development. In this light, it is essential that the IRB stand between the innovator and the patient, just as the FDA now stands between industry and the patient….

In this regard the sage advice of Dr. Agich bears repeating: “We need a well-grounded set of criteria to differentiate at least three types of cases: routine or
normal variation; innovation that is beyond routine, not formal research, yet requires review; and innovation that involves research and so requires formal IRB review.”

However, as with most gradations, the extremes are obvious (one and three), it is the middle ground (two) that provides the greatest challenge and concern…….

Both articles are worth reading and discussing.
REFERENCES
Dialogue: The Ethical Challenge Posed by Surgical Innovation by Ralph V Clayman, MD with Response by George J Agich, PhD; Lahey Clinic Journal of Medical Ethics, Fall 2008, Vol 15, Issue 3, pp 6-7 (pdf file)
The Ethical Challenge Posed by Surgical Innovation by George J Agich, PhD; Lahey Clinic Journal of Medical Ethics, Spring 2008, Vol 15, Issue 2, pp 1-2 (pdf file)