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Global Health, Haiti

SOS from Haitian hospitals

The morning after the Jan. 12 earthquake in Haiti, the halls of Hopital Albert Schweitzer in the Artibonite Valley, some 40 miles north of the capital of Port-Au-Prince, were filled with new patients, “traumatic injuries, mostly.” All available gurneys and benches were occupied, and, “patients are triaged and staged along the corridor to the operating suite and lab/radiology.”

That report was emailed to Stanford surgeon Ralph Greco, MD, who started volunteering at the rural hospital in the 1970s, as a Yale surgical resident. Greco took Stanford Hospital residents back to Haiti for more than 20 years, and he stays in touch with friends there. The email to him from the Schweitzer Hospital reported that it has enough doctors and nurses on hand, plus a full stock of medications and continuing power and supplies of water. Unfortunately, conditions are much worse at other medical sites in the impoverished nation.

In the hillside district of Petionville, on the outskirts of the capital, a hospital was reported to have collapsed. And in the Central Plateau, aftershocks were overwhelming local medical staff. Louise Ivers, clinical director of Partners in Health in Haiti, sent an urgent email, appealing for assistance. “Port-Au-Prince is devastated, lot of deaths. SOS, SOS…Temporary field hospital by us at UNDP needs supplies, pain meds, bandages. Please help us.”

Ophelia Dahl, PIH executive director, echoed that message. “The earthquake has destroyed much of the already fragile and overburdened infrastructure in the most densely populated part of the country,” she wrote in an email that reached Greco. “A massive and immediate international response is needed to provide food, water, shelter, and medical supplies for tens of thousands of people.”

Noting that conditions in Port-Au-Prince are a “nightmare,” Greco predicted that there could be hundreds of thousands of deaths. “It’s a city of three to four million people, and they’re living in shacks, living on nothing. It’s probably one of the poorest countries in the world, and there is so much need.”

In the News, Medicine and Society, Transplants

Valuing bone marrow

Valuing bone marrow

Interested in a $3,000 scholarship? Or perhaps you could use a housing allowance?

Under a pilot program, those could be some of the incentives offered to increase donations of blood-producing marrow cells.

Writing in the New York Times today, John Wagner, MD, a professor of pediatrics and director of the blood and marrow transplant program at the University of Minnesota, and Jeff Rowes, a senior lawyer with the Institute for Justice in Arlington, Va., lay out an intriguing proposal for meeting the challenge of finding marrow donors. They also have filed, in federal district court, a constitutional challenge to a prohibition on marrow donation included in the 1984 National Organ Transplant Act.

The intent of that law was to prevent the sale of human kidneys for transplant. But Wagner and Rowes argue that, “Unlike organs, marrow cells–basically, immature blood cells–are renewable. the body grows fresh ones quickly enough to replace those extracted for transplant in about a month. And donating marrow cells is now very safe–in most cases, it’s simply a matter of drawing blood from the donor’s arm and running it through a machine that skims off the marrow cells. Well under half of donations are conducted the old way, by harvesting marrow cells from the donor’s hip.”

The authors say their proposed incentives “would not create a freewheeling market in bone marrow donations” because there would be no buyers or sellers. Instead, people who wanted to donate marrow cells “could, in good conscience, get something in return for helping to save a life.”


Patient Care

Reducing surgical infections

Your mother was right: wash your hands and you’ll live a clean life.

Two new multicenter studies published in the New England Journal of Medicine on Jan. 7, and reported in the New York Times, take that homily to heart, showing that cleanliness is critical for people who are going into the hospital for surgery–and that screening and scrubbing pre-surgical patients can help to prevent some common infections.

In one study, some 500 patients who were scheduled for surgery and tested positive with nasal swabs for a common bacteria, staphylococcus aureus, were treated with an antibiotic ointment and special soap within 24 hours of being admitted to the hospital. After surgery, they were 60 percent less likely to develop infections than patients who were given a placebo ointment and soap.

In the second study, some 800 patients whose skin was cleaned with a special chlorhexidine-alcohol solution prior to surgery got 40 percent fewer infections than those who were scrubbed with a standard disinfectant.

Writing in a NEJM editorial, Richard P. Wenzel, MD, an infectious disease specialist at Virginia Commonwealth University, noted that the Centers for Disease Control and Prevention have long recommended chlorhexidine-alcohol as a prophylactic approach. Both studies, he added, “offer remarkably safer strategies for all patients who require surgery.”

Health Policy, In the News, Surgery

Taxing cosmetic surgery

As the overhaul of the nation’s health care system continues on Capitol Hill, some of the debate has the pop of prime-time medical dramas. One proposed five-percent tax on elective cosmetic surgery – not procedures to correct congenital defects, injuries resulting from trauma or disease – strikes some surgeons as egregious. Gordon Lee, MD, an assistant professor in Stanford’s plastic and reconstructive surgery department, also worries that the tax could have unintended consequences, ultimately leaving the nation with more costly health-care issues.

Echoing the concerns of colleagues nationwide, Lee, who is a member of the American Society of Plastic Surgeons, says the proposed tax might “drive patients to seeker ‘cheaper’ alternatives, such as unlicensed, uncertified, “discount” plastic surgery, either in the United States or outside the country.” Such so-called medical tourism, he argues, “is not a very good option.”

Some critics have suggested that the “Bo-Tax” would discriminate against women, who comprise the majority of cosmetic surgery patients. But Lee, who does breast and penis reconstructions, doesn’t share that concern. “Both men and women get plastic surgery, so I don’t think it is specifically targeting women.”


Face It

In the 1997 Academy Award-nominated movie Face/Off, terrorist Nicholas Cage had his face surgically replaced with that of FBI agent and sworn enemy John Travolta. Today, surgeons at Stanford Hospital & Clinics are debating the merits of real-life face transplants.

On Oct. 29 Stanford will host “Face and Hand Transplantation: Its Beginning, Current and Future Status,” the fourth annual Oscar Salvatierra, Jr., MD, Lectureship in Transplantation. The lecture by University of Lyon professor Jean-Michel Dubernard, who performed the world’s first face transplant, first hand transplant and first double-hand transplant, will be followed by a discussion with two Stanford surgeons, a transplant physicist, ethicist and immunologist.

I spoke about this recently with Stanford surgeon Gordon Lee, who is going to be one of the panelists. I was a bit surprised to learn that it’s not the mechanics of the surgery that make these procedures difficult, but the immunology and the ethics. “Transplant surgeons and immunologists here are saying, ‘We have the ability and technology to be the leader in this field, and we can be pioneers in developing new immunological regimens,” Lee told me. “But there’s also the question: ‘Just because we can do it, should we do it?'”

For patients who have complex defects–say, a gunshot shot wound to the face–Lee says composite tissue allotransplantation, or CTA, has great potential. It’s a relatively new surgical practice that combines the techniques of microsurgical reconstruction, connecting tiny blood vessels, and organ transplantation. It also can combine many kinds of transplanted tissue, including skin, bone, muscle, nerve and tendon.

“CTA sounds complicated, but the technical aspects have never been a barrier–it’s really nothing more than connecting cables, plumbing and wires,” Lee says. “It’s the immunology and the ethical issues that are challenging.”

The side effects of immunosuppressive drugs, which transplanted patients must take forever, include diabetes, kidney problems, increased blood pressure, and a tendency to develop infections–and cancer. “What are the quality-of-life issues, versus the costs of expensive drugs and side effects?” Lee asks. “These surgeries involve a lot of money and a lot of resources, and is the risk of immunosuppression justified by the benefit?”

Patient Care

Handle with care

At a time when patients nationwide are getting older, sicker and heavier, nurses also are aging, with micro tears and back injuries that result from years of lifting patients. “Now we understand that it can be the fragile, 100-pound elderly woman who can be the proverbial straw that breaks the nurse’s back,” says Joan Forte, interim director of nursing at Stanford Hospital & Clinics.

Forte spoke to hundreds of nurses and hospital administrators at a Safe Patient Handling conference in September, telling them how her hospital has invested $3 million in technology to take better care of patients–and nurses. The investment includes eight overhead lifts, 24 mobile lifts, one lift for bariatric patients and 26 air-powered systems for moving patients from their beds to an X-ray table.

The recipient of the Veteran Administration’s 2010 Best Practice Award for Safe Patient Handling, Stanford is now working with the VA and the American Nurses Association to design a template for other hospitals to use in adopting new technology and practices. “We think the new equipment will help us get patients up and out of bed and mobilized far sooner,” Forte says. “And that means becoming independent and going home sooner.”

In the News, Medicine and Society, Patient Care, Stanford News

Getting a good night's sleep

Getting a good night's sleep

You’re not likely to get well at the hospital if you can’t sleep. A new program at Stanford Hospital & Clinics recognizes this fundamental idea and takes practical steps to address one of the causes of sleepless nights: Noise. It’s a problem that plagues many hospitals, and Stanford is on the forefront of dealing with it in a comprehensive fashion. This approach is detailed in a story in today’s San Jose Mercury News.

I first wrote about this program in May, and the story can be found here. It will be interesting to see how it develops in the coming months.

In the News, Medicine and Society, Mental Health

Settlement reached in New York hospital death

Settlement reached in New York hospital death

A June 2008 videotape of Esmin Elizabeth Green lying on the floor of the psychiatric emergency room in Brooklyn’s Kings County Hospital provoked outrage among many who saw it. Green, age 49, collapsed and died after waiting more than 24 hours to be treated.

New York City’s Health and Hospitals Corporation has agreed to pay $2 million to Green’s family to settle a wrongful-death lawsuit. Meanwhile, readers of the New York Times are venting in e-mails to the Gray Lady, citing the city’s culpability and broader failings of the mental health care system, in addition to calling for a “one payer” health-care system. “I was livid,” one wrote about reading the story. “I have a close family member who suffers from bipolar disease and has had many visits to hospitals such as this.”

New York City’s Department of Investigation continues to look into charges of criminal culpability, and Green’s family is calling for those responsible for her death to be prosecuted. The hospital says it is reducing crowding in the psychiatric emergency room, and notes that it has hired more than 200 doctors, nurses, psychologists and social workers to manage patients. Which left one reader to ask, “Why is it that administrators have not been fired for institutionalizing neglect at this hospital?”


They're a family

Lambda Legal, the gay rights organization, has filed a federal lawsuit that could challenge policies at hospitals nationwide.

The suit against Jackson Memorial Hospital in Miami was brought on behalf of Janice Langbehn and her three children, who were not permitted to visit their mother – Langbehn’s same-sex partner, Lisa Pond – after she collapsed during a Florida vacation. That’s in spite of the couple’s living trusts, advanced health-care directives and power-of-attorney documents. Pond died eight hours after being admitted to the trauma center with an aneurysm.

“We want to send a message to hospitals,” said Lambda Legal lawyer Beth Littrell. “If they don’t treat families as such, if they don’t let patients define their own circle of intimacy and give them the dignity and care to be with their loved ones in this sort of crisis, then they will be held accountable.”

Infectious Disease

Hold that phone

Don’t take that call just yet. Researchers in Turkey who tested the cellular phones of 200 doctors and nurses in hospital intensive care units and operating rooms report that 95 percent of them carried at least one dangerous bacteria. Some 35 percent contained two bacterial strains, and more than 11 percent had three or more. And that’s in a population that prizes hand-washing.

Writing in Annals of Clinical Microbiology and Antimicrobials, the Turkish specialists in anesthesiology, infectious disease and microbiology from Ondokuz Mayis University noted, “These mobile phones could act as a reservoir of infection which may facilitate patient-to-patient transmission of bacteria in a hospital setting.”

Significantly, 12 percent of the cell phones tested positive for methicillin-resistant Staphylococcus aureus (MRSA), which accounts for 19,000 deaths per year in the United States and is thought to be responsible for 60 percent of hospital-acquired infections.

Ringtones, anyone? Can you hum I Wanna Hold Your Hand?

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