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Dealing With Cyclic Vomiting Syndrome Given How Little Is Known About The Condition

I have been working as an ER doctor for over a decade, and in that time I have come to recognize that there are certain complaints, and certain patients who bear these complaints, that are very challenging to take care of. I’m trying to be diplomatic here. What I really mean is that there are certain presentations that just make you cringe, drain the life force out of you, and make you wish you’d listened to mother and gone into investment banking instead. Among these, perhaps most prominently, is that of the patient with cyclic vomiting syndrome.

The diagnosis of cyclic vomiting syndrome, or CVS, is something which is only in recent years applied to adult patients.  Previously, it was only described in the pediatric population. It has generally been defined as a disease in which patients will have intermittent severe and prolonged episodes of intractable vomiting separated by asymptomatic intervals, over a period of years, for which no other adequate medical explanation can be found, and for which other causes have been ruled out.

That is not much in the way of good literature about this disease entity, which is surprising, because it is something that I see in the emergency department fairly regularly, and something with which nearly all emergency providers are quite familiar. These patients are familiar to us in part because we see them again and again, in part because they are memorable because they are so challenging to take care of.

Some things about the cyclic vomiting patient that pose particular challenges: Read more »

*This blog post was originally published at Movin' Meat*

Criminal Trial For Michael Jackson’s Physician Is Underway

The 2nd degree manslaughter trial of Dr. Conrad Murray, the doctor who attended Michael Jackson at the time of his death June 25, 2009,  is now underway in LA.  The testimony that is taking place is certainly revealing of the last day of Mr. Jackson’s life.  Michael Jackson died of an acute Propofol overdose and the toxicology report also revealed Valium, Lorezepam, Versed, Lidocaine  and Ephedrine in his system.  There were no illegal drugs.

Propofol is used as a powerful anesthetic and is given intravenously.  It is not a drug that would be used outside of a medical facility or hospital.  Versed (Midazolam) is also a drug that is used for conscious sedation for procedures in hospitals.

Dr. Conrad Murray is a cardiologist and served as Michael’s personal physician.  He was trained at Meharry Medical College and did post graduate work at Mayo Clinic and Loma Linda University Medical Center in California.  He studied Cardiology at Read more »

*This blog post was originally published at EverythingHealth*

Anesthesia Medications Automatically Delivered During Surgery

A team of French anesthesiologists has developed an automatic delivery system of propofol and remifentanil, which they recently tested in a multi-center trial involving 196 surgical patients. The researchers reported in Anesthesia & Analgesia that the system, which uses a Bispectral Index (BIS) monitor as a guide, performed better than manual administration:

We have developed a proportional-integral-derivative controller allowing the closed-loop coadministration of propofol and remifentanil, guided by a Bispectral Index (BIS) monitor, during induction and maintenance of general anesthesia. The controller was compared with manual target-controlled infusion.

The controller allows the automated delivery of propofol and remifentanil and maintains BIS values in predetermined boundaries during general anesthesia better than manual administration.

 Abstract in Anesthesia & Analgesia: Closed-Loop Coadministration of Propofol and Remifentanil Guided by Bispectral Index: A Randomized Multicenter Study


*This blog post was originally published at Medgadget*

Propofol: Will It Become Over-Regulated?

I enjoyed NYC Dr. Kent Sepkowitz’s column in Slate the other day — Paging Dr. Feelgood — where he recaps the careers of some celebrity docs and tries to imagine the pathway to enabling addicts. Key part:

In a strange way, I actually stand in awe of these guys. I have taken care of a few celebs in my career, and for me it was an awful experience. If you f*ck it up, you’re toast. Once I took care of a very important person, a person you have heard of and are very interested in, someone you would be shocked to know had the problem—asthma—that I treated him for. Well, almost treated him for. His complaints and his recollection of near death last time he had the identical symptoms so unnerved me that I asked a colleague to assume his care.

But the Dr. Feelgood experiences no such hesitancy… Perhaps it all starts innocently—a rich, famous guy with a tiny problem walks into the office. He can’t sleep at night. He’s so friendly, sincere, not stuck up like some celebs. Then he comes back a week later because of a sore ankle, wanting a little codeine and bearing an autographed photo or a CD. Other patients notice and figure you must be a pretty good doctor if Mr. Showbiz is coming in….

I once wrote about that concern over VIP complaints, in a medscape column. And, like the author, the only thing that impresses me about these celebrity docs is their creativity — Sepkowitz describes how the first Dr. Feelgood used solubilized placenta. And, while the risks of propofol dosing are drummed into our heads in training, it never occurred to me a doctor-to-the-stars might use propofol outside the hospital on an unmonitored patient.

While it didn’t surprise me that propofol has been considered in
palliative care
and even implicated in a murder, it turns out propofol (diprivan) abuse and dependency is not unheard of and, as this review by Roussin shows, some IRB actually permitted trials:

Normal healthy volunteers (n = 12) were exposed in a blind fashion to acute bolus injections of 0.6 mg/kg of propofol and to a similar volume of soy-based lipid emulsion (similar to the vehicule of propofol) twice. After these sampling sessions, they were asked to choose which drug they preferred to be injected with. Propofol was chosen by 50% of the subjects, and seemed to have been based on the pleasant subjective effects. In contrast, the choice of placebo (Intralipid®) seemed to have been based on either non-intense subjective effects during the propofol sampling session (increased dizziness, confusion) or residual effects (fatigue) after the sessions. These results suggest that, in some healthy volunteers, propofol functioned as a reward.

…From a psychopharmacologists’ standpoint, propofol shares properties in common with many drugs that are abused. In particular, the onset of the effects of propofol are rapid and this drug makes people ‘feel good’ and feel relaxed [45]. The mood-altering effects of subanaesthetic doses of propofol delivered via an infusion or by an acute bolus injection have been assessed in human healthy volunteers [44,52]. Subjects reported feeling high, lightheaded, spaced out and sedated….

I read up on propofol use a lot a year ago, in preparation for a talk on procedural sedation. At that point I think its only foray into pop culture’s collective consciousness was a poem by Karl Kirchwey called “Propofol” that ran a year ago in the New Yorker. It began:

Moly, mandragora, milk of oblivion:
I said to Doctor Day, “You bring on night.”
“But then,” he said, “I bring day back again,”
and smiled; except his smile was thin and slight.

Now everyone’s talking about propofol. The ASA is using this opportunity to reintroduce talk of restricting propofol to their specialty alone (despite abundant and mounting evidence that it’s used safely in ED procedural sedation). Reporters are wondering why propofol administration is not as closely logged as, say, opiates.

All this activity suggests it soon will be. And while keeping this drug out of the hands of abusers and enablers is a worthy goal of regulation, I hope those who’ve demonstrated a safe track record are not prohibited from using this unique medication.

*This blog post was originally published at Blogborygmi*

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