Another reason not to rely on medical advice from the Internet

On New Years Eve, The Daily Beast published an article with suggestions about how to avoid a hangover.

Some of the tips were reasonable such as limiting yourself to one alcoholic drink per hour and maybe avoiding certain beverages like wine, bourbon, and Scotch, which contain congeners and have been associated with worse hangovers.

However, some of the advice is wrong.

The article recommends this on the day you plan to party:

6 a.m.: Rise and hydrate! Drink early and drink often. One of the main causes of a hangover is dehydration. Women should be drinking 2.7 liters per day, and men should get 3.7 liters. Thats 0.7 gallon and 0.97 gallon, respectively.

After you party, at 12 a.m.: Drink some water and get to bed. It’s your last chance of the day to hydrate, so seize it! Sip some water before your head hits the pillow, but avoid popping any anti-hangover pills.

The 6 a.m. recommendation has two important bits of misinformation. One, dehydration is probably not a major factor causing a hangover. A 2010 literature review explains that hangovers are much more complicated than most people think. From the abstract:

Markers of dehydration were not significantly related to hangover severity. Some studies report a significant correlation between blood acetaldehyde concentration and hangover severity, but most convincing is the significant relationship between immune factors and hangover severity. The latter is supported by studies showing that hangover severity may be reduced by inhibitors of prostaglandin synthesis. Several factors do not cause alcohol hangover but can aggravate its severity. These include sleep deprivation, smoking, congeners, health status, genetics and individual differences.

Two, the idea that you need to drink 8 glasses of water per day is a myth. The best plain English explanation of this appeared in the New York Times last summer.

The 12 a.m. suggestion may also be incorrect. Do you really need more water right before you try to sleep?

As the 2010 review pointed out, blocking prostaglandins by taking an anti-inflammatory drug like ibuprofen might be useful. However, a small risk of bleeding from gastric mucosal damage with the combination of alcohol and anti-inflammatory drugs is a concern.

Abstaining from alcohol or drinking it in moderation is the best way to avoid a hangover. Once you have a hangover, the best remedy is time.

A Washington Post article on the dangers of overhydration in marathon runners quotes an expert as follows: “Drink when you’re thirsty. It’s not something you have to tell your body to do.”

If you have normal kidneys and drink as much water as The Daily Beast recommends, you may avoid hangover because instead of getting drunk, you will be spending a lot of time in the bathroom peeing.

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Is the surgeon still captain of the ship

A Kentucky appeals court ruled that a surgeon was not responsible for a burn caused by an instrument that had been removed from an autoclave and placed on an anesthetized patients abdomen.

According to an article in Outpatient Surgery, the surgeon was not in the room when the injury occurred and only discovered it when he was about to begin the procedure.

An insufflator valve had been sterilized and was apparently still hot when an unknown hospital staff member put it down on the patients exposed skin. [An insufflator is a machine that is used to pump CO2 through tubing into the abdomen for laparoscopic surgery.] When the doctor saw the mild second-degree burn, he asked what happened, but "but no one in the OR claimed any knowledge or responsibility."

The hospital had settled the suit on behalf of its staff, but the surgeon, who as a private practitioner had his own malpractice insurance, held out. The original lower court ruling dismissing the suit against him had been based on the plaintiffs lawyers failure to prove that the surgeon was responsible for the actions of the hospital staff.

In December 2012, I wrote a post stating my opinion that activities such as counting the sponges during an operation were not the responsibility of the surgeon. Many who commented on the post were highly indignant that I could suggest such a thing.

I wrote another post last year on the subject in response to another surgeons blog entitled "Everythings my fault: How a surgeon says Im sorry." I felt that many things that happened to patients were beyond the control of the surgeon. Most of the comments agreed with me.

I keep hearing that medical care has become a team sport. If thats true, then the surgeon, like everyone else, is simply a member of the team. People on teams have different roles and must execute properly for the team to succeed.

One of the most interesting things about the case in question was that none of the OR team members had any idea how that hot insufflator valve found its way to the patients abdomen.

One thing we know for sure, at least in Kentucky, is that a surgeon is not legally responsible for everything that happens to a patient in the operating room, particularly when he is not even present.

Is this decision the first nail in the coffin of the "captain of the ship" doctrine?

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Another Caribbean med school graduate needs advice

I did not attend St. Georges, Ross, or Saba. I chose my school because it has a premed program which leads to an MD program. My USMLE Scores on Step 1 and Step 2 CK are above 230.

I did not apply for the 2015 match because I did not have my step 2 CK results until November. It would have been too late. I could have rushed my step 2 but I wanted to get a good score and be a solid applicant. Also I would not have been able to complete my surgical electives in time to get letters of recommendation. At some point, I will be doing research at [a very well-known medical school]. I felt that for these reasons this would make me a better applicant the next year.

Since graduating I have been trying to find a medical related job (scribe) but have had no success. I have reached out to many institutions regarding research opportunities but have come up dry. I may be able to secure a volunteer research position by next month. Do you have any suggestions for me? I knew I would hate being out of the medical field for this long but this was my best bet. Does this gap hurt my chances?

I am concerned that despite your excellent USMLE scores, taking a year off from clinical medicine may cause your application to be rejected immediately. I do not know if a 9 week research elective, even at a premier med school, would be enough to offset your lack of clinical experience over the entire year. Acting as a scribe would not be considered clinical experience.

Another issue is what is the record of your school regarding matching graduates into surgical programs? Since you didn’t tell me your school’s name, I cannot give you any insight into that situation. Even if I did know the school’s name, it may not have published its match results.

To answer your specific questions:

How many gen surg programs should I apply to? I was thinking ~100. That seems reasonable. You should be able to gauge your chances better after you see if you receive any offers for interviews from the 100 programs.

During a gen surg interview, should I be open about my backup specialty? I would advise you to say that you would take a preliminary spot in general surgery if you didn’t match in a categorical position. Admitting that you would do internal medicine is often seen as a lack of commitment to surgery.

Most hospitals I am looking to apply are IMG friendly. Which means the surgery and medicine programs are both IMG friendly. Would it be a bad idea to apply to different specialties at the same hospital? I think it would be a bad idea. I suggest you wait and see if you get interviews from the general surgery programs. If you don’t, then there would be no problem applying to internal medicine at the same place. I doubt very much that the two services would talk about any specific applicants. Most surgery programs get hundreds of applications and those applicants who are not offered interviews are not remembered.

Some readers may have other opinions. I hope they will comment.

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A medical student in Cuba is looking for advice

Someone writes: I am trying to help a friends brother who is not a US citizen and currently a medical student in Cuba, and I came across your very informative web site. The brother most likely is going to be able to come to the United States in the fall.

My friend is wondering if he should complete the last year of medical school there in Cuba or come here and continue on. It seems like there is no benefit from completing med school in Cuba, given the difficulty to be licensed in the U.S. And the difficulty in getting a residency position.

Does any of the course work from his studies in Cuba transfer over to U.S? Is it likely that hed have to get a bachelors degree here before ever going to a U.S. Med school? My friend says that he has an outstanding record in the Cuban medical school, speaks excellent English, does well on tests, etc. Any advice you could give?

As far as I know, no medical students from Cuba have transferred to a med school in the United States recently or possibly ever. Regarding your questions, I can only give you my best guesses.

I doubt very much that a course from the Cuban medical school would be accepted here in the US. US med schools that accept a few transfers from Caribbean schools like Ross or St. Georges usually take those students at the beginning of the third year of medical school.

A few schools are doing combined BS/MD degrees in five or six years, but I dont know of a single US school that would take a student directly out of high school into a 4-year program.

A possibly more reliable way to become a physician in the United States would be to graduate from an American university, take the Medical College Admission Test, and apply to med school.

Last month, the ECFMG posted this on its website: "The ECFMG is pleased to announce that it will resume processing of service requests in relation to applicants from and institutions in Cuba. As previously announced, ECFMG was not processing such requests, pending approval of its license application for Cuba by the Office of Foreign Assets Control (OFAC) of the U.S. Department of the Treasury. Today, ECFMG was advised that OFAC has approved the license application."

There are 14 medical schools in Cuba. I do not know if any or all of them will be acceptable to the ECFMG or what position residency program directors will take on applications received from students in those schools. Many current offshore graduates are having problems obtaining residencies in US programs. What will happen with the addition of 14 more schools with an unknown number of graduates is anyone’s guess.The fact that he is a non-US citizen is not helpful.

One of the 14 is the ELAM medical school which has 19,550 students. Wikipedia says it is accredited by the ECFMG and the Medical Board of California.

It is not clear how that many students can be clinically trained in a country with only about 11 million citizens and 13 other med schools. For comparison, the US, which has 30 times the population of Cuba, has 140 allopathic medical schools with about 80,000 total students.

I dont know if Ive clarified things for you or made them more confusing. Your friends brother is going to have to decide for himself what he wants to do, but if he is a truly outstanding student, maybe he should stay in Cuba and finish his education. However, he must understand that there is no guarantee he will be able to obtain a residency in the US, and no residency means no ability to be licensed and no way to practice medicine here.

If any of my readers have other thoughts, I hope they will comment.

Addendum on 8/20/15 at 11:25 a.m. The medical student is not a US citizen.

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OR tech How do I deal with an abusive surgeon

Have you ever come across problems with rage and temperament issues in the OR. I have been an operating room tech for many years and have been in a variety of surgical settings.

A certain surgeon brings in a lot of money to the hospital, but he is terrible. I have been called things no one has ever called me. He throws instruments on my table and mayo stand, screams, and implies that I and my colleagues have no idea what we are doing. I have reported him to my manager and the OR director, but nothing ever comes of it.

Other surgeons have witnessed his behavior and have said something, but nothing was ever done. I understand the OR is a beast of its own, but the culture has to change with these newer guys coming out of residency. The mindset of the surgeon being our customer, which is being rolled out to us now, is not reason for us to put up with abuse. What have you encountered on a peer-to-peer level on how to handle such demeaning behavior? I trained and worked at a level 1 trauma center with emotions that constantly ran high, and still it was less stressful than this particular surgeon. Thank you for your advice. 

A recent paper in the American Journal of Surgery addressed this topic. The authors interviewed 19 OR personnel including nurses, medical students, surgical residents, anesthesiologists, and 2 scrub technicians. Dr. Amalia Cochran, the papers lead author, told me the reason there werent more scrub techs was that they were reluctant to participate.

This figure, modified slightly from the paper, describes the harm that disruptive surgeons can do and suggests some coping strategies.

Italicized items are discussed in the paper

I suggest you read the entire paper. Your hospitals medical librarian should be able to obtain a copy for you without difficulty.

Its a tough situation. When I was a surgical chairman, I had some experience with surgeons behaving badly. I always had trouble getting the nurses and techs to go on the record with their complaints.

If your immediate boss cant help, maybe you could try your hospitals risk management department. A surgeon who bullies the staff is a patient safety risk. Some hospitals have anonymous hotlines where complaints can be lodged.

The only other thing I can suggest is to get several other staff to join in the complaints. Administration can ignore one or two people but not eight or ten.

Can anyone else comment?

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The Sticky Business Principle by Marc Charles

5:29 AM

Hello:

My column this week is about "sticky business".....I hope you enjoy it.

Marc Charles

The “Sticky Business” Factor

By Marc Charles

A business partner said my idea was too “sticky”.

He meant it in a bad way. But at least he said it with a smile on his face.

My partner was referring to a business with endless tentacles, paperwork, overhead costs, government red tape and a potential lawsuit magnet.

I’m sure you’ve heard about or been involved with a “sticky” business on some level.  I tend avoid them like the plague.

That’s why I was surprised when my partner suggested my idea was too “sticky”…..the nerve.

In my launching, reviewing and advising hundreds of business ideas and products over the last 29 years or so, only a fraction of them could be considered “non-stick”.

However, that doesn’t mean sticky businesses aren’t profitable.

The “stickiest” business I ever saw was also one of the most profitable….transporting hazardous (and nuclear) waste. 

The entrepreneurs who worked this venture could make $20,000 to $70,000 per load. The cost (and headaches) of running this business included retrofitted tractor trailers, maintenance (cleaning), drivers, government inspections, insurance, fuel, special licenses and certifications.

I wouldn’t recommend transporting hazardous waste for anyone without political connections, world class insurance, smart people and very deep pockets. 

On top of that, you’ll need nerves of steel. My friends were threatened, shot at and their transport vehicles were sabotaged. 

There is a boatload of businesses in the “non-stick” category. When I dissected the business idea I mentioned earlier for my partner he reluctantly agreed it wasn’t as “sticky” as he thought….the nerve.

Granted, nothing is “non-stick” or problem free all the time.

The bestselling “non-stick” frying pans rarely offer a money back guarantee should something stick.

A great “non-stick” business I found focuses on a hot rising trend called China. 

Actually, the business focuses on Chinese products, commerce and worldwide demand. I’ll tell you about it in a second. 

But first, I’d like to show you some new things developing in China right now. These things leverage the opportunity in a big way.

According the Financial Times China has opened the floodgate of cash reserves to get their “export machine” cranked up again. Apparently some Chinese (in powerful places) believe the financial crisis the last two years is receding. 

Money is flowing to entrepreneurs and businesses again like it did pre-2007.

Granted, Brazil is getting the lion’s share of attention (and money) lately because they’re surpassing the US as China’s largest trading partner.

But entrepreneurs in any country can leverage the China trend and a “non-stick” business I discovered by becoming a “finder”…..more on this in a second.

Another issue is China’s currency.

Import and export entrepreneurs are wondering if they’ll suffer a backlash over China’s currency policy. It’s a no-brainer Chinese wants to control the value of their currency (Yuan) against all other currencies.

But China’s currency has a couple of things going for it. First, China’s economy is relatively stable compared to the US and other countries, and second they have low government debt.

I’m not an economist…but a sound economy and limited government typically increases the relative value of a currency.

In real world currency trading China won’t be able to “control” much of anything, if they plan to do business with other countries.

But overall the Chinese currency should play a major role in international commerce in a good way.

China needs trading partners to survive. The country does not have the resources to be self sufficient. That’s a good thing for the “non-stick” business I found.

China needs to make and export products to the world, as well as import and consume them.

China is a living, breathing money monster which needs to be fed.

Lastly….China’s population is still growing like wildfire despite all the restrictions on having kids.

According to the World Bank China’s population was 1.3 billion in 2009 (1,356,359,928 as of January 2011).

And get this….

Chinese planners want to merge nine cities around the Pearl River Delta in the southern part of the country. This would create the largest “mega city” in the world with a population of 42 million people. This is greater than the entire population of California (39 million)!

China has unlocked the cash vault, the population is skyrocketing and they need trading partners to survive.

A “non-stick” business opportunity…..

The opportunity is about bringing buyers and sellers together and earning a percentage of each deal. This is also referred to as an import export “finder”.

I saw this opportunity in action the first time in Wausau Wisconsin.

The entrepreneur was making money as a “finder” connecting buyers in China with sellers in the US. His product was the herb ginseng. The buyers were Chinese distributors and retail stores.  

The herb ginseng is still wildly popular in China.

The import export “finder” opportunity is one of the hottest “non-stick” opportunities around.

By “non-stick” I ‘m referring to a business minus the tentacles, paperwork, inventory, buildings, employees (unless you want them), red tape, and massive overhead costs.

When you’re a “finder” you match buyers with sellers or visa versa and make money if and when a transaction is completed.

In most cases a “finder” simply facilitate deals or makes introductions to prospective partners.

And the best part is the lawsuit magnet aspect is almost eliminated.

Granted, one downside to this business is the learning curve…..and don’t kid yourself, it takes time. There are no exceptions if you want to learn this business.

But in my research I stumbled on a website which can accelerate the learning curve a hundred fold.

On top of that, I was so impressed with the impact the site, market and trend was having on entrepreneurs I developed what became known as the China Wholesale Trader.

The China Wholesale Trader is the most comprehensive resource library, how to course and interactive community in the world. See what entrepreneurs are saying about it here.

China is on the move again and there’s money to be made.

China was crippled by the financial turmoil over the past two years just like every else. But they’ve opened the cash spigot enabling companies to import and export products again!

In addition, there are more than 70,000 importers and exporters registered on AliExpress.com right now.

There are more than a million companies and entrepreneurs registered on Alibaba.com. Most of these companies and entrepreneurs are aggressively seeking business partners and deals as we speak.

People have compared AliExpress and Alibaba.com to eBay.

But the comparison is weak.

eBay focuses on the consuming masses. And eBay is a great place to sell imported products!

AliExpress and Alibaba.com focus on businesses and entrepreneurs.

This is one of the great “non-stick” business opportunities of the 21^st century.

Is the opportunity a good fit for you? I’m not sure. But it’s worth a “peak”.

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