SurgeXperiences 221 – Call for Submissions

Updated 3/2017-- all links (except to my own posts) removed as many no longer active.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 is a change* in hosting for the next SurgeXperiences.  Edition 221 will now be hosted by me. The edition will be published on April 19th rather than April 12th. The deadline for submissions is midnight on Friday, April 17th.  Be sure to submit your post via this form.

SurgeXperiences is a blog carnival about surgical blogs. It is open to all (surgeon, nurse, anesthesia, patient, etc) who have a surgical blog or article to submit.

Here is the catalog of past SurgeXperiences editions for your reading pleasure. If you wish to host a future edition, please contact Jeffrey who runs the show here.

*updated April 6, 2009

Funtastic Baby Quilt

My husband has a friend who’s wife is pregnant with their first baby. He asked me to make a quilt for them. I had recently used this pattern for another baby quilt and loved how it came out. So I chose to use it again. The quilt is 42 in X 48 in. It is machine pieced and quilted. Not knowing whether the baby is a boy or girl, I tried to use lots of different colors and points of interest.

Here is a detail photo to show some of the points of interest: a pink elephant, an angel, a lamb, some trees, and some fishing flies.

Here is another detail photo to show more of the points of interest: a wheel, a sign, zebras, a purple camel, and a bird bath.

The young couple live in Texas, so I decided it was okay to use this lovely fabric even if the baby turns out to be a girl. I hope they agree.

Complications After Autologous Fat Injections to the Breast – an Article Review

Updated 3/2017-- all links (except to my own posts) removed as many no longer active.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

I reviewed a couple of articles on fat injections to the breast back in November.  Now I’ll like to review an article published in the January issue of the Journal of Plastic and Reconstructive Surgery  (PRS).  The full reference for the article is listed below.

The authors began by pointing out that autologous fat injection (fat grafting) to the breast has a history of being performed widely throughout the twentieth century, but  in 1987, the American Society of Plastic and Reconstructive Surgeons indicated that because of the side effects (i.e., tissue scarring, oil cysts, and calcification), autologous fat grafting to the breast might compromise breast cancer surveillance and should therefore be prohibited.  Most plastic surgeons stopped performing the procedure.  There were a few who continued to do the fat grafting to the breast and have published their results (several references given in this articles reference list).  As mentioned in the previous post, there are currently two clinical trials being done by Dr Scott Spear and Dr Roger Khouri. 

For any woman interested in being in one of the two clinical trials, you can find the information on the federal clinical trials Web site.

The authors had noticed that many of these breast augmentation procedures done using fat grafting are “performed incorrectly by untrained and untutored individuals.”   The paper was written to report on several cases of complications and to discuss the related issues.

The report is retrospective and involved 12 patients seen between 2001 and 2007.  The mean age of the women was 39.3 years.  All  the cases involved fat injections to the breast for cosmetic augmentation mammoplasty. The period from fat injection surgery to presentation ranged from 6 months to 6 years (mean, 3.25 years).   All of them presented with palpable indurations.  Others presented with pain (3), infection (1), abnormal breast discharge (1), and lymphadenopathy (1).   All patients were subjected to mammography, computed tomography, and magnetic resonance imaging to evaluate the injected fats.

Several cases were presented in detail with patient photos and radiographic photos, such as this one.

Case 2

A 37-year-old woman had undergone bilateral breast augmentation by autologous fat injection at a cosmetic clinic 3 years previously. Her breasts gradually became rigid and deformed, but she had no trouble with daily life. However, after having a child, she noticed an abnormal yellow secretion while breast-feeding. On her first visit to our facility, her breasts were clearly asymmetrical and deformed, and indurations were detected (Fig. 1). On mammography, computed tomography, and magnetic resonance imaging, large masses were detected in both breasts (Figs. 2 and 3). The tumors, which contained yellow fluid (Fig. 4), were removed surgically. Six months after the operation, both breasts were reconstructed with saline implants (Fig. 5). Abnormal breast secretion has not been observed since the masses were removed.

And this one (remember this study was done in Japan and I hope that the use of illegal silicone injection wouldn’t be done here in the U.S.)

Case 12

A 33-year-old woman underwent buttock liposuction and fat injection to the breast at a cosmetic clinic 2 years previously. After the operation, she became aware of indurations and disfiguration of both breasts and visited our facility. Asymmetry of the breasts and huge indurations were palpable (Fig. 18). On preoperative blood examination, high levels of antinuclear antibodies were detected. On mammography, huge masses were detected in the subcutaneous tissue (Fig. 19). Chest computed tomography revealed multiple low-density areas encapsulated with high-density areas in the subdermis in both breasts. Magnetic resonance imaging indicated multiple injected fat with high-iso signal intensity on T1-weighted images and low signal intensity on T2-weighted images (Fig. 20). Surgery to remove the subcutaneous masses was performed. Our routine examination for foreign bodies using nuclear magnetic resonance detected a small amount of silicone contamination. This suggests that the high levels of antinuclear antibodies in the blood may be the result of an immunologic reaction to silicone (human adjuvant diseases). These observations suggest that the patient had been injected with silicone at the time of surgery without her consent.

They give a very nice discussion of fat injection which includes some history

It appears that fat injection was first performed in 1893, when the German physician Franz Neuber9 used a small piece of upper arm fat to build up the face of a patient whose cheek bore a large pit caused by a tubercular inflammation of the underlying bone.

and continues to remind the reader of the virtual moratorium imposed in 1987, American Society of Plastic and Reconstructive Surgeons when the society recommended that autologous fat grafting to the breast be prohibited because of the relatively frequent occurrence of complications that compromised breast cancer screening.   They point out that this has resulted in little scientific literature or discussion on the procedure. 

As a result, there remains a dearth of studies examining the long-term safety and efficacy of this technique. This technology, especially with regard to its use in breast augmentation, must be tested by multi-institutional long-term studies with careful breast cancer surveillance.

They make the valid point the procedure continues to be performed even without good long-term outcome studies.

We believe that this has resulted in many victims, who are exemplified by the 12 patients that we have described in this article. The problems associated with this inadequately tested procedure are also exacerbated by a widespread decline in the skills of aesthetic surgeons because of the influx of many untrained and unskilled individuals, especially in some Asian countries, including Japan.

The complications associated with autologous fat grafting to the breast are well known, and include calcifications and oil cysts.  These calcifications may mask or cover the microcalcifications associated with carcinomas.  Remember fat grafting is “grafting” and there can be fat necrosis.

I admire their conclusions paragraph:

Autologous fat grafting to the breast is not a simple procedure and should be performed by well-trained and skilled surgeons. Patients should be informed that it is associated with a risk of calcification, multiple cyst formation, and indurations, and that breast cancer screens will always detect abnormalities. Patients should also be followed up over the long-term and imaging analyses (e.g., mammography, echography, computed tomography, and magnetic resonance imaging) should be performed.

Previous Post on Topic
Fat Injections for Breast Augmentation (November 6, 2008)

REFERENCE

Complications after Autologous Fat Injection to the Breast;  Plastic and Reconstructive Surgery:Volume 123(1)January 2009pp 360-370; Hyakusoku, Hiko M.D., Ph.D.; Ogawa, Rei M.D., Ph.D.; Ono, Shimpei M.D.; Ishii, Nobuaki M.D.; Hirakawa, Keiko Ph.D

Fluorouracil Treatment of Problematic Scars – an Article Review

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

I’d like to review this Plastic & Reconstructive Surgery article on using fluorouracil for the treatment of keloids. The full reference (first article listed) is given below. First, a little background on keloids and hypertrophic scars.

Keloids and hypertrophic scars are challenging to treat. Both are benign growths of dense fibrous tissue that develop due to an abnormal healing response to a injury to the skin. A keloid by definition extends beyond the original borders of the wound or inflammatory response. A hypertrophic scar remains within the original boundary. Both are frequently symptomatic. Patients often report tenderness or pruritis.

There are many proposed mechanisms for abnormal scar formation. These include altered growth factor regulation, abnormal collagen turnover, familial genetic predisposition, and immune dysfunction. Although progress has been made in understanding scar pathophysiology, the exact pathogenesis is still unknown.

The response to any accepted scar treatment runs the gamut from minimal to complete. The most commonly used treatment modalities include intralesional steroid injection, surgical excision, cryotherapy, laser therapy, radiation therapy and the application of silicon gel sheets.

Most evidence for these modalities is based on smaller studies that employed little or no placebo control nor blinding of participants or researchers. As the authors of the first article (the one to be reviewed) point out:

Beyond the litany of treatment options, another obstacle in the scar literature is a lack of uniformity in reporting clinical results. This makes extrapolating from or comparing studies difficult. Many authors quantify treatment outcome using a visual appearance rating scale. Other outcome measurement options include symptom relief and direct scar size measurement. Qualitative descriptive scales are available for scars but are far from being widely accepted

And as the authors of the Medscape article point out:

A recent meta-analysis of 39 studies, representing 27 different treatments, reported a 70 percent chance of clinical improvement with any type of treatment.^[34]Therefore, it is possible that current treatments may not have any significant effect on clinical improvement. Based on emerging information on keloid pathophysiology, there is a need for further studies in order to develop better therapies for pathologic scarring.

Now for the article review. The authors stated that after noticing anecdotal reports suggesting low-dose intralesional fluorouracil could be used for treating undesirable scars, they decided to do a prospective case series. As noted above, we need prospective, well designed studies to truly define the best treatment of these scars.

Their method included both keloid and hypertrophic scar patients. Note the small number of patients in the study:

Keloid patients underwent excision followed by a series of treatments with intralesional 5-fluorouracil into the healing scar to prevent recurrence (n = 32).

The hypertrophic scar patients were treated with the same series of injections without scar excision to both control symptoms and improve scar appearance (n = 21).

The primary outcome measures were scar volume and a symptom questionnaire.

Patients were followed for 1 year after completing the injection treatments.

Only patients who had failed corticosteroid therapy were entered in the study. Some had failed other conventional treatments for abnormal scars (ie excision, radiation therapy, topical silicone, and/or pressure therapy). They did not include a control group because “we felt it was unethical to offer patients who had previous failed corticosteroid treatments the potential of the same treatment that did not help them the first time.” I’m not sure I agree with them as the control patients could have received “delayed” treatment in the interest of a better scientific study.

Treatment

Keloid Group (Group 1) patients had their scars excised and primary repair of the defects. Each patient received a total of 10 treatments at least a month apart. If any reaction or infection was identified, no treatment was performed at that visit. The patients returned weekly until the adverse reaction resolved at which time the injections were resumed.

Hypertrophic Scar Group (Group 2) patients did not require excision of the scar. Therefore injection treatment was started after the baseline documentation was obtained.

Baseline documentation included completion of a symptom questionnaire and vinyl polysiloxane molds. Symptom assessment and polyvinyl molds were repeated at the completion of the injection protocol (11 months after the baseline scar documentation) and again at the 1-year posttreatment follow-up

Because of the off-label use of 5-fluorouracil for the treatment of scars, time was spent explaining the indications, techniques, alternatives, benefits, and risks of the therapy. This was reinforced to the patients at each of the 10 injections in the treatment series.
Each treatment involved intralesional injection of 50 mg of 5-fluorouracil (50 mg/ml; American Pharmaceutical Partners, Inc., Schaumburg, Ill.) and 10 mg of lidocaine 1% (Hospira Worldwide, Schaumburg, Ill.).
For most of the scars, the medication was distributed evenly throughout the scar or the healing incision for the keloid group.
For large hypertrophic scars, the medication was injected into the most symptomatic part of the scar at that particular visit.
Treatments were continued until the maximum dose of 500 mg (10 injections) was reached.

Results
Their definition of recurrence was any visible evidence of scar growth. “It did not mean the scar returned to preexcision size or that the patient was dissatisfied with the result.”
In the keloid group, there were no recurrences during the course of the treatment, but there were six (6 / 32) at 1 year follow-up. This represents a success rate of greater than 80% at one year. The literature reports a success rate of 75 – 95 % for radiation combined with excision.
Of the hypertrophic scar patients, 86 percent had symptom improvement which was maintained for 1 year after treatment. More than one-third had complete resolution of the symptoms. Median scar volume reduction was 40 percent in this group.
I find this article interesting, but am not ready to begin using 5-fluorouracil prior to the tradition treatment courses. As the authors point out,

One weakness of the study is the length of follow-up. Although most studies do not report results longer than 1 year after treatment, it is clear that keloid recurrence can occur years later.

REFERENCE

Fluorouracil Treatment of Problematic Scars; Plastic and Reconstructive Surgery:Volume 123(1)January 2009pp 139-1485; Haurani, Mounir J. M.D.; Foreman, Kenneth M.D.; Yang, James J. Ph.D.; Siddiqui, Aamir M.D. (need subscription for access online)

Keloids: Pathophysiology and Management; Medscape Online Article, Posted 08/23/2007; David T. Robles MD PhD; Erin Moore; Michelle Draznin MD; Daniel Berg MD

Shout Outs

 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. 

Paul Levy, Running a Hospital, is this week's host of Grand Rounds.  It is a the “when things go awry” edition.  Read it here.   

Welcome to this week's edition of Grand Rounds, the weekly rotating carnival of the best of the medical blogosphere. (The host next week is Leslie at Getting Closer to Myself.) Our theme draws on my desire to encourage greater transparency in the delivery of clinical care. In the spirit of Dr. Ernest Codman, I asked doctors, nurses, and other providers to write about incidents in which they made or were present for a medical error. What were the circumstances, and what did you do in response to the situation? How did you feel about the event, and how did it change your practice of medicine afterward

What is acceptable dinner conversation?  Well, we doctors don’t always seem to know.  Check out this nice post by Artemis “No Mom, Billy Doesn’t Want to Stay for Dinner”

I looked up from my plate to see three faces staring at me in horror. Mouths agape, eyes wide, silverware down; my family finally burst out as one: “That’s revolting!

A plea from “A Chance to Cut is a Chance to Cure” who has returned to blogging.

Now if Grunt Doc will only take me off the dead blog list.

“In Case of Emergency:  How to Be Prepared for the Unexpected”  is the beginning of a series that will provide a look at a patient’s trip through the “unexpected emergency”.    Be sure to watch the video that accompanies the post.

During the next two segments, I will take you way behind the scenes and give you tips on how to be prepared in case the unexpected happens and you end up on your way to an emergency room.  This week I play the part of a patient with chest pain and take you inside a New York City ambulance with paramedics Ray Cordi and Hanan Cohen.  Next week my colleague, Richard Schlesinger, and I continue your tour inside the emergency room at New York Presbyterian Hospital/Columbia University Medical Center, the first time this institution (where I am on staff) has ever allowed such inside access to the media.

I participated in the first two “Another Little Quilt Swap” rounds.  I am still deciding about this next one as it leans more to “Art” quilts.  It would force me out of my comfort zone, so maybe I will.  We’ll see.  Anyway, anyone interested in participating are encouraged to head over here and read the rules.

This week Dr Anonymous’ guest will be Victoria Powell whose blog is VP Medical .   She is a nurse who lives in Benton, Arkansas.   Check out her post “I am a Nurse” which tells how she became one.  The show begins at  9 pm EST. 

Happy Doctor’s Day

 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.

History of Doctor's Day

The first Doctor's Day observance was held on March 30, 1933, by the Barrow County Alliance, in Winder, Georgia. Eudora B Almond, the wife of Dr Charles B Almond, conceived the idea of setting aside a day to honor physicians. The day set for the recognition occurred on the anniversary of the first administration of anesthesia by Dr. Crawford W. Long in Barrow County, Georgia, in 1842. 

This first observance included the mailing cards to the physicians and their wives, placing flowers on graves of deceased doctors, and a formal dinner in the home of Dr. and Mrs. William T. Randolph.

The full history of how it went from a locally observed day (1933) to a national observed day (1990) can be found here.

Through the years the red carnation has been used as the symbol of Doctors' Day.
Meanings of the Carnation Flower : Fascination, devoted Love
Deep Red Carnation : My heart aches for you or I admire you

Happy Doctor's Day to all of you!

SurgeXperiences 220 is Up!

  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.

This edition (220) of SurgeXperiences is hosted by Jeffrey, Vagus Surgicalis. He’s the one who began and keeps this blog carnival going. You can read this edition here.

To a medical student like me, the field of surgery is very intriguing, to say the least. The daily working life of a surgeon, or even that of a surgical trainee, can be jam-packed full of action, blood, guts and gore. Dull moments in surgery are hard to come by. Surgeons are able to test their hypotheses and see rapid, graphic results from their work. Students are often awed by this process. What also draws me to surgery is the immense satisfaction of being able to completely excise a cancer (hence providing a definitive cure), or relieve the pain of an intra-abdominal catastrophe, e.g. perforated appendix.

The host of the next edition (221), April 12th will be Lisa from InsideSurgery.com. The deadline for submissions is midnight on Friday, April 10th. Be sure to submit your post via this form.

SurgeXperiences is a blog carnival about surgical blogs. It is open to all (surgeon, nurse, anesthesia, patient, etc) who have a surgical blog or article to submit.

Here is the catalog of past SurgeXperiences editions for your reading pleasure. If you wish to host a future edition, please contact Jeffrey who runs the show here.

Alzheimer Donation Quilt

 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.

I learned about this initiative from two places:  the Quilting Gallery and Jude (Spirit Cloth).  

The Alzheimer’s Art Quilt Initiative (AAQI) is an Internet-driven, grassroots, totally volunteer effort to raise awareness and fund research through art.

It has taken me quite a while to get around to doing one for them.   The requirements for one of the donation quilts

mini art quilts in any theme

with a maximum size of just 9" x 12" (so that it fits a USPS Priority Mailer without folding)

Auctions are held during the first 10 days of each month.  All profit is used to fund Alzheimer's research.
This project is ongoing.

We welcome your quilt at any time.

In the later part of February I got one finished, registered, and mailed.   Here it is.  It is a whole cloth quilt that I hand quilted.  It is 8 in X 11.5 in.  If you want to bid on it, it is quilt #3528.

I used the “quick triangle” method for the “sleeve” to allow hanging.  I will use this method again on small quilts.

This link gives you the instructions and some good tips on binding and making a sleeve for the small quilt.

I made a second one and mailed it to my friend Herbie Krisle.  She runs an adult day care for people with Alzheimer’s (Page Robbins Adult Day Care).  I learned recently that part of her responsibility is raising several hundred thousand of dollars each year to keep it running.  She has several quilters in her community that might help her get their own up and running as a way to raise money.  If not, then she’ll have it for her own wall.

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

Shout Outs

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

Code Blog is this week's host of Grand Rounds.  It is a really “grand” edition.  Read it here.   

Welcome!  This is fifth time I’ve hosted Grand Rounds here at code blog.  Although my previous four attempts were fairly creative, I decided to keep this edition simple.  All submissions were included - if you do not see yours here, I did not get it for some reason!

The first post is one that I immediately balked at even including because the opening paragraph sounded absurd to me.  But the more I read, the more I realized there were some good points and it quickly became one of the more intriguing posts submitted.  Head over to Duncan Cross to read Don’t Walk and find out why research/fund-raising organizations are not as helpful to those they purport to assist as we’d like to think.

The latest edition of Change of Shift (Vol 3, No 19)  is hosted by none other than Kim, Emergiblog!    I hope you will check it out.  You can find the schedule and the COS archives at Emergiblog. 

Welcome to the Emergiblog version of Change of Shift!

It’s been a while since I have hosted, and it’s fun to check out the posts as they arrive! Oh who am I kidding, I wait until almost the last minute!

Check out the calendar, if you are interested in hosting our esteemed carnival there are openings available.

Send me a postcard, drop me a line…all together now….and let me know what date you would like to host!

Check out this post over at Better Health:  Neuroticism Versus Hypochondria: Dr. Jon LaPook Explores The Differences

In this week’s CBSdoc.com video, Dr. Jon LaPook conducts a two-part interview with a colleague who thinks he might be a hypochondriac.

H/T to Cathy who twittered this link

A computer programmer who lost half his finger after his motorbike crashed into a deer has had the finger replaced with a USB drive.

A Respository of Bottled Monsters links to an article that used their photos from the Civil War.

Michael Hughes called in the other day and mentioned an article he wrote on Civil War ophthalmology that he used some of the museum's pictures in - Eye Injuries and Prosthetic Restoration in the American Civil War Years

The  Literature, Arts, and Medicine Blog has a nice post on the “Ethics and Aesthetics:  Photographing Patients.”   Here is a small exert:

At first, I started taking Polaroids to help inform the medical history. We are a group practice and often care for each other’s patients over the phone, and in such a setting a photograph can be an invaluable aide in medical decision-making. The photos also helped me recall my patients when I was new on the job. I didn’t think twice about the propriety of taking these pictures, they were an invaluable part of the medical record and were only used as such. The consent form was signed as a bureaucratic formality.

Almost immediately, I started to appreciate the Polaroids aesthetically. There was something touching in my patient’s expression, something timeless in the corners of the room that were visible in the background. I found myself composing the images deliberately; I tried to include a colorful quilt, a glowing Christmas tree, a stuffed animal collection.

Peggikaye Eagler is a MDA's MOST WANTED CITIZEN!  She needs your help to “get out of jail.”  The money raised is for the Multiple Dystrophy Association.

If you know me, if you're a friend of me ... then you've been touched in some way by one of these 40 neuromuscular diseases. I cannot imagine how different my life would be without the research and services that the MDA has provided for those of us with Myasthenia Gravis. I know for sure, they have made a difference, both in my health, and my learning about the disease when I first got sick. PLEASE give to MDA so other families can benefit from their desperately needed services!

This week Dr Anonymous’ guest will be Brandice as they talk about Podcamp Ohio.   The show begins at  9 pm EST. You can check out the archives of his Blog Talk Radio show.   

Be a Potential Hero – Learn CPR

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. 

Earlier this month the Arkansas Legislators passed a bill to put AED devices in all public schools in our state. The bill was sponsored by Senator Tracy Steele. It is estimated that about $1 million dollars will be needed to pay for the devices. The money is expected to come from the recently passed increased tobacco tax (an extra 56 cents per pack).

The Antony Hobbs III Act was named in honor of 17 yr Parkview High School basketball player who died after collapsing at a game. He died of complications from an undiagnosed heart defect.

I renewed my ACLS this past Thursday evening. Some of my nurse friends ask me to go with them as a way of getting together. They needed to recertify and assumed I might. We meet for dinner before the class and enjoyed the time together.

During the evening, the EMT who reviewed the AED devices with us mentioned having responded to the collapse of Antony Hobbs. He wanted to stress the importance of knowing basic CPR and BLS as most arrthymias are not shockable. He ask if we wanted to guess how many people at the basketball game attempted to help.

Can you guess?

When the crowd was asked if there were any medical folks there, one nurse stood up and responded. None of the teachers, coaches, parents responded “I know CPR. Can I help?”

I found that sad. CPR is much more important in most life situations than ACLS. I would like to encourage all to learn CPR. Even if the AED finds a shockable rhythm, the recommendation is a minimum of 2 minutes of good quality CPR immediately after the shock even if a normal rhythm is seen.

So having the AEDs in airports, in schools, at your work place does not replace the need for CPR. We all need to know how to do good quality CPR. It is the CPR that is most likely to save some one.

It is easy to find classes. Look to your local Red Cross chapter. They have classes on a regular basis to teach basic CPR and AED use. Or contact a group like America First Response.

Get your entire family to take the class. Learn CPR --you might end up being a hero.

Sources

Arkansas Online

Red Cross CPR Classes

American First Response