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Archive for April, 2010

Monday, April 12th 2010

Mobile Trauma Bay

The Marine Corp utilizes what can only be described as a bad ass ambulance, a mobile trauma bay, in resuccetating combat victims at the site of injury.

Pretty cool how far trauma care reaches nowadays. Improvements in prehospital care have had such an impact on morbidity and mortality in trauma care in the civilian sector; looks like it’s true for the military experience as well.

Monday, April 12th 2010

Talk Amongst Yourselves

I’ve opened up commenting. Probably a smart and long overdue idea if I want to promote discussion on Residency Notes. And that’s certainly a big goal of mine.

When I relaunched the blog I thought I’d get cute and help support OpenID, which is an open source online ID project wherein a single ID can allow you to log into any participating website. Well, forget that. No more logging in, no Captha, no more hoops to jump through. If you have something to say, then say it.

Monday, April 12th 2010

Big Pharma

Are the big pharmaceuticals too big to fail? Is that a necessary characteristic for successful, expensive drug development?

Usually so opinionated I’ve got mixed feelings on big pharma. Consider those feelings doubly mixed after reading this CNN special investigation concerning the COX-2 inhibitor Bextra which Pfizer (or at least, controversially, it’s subsidiaries) was accussed of marketing illegally.

By April 2005, when Bextra was taken off the market, more than half of its $1.7 billion in profits had come from prescriptions written for uses the FDA had rejected.

But when it came to prosecuting Pfizer for its fraudulent marketing, the pharmaceutical giant had a trump card: Just as the giant banks on Wall Street were deemed too big to fail, Pfizer was considered too big to nail.

Why? Because any company convicted of a major health care fraud is automatically excluded from Medicare and Medicaid. Convicting Pfizer on Bextra would prevent the company from billing federal health programs for any of its products. It would be a corporate death sentence.

Prosecutors said that excluding Pfizer would most likely lead to Pfizer’s collapse, with collateral consequences: disrupting the flow of Pfizer products to Medicare and Medicaid recipients, causing the loss of jobs including those of Pfizer employees who were not involved in the fraud, and causing significant losses for Pfizer shareholders.


So Pfizer and the feds cut a deal. Instead of charging Pfizer with a crime, prosecutors would charge a Pfizer subsidiary, Pharmacia & Upjohn Co. Inc.

The CNN Special Investigation found that the subsidiary is nothing more than a shell company whose only function is to plead guilty.

I suppose I can’t support the break up of big pharma for both practical and philosophical reasons. But this kind’ve three card monty prosecution game seems beyond the verge.

Wednesday, April 7th 2010

Do We Need An ACGSE?

There’s been a lot of dissatisfaction in surgical training with work hour restrictions. Perhaps I shouldn’t limit it to surgical residencies, merely to say, instead, that they’ve been the most vocal for my experience.

The 80 hour work week and the 30 hour work shift restrictions have been bemoaned by academic surgeons. Fears that resident’s hand offs of patients would harm continuity of care and thus patient outcomes were front and center, and voiced by all specialties. Fears that resident surgeons would get less hands on surgical experience were unique to surgery but no less concerning.

Talk that further restrictions on how much residents can work are coming brings the issue front and center again. A not too distant IOM report commissioned by the AHRQ recommended such further limitations on resident work hours. And decried by surgical specialists and others alike. I’ve heard prominent individuals from within organized surgery, of course being explicit that they’re voicing their opinions as individuals, decry any further attempt to limit the surgical resident experience.

The surgical specialties are poorly represented in the decision making process. The IOM committee which so recently commented on resident work hours had a single surgical subspecialists on it. The current ACGME Board of Directors has two surgeons sitting on it (and I’m explicitly excluding the ophthalmologists serving on it, and for reason I believe considering their training experience as compared to say that of an orthopedic surgeon). That is two representatives out of thirty or 6% of the vote on the body that will ultimately, at present, determine any further resident work hour restrictions.

With relatively broad coverage in the media of the issue, a decided bent in the public for support of work hour restrictions, and significant public advocacy money in play to influence the decision the whispers from within the ACGME are that further restrictions are inevitable in the next 2 years.

But what if the decision was taken out of the hands of the ACGME, at least for surgical residencies?

There is a growing movement amongst rather prominent academic surgeons for an Accreditation Council for Graduate Surgical Education. Organizing such would be no small feat. Getting the state boards, with public pressure in favor of restrictions, to recognize it may be even more of a hurdle. And that presumes that the inevitability of all of this mess isn’t Congress legislating resident work hours as say the Patient and Physician Protection and Safety Act [PDF] tried to do early last decade.

It’s true, work hour restrictions have worked the rest of the world over. European registars are limited to 48 hours a week and it is hard to demonstrate a qualitative difference between a CABG here and over there. And while the design of their health care system necessitates that many of them will spend years as SHOs (or even lower on the training pole) before a consultant spot opens up.

Drawing the analogy with other other surgical training experiences across the world would require a reimagining of how health care is organized in America. A more tertiary experience with fewer surgeons and lengthier training with further graduation of responsibility during it. That’s not something I’m personally willing to accept. As much as residents still bemoan their hours in the hospital, if push came to shove, and an ACGSE could postpone further reductions in my operative experience I am all for it.

Saturday, April 3rd 2010

The World Is Just Awesome

Life is incredible.

Consider that the thesis of this post. It is a rehashing, I’ve posted a post similar to this before, but since I continue to be lucky to be alive and because I can’t find that original post I’ll rehash the point of it.

I’m sorry to share a commercial for a television station to make my point but the ad expresses a truth wrapped in a production quality that I can’t find elsewhere.

It is a beautiful day outside, I am so lucky and blessed to be alive. And while I’ve been comparatively blessed the whole of my life and, only in brief truly experienced suffering, as it should be defined when looking at the range of human experience, I feel comfortable in claiming the impressiveness of humanity.

The fact that life or the rest of the natural world or human achievement somehow seems common place is depressing. The universe is incredible and wonderful. The mere fact life exists at all is something amazing. I think that a single day of life, even one filled with suffering, would be worth it for the observations and the experience in general.

I love the whole world.