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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*

Do Physicians Prefer Ventilated And Sedated Patients?

You ever wonder what doctors really think but are afraid to say out loud?  Here’s one example:

“I wish all my patients were on a ventilator”

There’s a reason vented and sedated patients are considered desirable.  In addition to the obvious economic benefits of

There are the less talked about, but equally pleasant side effects most hospitalists, ER doctors, cardiologists, gastroenterologists, pulmonologists,  surgeons, infectious disease doctors, endocrinologists, psychiatrists, rheumatologists, dermatologists, nurses, respiratory therapists and physical therapists wouldn’t admit, but would agree, without hesitation.  As a general rule:

  • Patients on ventilators are just faster, easier and more pleasant to take care of. Read more »

*This blog post was originally published at The Happy Hospitalist*

Variations In Retrieving A Foreign Body From The Stomach

I have observed extreme variation in how my colleagues manage GI foreign-body retrieval from the stomach. Some always use general anesthesia and endotracheal intubation; others (myself included) use conscious sedation. Some use an overtube to withdraw the object into if possible; others simply pull it up to the endoscope and use the endoscope to guide it through the esophagogastric junction and upper esophageal sphincter. The reasons for this variation are clearly related to the perceived risk of airway compromise or gastrointestinal wall injury during withdrawal of the object from the stomach.

So my questions to you are:

1)      When do you ask for endotracheal intubation during foreign-body retrieval?

2)      Do you use an overtube when removing foreign bodies from the stomach, and, if so, always or in what situations?

3)      If you don’t use an overtube, what technique do you use during withdrawal of the object?

4)      What is your favorite “tool” or endoscopic accessory to grab objects from the stomach?

I look forward to hearing your thoughts on this issue.

*This blog post was originally published at Gut Check on Gastroenterology*

Is IV Sedation Over-Used?

We criticize alternative medicine for not being evidence-based, and they criticize conventional medicine in turn, saying that much of what conventional medicine does is not based on evidence either. Sometimes that criticism is justified. I have run across a conventional practice that I suspect began because it sounded like a good idea, but that never was adequately tested and is not carefully thought out for individual patients.

I recently had a bone marrow aspiration. The written instructions said not to eat or drink for 6 hours before the procedure, to bring someone to drive me home, and to expect an IV. I suspected from these instructions that they were planning to use IV sedation, and I was right.

I questioned the need for sedation. I am prejudiced about bone marrow aspirations. I observed several and did one myself during my internship. When I had finished, the patient asked me when I was going to start. We did the procedure at the patient’s bedside in a multi-bed ward with no sedation, only local anesthesia. So my prejudice was that the procedure was no big deal and was not terribly painful.

I can imagine that some patients may be terrified by the idea of a needle going into their bone and may want to be sedated and not remember the experience. But I was not anxious about it, and I saw no need for the fentanyl and Versed they wanted to give me. I figured it would only prolong my time in the hospital, produce amnesia, expose me to a small risk of adverse effects, and leave me groggy; so I asked to opt out. They readily agreed – although they did keep asking me if I was really sure I didn’t want it. They would not have offered the option of no sedation if I had not known to ask.

The pathologist doing the procedure told me the injection of local anesthetic into the skin was the most painful part of the procedure. He was wrong. It was the ONLY painful part of the procedure. The penetration of bone and the aspiration of marrow produced only a pressure sensation.

This study reported that 85% of non-sedated patients had intense pain. I find that hard to believe, based on my personal experience and the experience of the pathologist that the local anesthetic was the worst part of the procedure. I wonder if those patients were anxious and were expecting intense pain. At any rate, I think giving me IV sedation would have been the wrong thing to do.

I had a similar experience with an excisional breast biopsy. They offered me general or local anesthesia and I chose local as presumably the safer option. Then they said they would use IV sedation along with the local. I asked why. They said to relieve anxiety. I told them I wasn’t anxious so if that was the only reason for sedation, I didn’t want it. I finally prevailed. I was comfortable, alert, had a good time chatting with the anesthesiologist, and was able to leave the recovery room much sooner than sedated patients.

I’m not saying that IV sedation is not indicated for some patients, but I am convinced it was not indicated for me. Has it become a knee-jerk reflex to sedate everyone as a general principle? Why? To avoid complaints and keep patients more cooperative during procedures? Are we paternalistically deciding that it is better if the patients don’t remember the procedure? I wonder: if minor procedures are not remembered, might the mystery increase anxiety and fear of the unknown for future procedures? We must ask seriously whether IV sedation is done more for the patient’s benefit or the doctor’s. The answer will vary with the procedure and the patient.

Rather than sedating every patient, why not use some judgment? Even if the patient is anxious, perhaps a non-drug option could relieve that anxiety without risking the side effects of drugs. Surely some anxiety is due to fear of the unknown. Would it help to show patients a video of someone comfortably undergoing the procedure without sedation, with an explanation of exactly what was happening? Would simple reassurance or personal attention from a patient advocate be helpful? Worth looking into? I think so.

Doctors are frequently accused of prescribing unnecessary drugs out of habit or reflex. I suggest that IV sedation for minor procedures is an example of over-prescription that is based more on custom than on good evidence.

*This blog post was originally published at Science Based Medicine.*

Latest Interviews

IDEA Labs: Medical Students Take The Lead In Healthcare Innovation

It’s no secret that doctors are disappointed with the way that the U.S. healthcare system is evolving. Most feel helpless about improving their work conditions or solving technical problems in patient care. Fortunately one young medical student was undeterred by the mountain of disappointment carried by his senior clinician mentors…

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How To Be A Successful Patient: Young Doctors Offer Some Advice

I am proud to be a part of the American Resident Project an initiative that promotes the writing of medical students residents and new physicians as they explore ideas for transforming American health care delivery. I recently had the opportunity to interview three of the writing fellows about how to…

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Latest Book Reviews

Book Review: Is Empathy Learned By Faking It Till It’s Real?

I m often asked to do book reviews on my blog and I rarely agree to them. This is because it takes me a long time to read a book and then if I don t enjoy it I figure the author would rather me remain silent than publish my…

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The Spirit Of The Place: Samuel Shem’s New Book May Depress You

When I was in medical school I read Samuel Shem s House Of God as a right of passage. At the time I found it to be a cynical yet eerily accurate portrayal of the underbelly of academic medicine. I gained comfort from its gallows humor and it made me…

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Eat To Save Your Life: Another Half-True Diet Book

I am hesitant to review diet books because they are so often a tangled mess of fact and fiction. Teasing out their truth from falsehood is about as exhausting as delousing a long-haired elementary school student. However after being approached by the authors’ PR agency with the promise of a…

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