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Tuesday, November 27, 2012

Is Patient Abandonment in the Operating Room Ever Justified?

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I ask this question mainly because there WAS an ENT who WAS sued (and settled) for NOT abandoning his patient in the operating room. [link]

Imagine this hypothetical scenario...

You are an ENT surgeon in a rural community hospital performing a fairly difficult but elective sinus surgery on a 12 years old child with cystic fibrosis with extensive pan-sinus nasal polypoid disease. Given the extensive nasal polypoid disease, a fair amount of bleeding is occurring which was not unanticipated.

Suddenly, you get a phone call from the emergency room regarding a patient with progressive difficulty breathing suspected to have epiglottitis.

What do you do if you are the only ENT in the hospital?

Do you "abandon" the 12 years old child in the operating room, still bleeding, still under general anesthesia and attend to the ER patient who himself might die without an emergency tracheostomy? Doing an evaluation to determine how critical the ER patient may take anywhere from 15 - 60 minutes including the tracheostomy itself.

What if you are the only ENT available in the region let alone the hospital? No fellow ENT colleagues to call upon for help. General surgery is "unavailable" or not comfortable with performing tracheostomies especially given ENT performs all tracheostomies in the hospital?

Patient abandonment is defined as:
  • Failing to transfer a patient to an appropriate level of care
  • Failing to respond to calls from a hospital regarding a patient
  • Refusing to care for a patient after arranging the patient's admission
  • Failing to treat a patient until new coverage is arranged
Proving patient abandonment includes:
  • Your doctor had a duty to treat you - a duty was created when the physician-patient relationship was established
  • You had a reasonable expectation that your doctor would treat you
  • Your doctor failed to treat you although he or she was obligated to do so
  • You suffered injury as a result
Well, according to one lawsuit, it seems that the ENT was required to abandon his patient in the operating room and attend to the ER patient. The lawsuit stemmed from the fact that the ENT did not abandon his patient in the operating room and the ER patient did die as a result of not being attended to quickly and a tracheostomy performed. Of course, the settled lawsuit also blamed the hospital, general surgery, and anesthesiology.

However, abandoning a patient on the operating room table is also tantamount to medical malpractice according to the very definition of patient abandonment.

And, I would not be surprised if the patient on the operating room table would have sued the ENT if he DID leave the operating room in the middle of surgery to attend to another patient.

What to do?

I have no answer...

Doing an emergency tracheostomy is HARD, even for someone who has performed hundreds of elective tracheostomies. I know... I've done perhaps a half-dozen emergency trachs in my career so far. In this particular lawsuit, I found it incredible that a hospitalist (not a surgeon) was the one who finally attempted the emergency tracheostomy (albeit unsuccessfully).

Do you consider the patient you are CURRENTLY caring for has a higher priority than a patient you have never met, even if possible life-threatening illness is involved? (Keep in mind that when called for an airway problem, that 99% of the time, an emergency tracheostomy is not needed.)

OR, do you prioritize the patient you have never met given the possible life-and-death circumstances involved, even if 99% of the time, no surgical airway is required.

What would YOU do? What should you do? Feel free to comment below!

Hospital settles wrongful death lawsuit. Curry Coastal Pilot 10/31/12

Saturday, November 17, 2012

Taste Changes after Tonsillectomy

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Very rarely, patients will complain of taste changes after tonsillectomy. Such taste changes (aka dysgeusia) is most often described as metallic though other taste variations or absences may be reported.

Depending on what study you look at, this complaint occurs anywhere from 0.3% to as high as 9% of tonsillectomy cases. Dysgeusia after tonsillectomy is felt to be due to a number of different causes including:

1) medication side effect
2) injury to the lingual branch of the glossopharyngeal nerve
3) zinc deficiency

Regardless of the etiology, most cases of post-tonsillectomy dysgeusia spontaneously resolves within a few months without any specific intervention.

However, there are a few things a patient can try that might help accelerate normal taste recovery including:

1) Stopping all unnecessary medications
2) Zinc gluconate 50mg 3 times per day
3) Alpha Lipoic Acid 200mg 3 times per day
4) Rinsing mouth with watered down milk-of-magnesia
5) Chewing non-mint flavored gum

I did want to point out that there are no comprehensive studies to support any of these interventions. But, it certainly can't hurt to try it.

Taste disturbance after tonsillectomy. Acta Otolaryngol Suppl. 2002;(546):164-72.

Taste disorders after tonsillectomy: case report and literature review. Ann Otol Rhinol Laryngol. 2005 Mar;114(3):233-6.

Posttonsillectomy taste distortion: a significant complication. Laryngoscope. 2004 Jul;114(7):1206-13.

Taste disturbance after tonsillectomy and laryngomicrosurgery. Auris Nasus Larynx. 2005 Dec;32(4):381-6. Epub 2005 Jul 19.

Thursday, November 8, 2012

Brooke Burke Has Thyroid Cancer

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Brooke Burke, TV personality best known for winning the 7th season of Dancing with the Stars and later co-hosting the show starting in 2010 announced in a self-published video the fact that she has thyroid cancer and will soon be undergoing thyroid surgery.

Apparently, on a routine physical exam, a thyroid nodule was appreciated in July 2012. This was biopsied (presumably via an ultrasound guided fine needle aspiration) and came back as "atypical". Given atypical findings, a diagnosis of cancer or no cancer can not be definitively made. As such, more studies were than pursued and finally, she was informed she had a "good" type of thyroid cancer if there is such a thing.

Some of these additional studies may have included CT scan of the neck and thyroid scan.

The type of thyroid cancer was never specifically mentioned, but she most likely has papillary thyroid carcinoma which is the most common form of thyroid cancer and is highly curable (which is where the comment of being a "good" cancer comes from).

Other less common thyroid cancers include follicular thyroid carcinoma and medullary thyroid carcinoma.

Thyroid cancer mandates thyroidectomy with post-operative radioactive iodine treatment to ensure complete thyroid tissue eradication.

Her surgery date has not been announced.

It should be stated that until the thyroid is removed, one can NOT be absolutely sure that thyroid cancer actually truly is present. Indeed, the president of Argentina made a similar announcement of thyroid cancer only to find out after her thyroid was removed that no cancer was actually present. Read blog post about this "mistake".

Brooke Burke: I Have Cancer. NY Post 11/8/12

Sunday, November 4, 2012

Breathing or Voice... You Can Only Have One...

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Sounds like a choice taken out of a morbid horror movie...

"You can ONLY have one... Your voice or your breath..."

The victim than loses one or the other after making a choice getting either the tongue or head cut off with a knife.

But patients with vocal cord paralysis on both sides are essentially faced with this very question.

Normally, the vocal cords (TVC in picture below) found in the voicebox move to accommodate talking or breathing.

When the vocal cords are apart, breathing occurs allowing air to pass unimpeded between the vocal cords and down into the lungs. However, with talking, the vocal cords come together tightly and vibrate creating voice. Watch a movie.

However, when both vocal cords become paralyzed, they neither move apart to help with breathing nor come together to assist with talking. Indeed, the voice and breathing BOTH stink.

It is in just this situation that the choice of breathing or voice becomes important because a patient can not have both. Improving one will sacrifice the other.

To explain this connection of voice and breathing further, normally, when the vocal cords are both moving fine, the voice is at 100% and breathing is at 100%. However, with bilateral paralysis, the voice and breathing are now linked to each other and collectively can not exceed 100%. As such, a patient with new onset bilateral vocal cord paralysis may start with a 40% of normal vocal quality and 60% of normal breathing ability for a total of 100%.

Using this scenario as a starting point where vocal quality is at 40% and breathing is at 60% of normal...

If a patient chooses to improve the vocal quality from 40% to 100% (an improvement of 60%), then breathing WILL correspondingly decrease 60% down to 0%... and potentially die given the ability to breathe is lost. Why? Because the vocal cords can be surgically forced together to allow for voice... but given the vocal cords are paralyzed, they can not move back apart to allow for breathing.

If a patient chooses to improve breathing quality from 60% to 100% (an improvement of 40%),  then the vocal quality WILL correspondingly decrease 40% down to 0%... and lose the ability to talk. Why? Because the vocal cords can be surgically forced apart to allow for breathing... but given the vocal cords are paralyzed, they can not move back together to allow for vocal cord vibration.

The total percentage of vocal and breathing quality can never be more than 100%. If a patient wants the best possibly voice and breathing, than a compromise would be to increase the vocal quality 10% from 40% to 50%, but understanding that this 10% improvement in vocal quality WILL mean a corresponding 10% decrease in breathing ability from 60% to 50%. This 10% change means that in the end, the voice and breathing would both end up at 50% of normal.

In most cases of bilateral vocal cord paralysis, it is the reduced breathing and shortness of breath that bothers people the most. The voice isn't good, but when given the choice, most people choose to try and improve their breathing ability understanding their voice may further deteriorate.

To read more about such treatment options, click here.

Saturday, November 3, 2012

Nasal Sounding Speech

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There are actually TWO different flavors of nasal sounding speech.

HYPO-nasal speech is due to reduced or no nasal airflow and HYPER-nasal speech due to too much nasal airflow.

HYPO-nasal speech is by far the most common cause of nasal-sounding speech. It is similar to how a person would sound if they pinched their nose shut while talking. As such, ANY anatomic nasal obstruction would by definition lead to such hypo-nasal speech. Treatment, obviously, is to remove this anatomic nasal obstruction whatever it may be either with medications or surgery. Examples of hypo-nasal speech causes include:
HYPER-nasal speech itself has several different flavors, but the key concept is the presence of an opening between the mouth and nose when it should be sealed shut during speech. Normally, complete closure should occur with certain sounds like /s/, /sh/, /b/, and /p/. Such sounds are called plosives and sibilants. This link provides a cartoon animation of how each sound in the English language is produced from an anatomical standpoint.

Now what are some of the causes of HYPER-nasal speech? Causes can be divided broadly into either anatomic and functional variants.

Anatomic HYPER-nasal speech include:
Functional HYPER-nasal speech include:
  • Velopharyngeal insufficiency without anatomic cause. Velopharyngeal insufficiency or VPI occurs when the soft palate does not seal against the back of the mouth during appropriate speech sounds.
  • Poor articulation (person is not correctly pronouncing words)
Treatment of HYPER-nasal speech may include speech therapy and surgery depending on the cause.

Given the subtleties involved in differentiating the different causes of nasal speech, workup typically involves not only just looking in the nose or mouth, but also performing a nasal endoscopic examination.

Below is a video showing a young child undergoing just such an endoscopic exam. Here are some other videos containing audio of abnormal endoscopic exams.

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