Safe Medical Waste Disposal

Updated 3/2017 -- all links removed (except to my own posts) as many no longer active.

All medical offices must dispose of medical waste in a safe manner.  I closed my office at the end of September, but my last medical waste pickup is the first Friday of December.  My dear husband is going to open the office and wait for them.

How have you told patients over the years to deal with their medical waste?  Needles?  Syringes?  JP drains they pull out or that fall out before they get back for follow up? 

Last week the FDA sent out a press release announcing the launch a new website for patients and caregivers on the safe disposal of needles and other so-called “sharps” that are used at home, at work and while traveling.

…….Sharps disposal guidelines and programs vary by jurisdiction. For example, in 2008, California passed legislation banning throwing needles in household trash. Florida, New Jersey and New York have established community drop off programs at hospitals and other health care facilities. People using sharps at home or work or while traveling should check with their local trash removal services or health department to find out about disposal methods available in their area.

For the safe disposal of needles and other sharps used outside of the health care setting, the FDA recommends the following:

DO:

• Immediately place used sharps in an FDA-cleared sharps disposal container to reduce the risk of needle-sticks, cuts or punctures from loose sharps. (A list of products and companies with FDA-cleared sharps disposal containers is available on the FDA website. Although the products on the list have received FDA clearance, all products may not be currently available on the market.)    
• If an FDA-cleared container is not available, some associations and community guidelines recommend using a heavy-duty plastic household container as an alternative. The container should be leak-resistant, remain upright during use and have a tight fitting, puncture-resistant lid, such as a plastic laundry detergent container.
• Keep sharps and sharps disposal containers out of reach of children and pets.
• Call your local trash or public health department in your phone book to find out about sharps disposal programs in your area. 
• Follow your community guidelines for getting rid of your sharps disposal container.

DO NOT:

• Throw loose sharps into the trash.
• Flush sharps down the toilet.
• Put sharps in a recycling bin; they are not recyclable.
• Try to remove, bend, break or recap sharps used by another person.
• Attempt to remove a needle without a needle clipper device.

 

For more information:

• Needles and Other Sharps (Safe Disposal Outside of Health Care Settings)
• Improperly Discarded ‘Sharps’ Can Be Dangerous – Consumer Update
• Sharps Flickr Slideshow

Guidelines for Injector in Aesthetic Medicine

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

There is a great article in the “throw-away” MedEsthetics magazine (July/August 2011 issue) written by Padriac B. Deighan, MBA, JD, PhD.  You can read the entire article here (pp 16-20; online issue).   If you employ any practice extenders in your office or run a medical day spa, you will find the article useful.

Deighan categorizes injectables in three ways:  botulinum toxins, dermal fillers, and sclerotherapy.

Botulinum toxins are prescription only drugs which are available to physician offices and via pharmacies, but not directly to non-physicians.  In other words, a registered nurse can inject neurotoxins under physician supervision, but cannot acquire them.

Botulinum toxin injection is considered a medical procedure which should only be provided in a medical setting by a trained and licensed provider (ie physician, registered nurse, nurse practitioner or physician assistant). 

Deighan notes that a medical spa is a medical setting ONLY if it is owned by a physician.  He recommends against Botox parties in patient’s homes, even though a physician can legally provide this service in that setting.

……

Injectable dermal fillers are not prescription drugs, but are medical devices

As such, they are delivered pursuant to the practice of medicine and all state and federal guidelines.  This is a distinction without difference because, although they are not prescriptive, medical devices – as categorized by the United States Food and Drug Administration (FDA) – can only be utilized in a medical facility and delivered to patients by an appropriate medical provider.

Non-medical day spas or even medical day spas without physician supervision should not be injecting dermal fillers.

……

Moving on to sclerotherapy used most commonly to treat leg veins but also other areas.  Sclerotherapy is the introduction of a foreign substance into the lumen of the vein to cause thrombosis and subsequent fibrosis.  The injected solution falls into three types:  Chemical Irritants (glycerin, polyiodinated Iodine), Hypertonic solutions (Hypertonic-saline 11.7%, Hypertonic-glucose), and Detergent sclerosants (Sodium morrhuate, Sodium tetradecyl sulfate, 0.25% -3%, Ethanolamine oleate, and Polidocanol foam, 0.5-5% ).

Deighan states that saline is not considered a medical device or product, but the others are and therefore are subject to medical practice guidelines for the particular state and must be delivered in a medical setting.

…….

Please go read the article for his take  on CMAs (certified medical assistants) and cosmetic medical procedures.  Here’s part of it:

Recently, many CMAs have wrongfully asserted that they are allowed to inject and, therefore, have been injecting botulinum toxins, dermal fillers and sclerosants.  CMAs are marginally trained, non-medical personnel………

It will also be a huge problem in any professional negligence claim, because there will be no coverage for such a loss.  An insurance carrier will not provide a defense or indemnity for any claim related to these procedures. …….

He extends this same stand to “certified” technicians. 

For example, some “certified laser technicians” and their employers incorrectly believe that the designation “certified” elevated their stature and allows them to perform medical services.  Certified Laser Technician, Certified Medical Esthetician, and Medical Esthetician are not categories of medical providers. ……..

Related posts:

Medical Spa Regulations (March 26, 2009)

Medical Lasers and the Law (March 25, 2009)

Sunscreen Graphics

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

Information is Beautiful has a superb post:  The Sunscreen Smokescreen meant to answer the question “How much sunscreen should you wear?”

The full graphic can be found here.  It begins by explaining UVA and UVB rays, goes on to explain SPF (UVA protection) and the star rating (UVB protection),  and protection times avoided by sunscreen.

I cropped out the middle section which is specific to the amount of sunscreen which should be used and how often it should be reapplied.  Not many (if any) of use use enough or reapply often enough.

The lower portion of the Information is Beautiful graph gives info on how cloud cover, reflective surfaces (snow, lakes, etc), and altitude affects the amount of  UVA/UVB radiation.  There is a section on skin cancers and one on the possible harmful effects of sunscreens.

Related posts:

Sun Protection (March 19, 2009)
Melanoma Review (February 25, 2008)
Melanoma Skin Screening Is Important (April 29, 2009)
Tanning Beds = High Cancer Risk (August 3, 2009)
Skin Cancer (March 24, 2010)
Safety of Sunscreens (June 14, 2010)
Dear 16-Year-Old Me (May 18, 2011)

New FDA Sunscreen Labeling  (June 15, 2011)

Shout Outs

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

Hank Stern, Insure Blog, is the host for this week’s Grand Rounds. You can read the “It’s Up to Us” edition here (photo credit).

Our theme this week is "Personal Responsibility" - only posts that address this issue have been included. I was quite impressed with the creativity that potential contributors brought to the table to make sure their posts fit the bill.

We like outside-the-bun thinkers.

The concept of personal responsibility (or accountability, if you prefer) has been a consistent meme here at IB since our earliest days some 6+ years ago. So it seemed appropriate to use that as the theme for this edition of the venerable Grand Rounds:  ……….

……………………………

It’s been very hot here in Arkansas lately.  Here is a great sheet put together and tweeted by the Arkansas Children’s Hosp (@archildrens): “This handy sheet on kids and heat illness is a good primer. Put it on the fridge or leave for a babysitter”

……………………………….

A NY Times article by Andrew Revkin:  On Strokes and (Personal) Sustainability (photo credit)

I have a long list of backlogged posts but am taking a brief break from tracking global sustainability to check my personal operating systems.* A stroke will do that to you.

I summarized one moral of the story below in this Tweet:

Don’t stress your carotid arteries if you like your brain & the things it does for you.

There are other lessons here, one being that stroke is not restricted to what you might call “the usual suspects.” Here’s what happened. …..

……………………………………….

H/T to @EllenRichter for the link to the NY Times article by  @theresabrown:  When Nurses Make Mistakes 

This year, a Seattle nurse named Kim Hiatt committed suicide. Ms. Hiatt’s death came nearly seven months after she had given an unintended overdose to an infant heart patient, a medical error that was said to have contributed to the child’s death days later. ….

This story makes me feel sick — sick for that dead baby and her parents, and sick for Kim, who must have felt so alone with her pain.

It’s a pain that I, and every nurse and doctor, can relate to on some level. We’ve all made mistakes, most of them small and inconsequential to the patient’s health, but sometimes the mistakes are serious……….

………………………….

H/T to @hrana for the link to the Columbia Journalism Review article by Trudy Lieberman: Keeping an Eye on Patient Safety, Part III

Slowly the public is coming to realize that hospitals are not always safe places. …. The series is archived here.

I have just returned from England, where as a Fulbright Senior Specialist I attended a conference of European health journos and participated in meetings with health care academics and government officials. …. At the NHS Institute for Innovation and Improvement I learned about some pretty cool stuff that has found its way into UK hospitals and improved care for patients. ….

One practice that intrigued me was a way to cut down on errors made by nurses when they give patients their meds. Taylor told me that medication errors are a problem in the UK as they are in the US. Any reporter who has spent time examining hospital or nursing home inspection reports knows how frequent they are. Taylor explained that nurses administering medications too often are interrupted, causing them to lose focus and increasing the chance for a deadly mistake. To solve this problem nurses started wearing red pinafores over their uniforms when they gave patients their medicines. That signaled to others not to bother them. “It’s so simple,” said Taylor…….

………………………………

H/T to @sterileeye who tweeted the link to this “beautiful photo project about aging”:  Timeless Memories (photo credit)

A personal journey to find the oldest person in the city of Barcelona.  After weeks of taking photos I thought the search was over after meeting Matilde who is 101. However, the next day I visited another retirement home and after taking a couple of photos I was ready to leave when one of the care takers told me ¨There is a person you should meet before you go, her name is Ana Maria, she is 108 years old and will be 109 in July¨…

…………………………………

An interesting Star Tribune article (H/T @garyschwitzer)  by Michael Nesset: Masterpieces, but only if unmedicated

We could diagnose and heal the human frailties found in literature. But why?

Not long ago, members of my American lit survey class decided that the disturbing behaviors of Herman Melville's Bartleby the Scrivener -- staring out the window at a blank brick wall, preferring not to do pretty much whatever he's asked to do -- were symptoms of clinical depression.

Paxil or Prozac, along with some good counseling, maybe group therapy to help with his peer interactions, was what the poor fellow needed. …..

………………………………………………..

Justine Abbitt, BurdaStyle blog, has written a nice article: Madeleine Vionnet and the Bias Cut  (photo credit)

Madeleine Vionnet was a revolutionary designer for her time; not as universally well known as Coco Chanel but just as influential to the world of fashion. She is credited with creating the bias cut, a technique of cutting on the diagonal grain of the fabric which creates a sinuous and slightly clingy silhouette. The designer regularly had fabric custom made for her as wide as 180 inches to cut her dresses from. …..

If you want to read more on Madeleine Vionnet and her influence in fashion, Betty Kirke wrote a wonderfully comprehensive article for Threads magazine which you can check out here.

Lawn Mower Safety

The power lawn mower is considered one of the most dangerous tools around the home. Each year, more than 74,000 small children, adolescents and adults are injured by rotary, hand and riding power mowers due to improper handling.

Lawn mower injuries include deep cuts, loss of fingers and toes, broken and dislocated bones, burns, and eye and other injuries. Some injuries are very serious. Both users of mowers and those who are nearby can be hurt.

The kinetic energy (motion) imparted by a standard rotary blade is comparable to the energy generated by dropping a 21-pound weight from a height of 100 feet or is equal to three times the muzzle energy of a .357 Magnum pistol. Blade speed can eject a piece of wire or an object at speeds up to 100 miles per hour.

The most commonly injured person is an adult 25-64 (those most often doing the mowing) or a child under age five. About a fourth of all lawnmower injuries (22%) involve the wrist, hand or finger. About 14% involve foot, ankle or toes. Of all the hand and foot injuries, about 25% will result in amputation.

Safety Tips

• As with other power tools and equipment, do not operate a lawn mower when consuming alcohol.
• Wear appropriate clothing: sturdy shoe, not sandal; eye and hearing protection.
• Children should be at least 12-years-old before they operate any lawn mower, and at least 16 years old for a ride-on mower.
• Children should never be passengers on ride-on mowers.
• Young children should be at a safe distance from the area you are mowing.
• Pick up stones, toys and debris from the lawn to prevent injuries from flying objects.
• Use a mower with a control that stops it from moving forward if the handle is released.
• Never pull backward or mow in reverse unless absolutely necessary - carefully look for others behind you when you do.
• Start and refuel mowers outdoors - not in a garage. Refuel with the motor turned off and cool.
• Blade settings should be set by an adult only.
• Wait for blades to stop completely before removing the grass catcher, unclogging the discharge chute, or crossing gravel roads. (As a safety feature, some newer models have a blade/brake clutch that stops the blade each time the operator releases the handle.)

To help educate the public and prevent injuries, the American Society for Reconstructive Microsurgery (ASRM), American Society of Plastic Surgeons (ASPS), and American Society of Maxillofacial Surgeons (ASMS) offer a video, “When Lawn Mowers Attack,” with tips on how to avoid injuries

 

 

REFERENCES

U.S. Consumer Product Safety Commission, National Electronic Injury Surveillance System (NEISS) Online.

Lawn Mower Safety; American Academy of Pediatrics

Keep Your Hands Safe: Follow Lawnmower Safety Tips; American Society for Surgery of the Hand

Lawn mower-related injuries to children; J Trauma. 2005; 59(3):724-8; Abstract

Fireworks Safety Review

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

As the 4th of July approaches, I’ve begun to hear fireworks exploring in my neighborhood.  It’s been dry here, so in addition to the risk of injury to person there is a risk of setting the fields on fire.  I sure hope my neighbors are being responsible.

I hope you will all have a safe and happy July 4th.  Be safe and stay out of the ER.

Please use the following tips:

• Never allow children to play with or ignite fireworks.  A responsible adult should be in charge.
• Read and follow all warnings and instructions. 
• Be sure other people are out-of-range before lighting fireworks. Small children should be kept a safe distance from the fireworks; older children that use fireworks need to be carefully supervised.
• Do not smoke when handling any type of "live" firecracker, rocket, or aerial display.
• Keep all fireworks away from any flammable liquids, dry grassy areas, or open bonfires.
• Keep a bucket of water or working garden hose nearby in case of a malfunction or fire.
• Take note of any sudden wind change that could cause sparks or debris to fall on a car, house, or person.
• Never attempt to pick up and relight a "fizzled" firework device that has failed to light or "go off"
• Do not use any aluminum or metal soda/beer can or glass bottle to stage or hold fireworks before lighting.
• Do not use any tightly closed container for these lighted devices to add to the exploding effect or to increase noise.
• Never attempt to make your own exploding device from raw gunpowder or similar flammable substance. The results are too unpredictable.
• Never use mail-order fireworks kits. These do-it-yourself kits are simply unsafe.

You might also like:

• Fireworks Safety (June 28, 2008)
• Fireworks Safety  (July 2, 2009)
• Fireworks Safety (June 30, 2010)

Surgical Safety Checklists

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

Last week I received the December 2010 issue (pdf, pp 9 - 20) of the Arkansas BCBS Provider’s News. The item that caught my eye was: Blue Surgical Safety Checklist Implementation.

If your hospital or surgery center is looking to implement the use of a surgical safety checklist, then this will be quite helpful.

If you have missed it, the background of surgical safety checklist:

In January of 2007 WHO began a program aimed at improving the safety of surgical care globally. The initiative, Safe Surgery Saves Lives, aims to identify minimum standards of surgical care that can be universally applied across countries and settings.

…. Through a two-year process involving international input from surgeons, anesthesiologists, nurses, infectious disease specialists, epidemiologists,
biomedical engineers, and quality improvement experts, as well as patients and patient safety groups, WHO created a surgical safety checklist that encompasses a simple set of safety standards that can be used in any surgical setting.

….. the checklist, which was officially launched on June 25, 2008, in Washington, D.C. Surgical safety is
now a priority for health care safety and quality improvement.

….

Recently, Stephen Colbert hosted Dr. Atul Gawande who attempted to explained how checklists make flying, surgery and Van Halen shows safer.

…..
From WHO:
Integrated Management for Emergency and Essential Surgical Care (IMEESC) tool kit
WHO Surgical Safety Checklist

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.

Team Work

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.

There’s an article in the Oct 20, 2010 issue of the Journal of the American Medical Association (JAMA) which discusses surgical team training and team work in the operating room.

Most surgeons have crews or individuals in the operating rooms they prefer to work along side.  Things just go smoother.  We work more as a team, more as one.

Why?  Personalities.  Communication styles that work well together.  Skills that compliment.  Each person knows and does their job, not trying to do someone else’s.  Each knowing that even the smallest task is important to the whole.

Ideally, we could create teams like this at all times in the operating room.  In reality, its not so easy.  Change in personnel happens.  Team members get sick, so there is great need for cross-training and flexibility.  Personnel (including surgeons) need to be able to work with these changes.

I know currently the comparison is to racecar teams that change the tires, etc with great efficiency or the aviation industry with their check lists.  While we should learn from these industries, we must not forget that medicine is far more diverse. 

Surgeries are not all the same.  The cars are.

Ask your personnel.  I know OR nurses and scrub techs who detest certain surgeries and try very hard not to be in those rooms.  Some like eye surgeries.  Some like orthopedics.  Some like the laparoscopic cases.  Others do not.  Others even after doing similar cases with you multiple times, never seem to pay enough attention to be able to “anticipate” what comes next.

The really good OR nurses and scrub techs will put aside their distaste for the procedure (or surgeon) and function within the team framework.  Others will let their boredom distract them.

In the racecar industry, the guys changing the tires are thrilled to be there.  Thrilled to be part of it all. 

We should strive to work as a team.  We should each learn our job and give it our best.  Like all teams, there have to be second and possibly third strings for backup when a team member is absent (personal sickness, family illness, jury duty, etc). 

The study’s lead author Dr. James Bagian is a former NASA astronaut.  The VA training took a page from the aviation and the nuclear power industries, which have used checklists and improved communication to reduce risks.  The adoption of surgical team training saw a mortality rates drop from 17 deaths per 1,000 cases to 14 deaths per 1,000 cases.

The Medical Team Training program includes 2 months of preparation and planning with each facility's implementation surgical care team. This is followed by a day-long onsite learning session. To allow surgical staff to attend as a team (surgeons, anesthesiologists, nurse anesthetists, nurses, and technicians), the operating room (OR) is closed.

Using the crew resource management theory from aviation adapted for health care, clinicians were trained to work as a team; challenge each other when they identify safety risks; conduct checklist-guided preoperative briefings and postoperative debriefings; and implement other communication strategies such as recognizing red flags, rules of conduct for communication, stepping back to reassess a situation, and how to conduct effective communication between clinicians during care transitions.

The learning session included lecture, group interaction, and videos. After the learning session, 4 quarterly follow-up structured telephone interviews were conducted with the team for 1 year to support, coach, and assess the Medical Team Training implementation. Follow-up calls were usually conducted with the OR nurse manager or an OR nurse, a surgeon or chief of surgery, and other staff nurses, and administrative support staff also frequently participated.

. 

REFERENCE

Association Between Implementation of a Medical Team Training Program and Surgical Mortality; Julia Neily; Peter D. Mills; Yinong Young-Xu; Brian T. Carney; Priscilla West; David H. Berger; Lisa M. Mazzia; Douglas E. Paull; James P. Bagian; JAMA. 2010;304(15):1693-1700.; doi:10.1001/jama.2010.1506

Improving Teamwork to Reduce Surgical Mortality; Peter J. Pronovost, MD, PhD; Julie A. Freischlag, MD; JAMA. 2010;304(15):1721-1722. doi:10.1001/jama.2010.1542

Safe Pumpkin Carving

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 that time of year again!  Carving pumpkins for jack o’lanterns can be fun, but if safety isn’t kept in mind can also result in cut fingers.

Minor cuts will often stop bleeding on their own or by applying direct pressure to the wound. Most of these cuts and scraps will be minor and can be treated by washing with soap and water initially. After this initial care, keep the wound clean and dry while it heals.

However, if the bleeding continues after 15 minutes or if you lose the ability to move the finger properly (very likely a tendon injury), then seek medical attention at a hospital emergency department.

Rather than treating injuries, let's prevent the injuries.

It is best to keep these tips in mind:

• Carve in a clean, dry, well-lit area.   If your tools, hands or cutting table are wet, this can cause slippage and lead to injuries.
• Always have adult supervision (without alcohol use).  Children under age five should never carve. Instead, allow kids to draw a pattern or face on the pumpkin and have an adult carve. Allow the child to be responsible for cleaning out the inside pulp and seeds. They can use their hands or a spoon for this. Children, ages five to ten, can carve but only with adult supervision.
• The right way to cut.   You should always cut away from yourself in small, controlled strokes. A sharp knife is not necessarily the best tool because it often becomes wedged in the thicker part of the pumpkin, requiring force to remove it. An injury can occur if your hand is placed incorrectly when the knife dislodges from the thicker part or slips.
• Use a pumpkin carving kit.
  Special pumpkin carving kits are available for purchase and  include small serrated saws that are less likely to get stuck in the thick pumpkin. If the saw does get stuck and then becomes free, it is not sharp enough to cause a major cut. Fewer injuries occur with use of carving kits.

Here’s my finished carving

Once carved, it is important to remember to KEEP dogs and cats away from Jack o'Lanterns or lighted candles as they could knock them over and start a fire.

Have a safe Halloween season!