Surgeon's Point-of-View (POV) Video Recording

Learning how to video record vivid, stable, high-def, and focussed shots from my (surgeon's) point-of-view has not been an easy endeavor due to technology limitations, though things do appear to be slowly improving. There have been pros and cons with most video-recording systems to date which I have summarized below. The "perfect" video-recording system has yet to be developed which must include all these elements:

• Wearable on headlight or glasses
• Camera located between the eyes that is maneuverable to adjust recording angle
• Head-up view to see what is being recorded real-time
• Manual white balance adjustment

• Manual exposure adjustment (bright lights used in surgery often confuse auto-exposure settings which result in washed-out pictures)

• Auto-focussing with adjustable zoom

• VERY good image stabilization

• HD video-recording

General Problems with Head-Mounted Video Recordings

The problem with current head mounted video-recording systems including Google Glass are several-fold. First of all, no matter how good you think you are staying still, there are constant micro-motions/tremors which produce unusable erratic videos. This annoying camera movement becomes even more pronounced when using cameras with longer focal lengths which is why most head-mounted camera systems come with a fixed, wide-angle lens which unfortunately takes away from the narrow-angle, focussed shot a surgeon would like recorded.

Also, the smaller and lighter the camera, the more inferior the optics resulting in poor video quality (compared to high-resolution, 3CCD, HD recordings which is what the surgeon's want).

These short-comings are common with all head-mounted video-recording systems. Unfortunately, there are even more problems depending the camera.

Google Glass (or any eyeglass side-mounted camera)

Typically, when a surgeon operates, the surgical field (green) is a certain distance from the his/her face. When in a comfortable position, wearing any type of head-mounted camera system located on the side like Google Glass unfortunately ends up video-recording a point that is above and to the side (purple) of what is actually desired.

In order to compensate the vertical offset, either the surgeon has to flex the head more or move the eyeglass down towards the lip.

To adjust the horizontal offset, the surgeon would have to turn and move the head to one side such that the camera has a more direct line shot into the surgical field... but that would mean the surgeon would be operating off-centered, almost looking over one shoulder.

Although doable, this is far from perfect or comfortable.

Central Head-Mounted Video Camera Systems

There ARE video-recording cameras that contain a camera that can be placed centrally over the forehead or between the eyes including Luxtec and SurgeonCam which are mounted on the headlight and PivotHead glasses (among others) where the camera is built into the frame between the eyes.

The headlight mounted systems'  camera angle can be adjusted to provide a more precise POV recording, but the general disadvantages of body-worn cameras still apply with constant erratic motion and wide-angle shots that do not specifically focus in on the surgical field.

The PivotHead glasses do provide perfect central shots, but still suffer from a vertical offset (orange) which cannot be adjusted like the headlight mounted systems.

Overhead Mounted Camera Systems

For the same reason the best photos are obtained by cameras fixed to a tripod, the best videos are often obtained by cameras fixed into position by a stationary object.

One object cameras can be attached to are overhead fixtures.. specifically the operating room lights.

Such cameras are attached typically to the light-handle of such overhead operating room lights which are directed down into the surgical field. Such systems provide excellent focussed, stable, high-quality video-recordings with one BIG disadvantage. The surgeon's head keeps getting in the way.

Also, the light-handle is positioned for optimal lighting of the surgical field... not optimal framing for capturing good videos.

Bed-Mounted Camera Systems

Using a Thompson Laparoscopic Retractor System, the video camera can be attached to one of the articulating arms and adjusted sterilely as needed. Using this retractor system can allow the camera to be positioned independently of the overhead operating room lights and to be as close to the surgical field as necessary.

The video is limited by how good the camera is that is attached. The best one I've been able to find is the Sony HXR-MC1 which incorporates a large-sized lipstick camera that is attached to a controller where manual controls for focus, zoom, white balance, exposure, etc can be made. Other than the built-in LCD screen, there are included plugs (Component, RCA, and with adapter S-Video) that allow what the camera is recording to be thrown up onto a large screen.

Other wireless video lipstick cameras are now being produced, but lack manual controls to adjust zoom, white balance, and exposure. Some offer real-time video display so it may be just a matter of time before all other manual controls found with the Sony HXR-MC1 become more widely available.

The main disadvantage with this setup is that the setup itself can get in the way of the surgeon.

Conclusion

So there you have it... No perfect surgical POV video system yet... Maybe in the next few years if technology keeps moving the way it is.

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Hearing Protection and NRR (Noise Reduction Rating)

For all hearing protection devices from ear plugs to ear muffs, there is a NRR (Noise Reduction Rating) score that informs consumers how much of a decrease in noise exposure to expect with use. For example, if an ear plug has a NRR score of 30, use of the device would be expected to reduce a 90 decibel sound by 30 decibels resulting in a noise exposure of 60 decibels.

If two hearing protection devices are used, an ear plug inside the ear canal followed by ear muffs over the ear, the ultimate noise exposure would be an additional 5 to 10 decibels greater than the higher rated NRR of the two devices.

How is NRR determined anyways? This single number rating is determined by the Environmental Protection Agency as specified under 40 CFR (Code of Federal Regulations) Part 211, Product Noise Labeling, Subpart B - Hearing Protective Devices. The raw data compiled from test subjects is than plugged into a formula which than produces the NRR:

Given that, there are MANY different types of hearing protection devices on the market. Regardless of style, most devices offer a NRR between 20-30. However, as a general rule, ear plugs typically offer a higher NRR than ear muffs. Among high NRR earplugs, disposables offer higher NRR than reusables. BUT... ear muffs typically block sound more consistently than ear plugs which require some degree of molding and fit for optimal effectiveness. Using both obviously is better than using just one.

Also, keep in mind that unless hearing protection devices are correctly fit and used properly, the attenuation suggested by NRR may not over-estimated. Indeed, lay-use of such devices without training typically result in sound attenuation far below what NRR may suggest.

The highest rated NRR disposable ear plugs are around 33:


The highest rated NRR ear muffs are around 30:

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Surgeons Should be Good at Social Media

Not just surgeons, but also any procedural intensive medical specialties like interventional cardiology and radiology should be reasonably good at social media.

Why?

Because we have built-in time points within our daily routine schedule that enable such activities.

Let me explain... Between every surgical case, there is downtime that lasts anywhere from 15 minutes to as long as 45 minutes.

It is the time during which the operating room is being cleaned, sterilized, and new instruments are brought in and set up.

Before the days of social media, this is the time when many surgeons would read the newspaper/magazine, eat in the cafeteria, surf the internet, chat with staff, etc. Of course, any consults and paperwork that are pending would first be addressed.

But now... this time can be used for social media activities.

This time can now be used to read/write blogs, read/post tweets, and generally think of ideas worthy of sharing.

OR... if you are just sitting there waiting for a surgical case to start, check out my tweets or blog!

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What is the Best Antibiotic for Strep Throat?

The traditional answer for the best antibiotic to treat strep throat is penicillin. This antibiotic works astoundingly well... until it doesn't. Why is that?

Although in the lab, penicillin is probably the most effective antibiotic against Group A beta-hemolytic streptococci (GABHS) or "strep throat" infection, when it comes to human beings, it doesn't always work. A recent paper out of Georgetown elucidates the reasons why that might be the case and also explains why if you took a survey of ENT doctors, clindamycin and augmentin are perhaps the two most popular antibiotics used in our patient population (patients seen in an ENT practice suffering from recurrent and/or severe infections of the head and neck region).

Penicillin may fail to work because:

• presence of beta-lactamase producing bacteria that "protect" strep from penicillins
• absence of bacteria that interfere with the growth of strep
• co-aggregation between strep and Moraxella catarrhalis
• poor penetration of penicillin into the tonsillar tissue cells which allows intra-cellular strep and Staphylococcus aureus to survive

Indeed, in the treatment of recurrent and chronic strep throat, clindamycin or amoxicillin-clavulanic acid (augmentin) can eradicate both aerobic and anaerobic beta-lactamase producing bacteria as well as strep itself. Cephalosporins and clindamycin have superior intracellular penetration which enhances their efficacy as well.

Of course, if a patient has suffered from such severe and recurrent strep infections, it just might be time to remove and tonsils and adenoids surgically.

Reference:
Penicillin failure in the treatment of group A streptococcal pharyngo-tonsillitis: Causes and solutions. Journal of Pediatric Infectious Diseases. Volume 8, Number 2 / 2013 Pages 59-69

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What Reflux Meds are Best in Infants and Children?

Once a decision is made to start medications beyond the conservative ways of dealing with reflux, the most common reflux medications used to treat adults are also used to treat reflux in infants and children. They are the same exact medications, albeit at lower dosages.

Although the effectiveness of such drugs are clear in adults suffering from acid reflux, it is less so in children. As is true with so much of medicine, there's no clear answer to the question of what the best reflux med is for infants and children. According to one review of literature, the answer is decidedly mixed and variable depending on what outcome was looked at (subjective symptom improvement or objective test findings).

In fact, symptom improvement (or lack of) did not always correlate with objective test findings (24 hour testing, barium swallow, EGD, etc) of reflux improvement and vice-versa. The most common finding was reduction in reflux based on tests, but no significant improvement in symptoms. Such findings does bring into question whether the diagnosis of reflux was even accurate.

In any case, when looking at SYMPTOMS in infants (less than 12 years of age) use of proton pump inhibitors was decidedly not favorable (one study in support and 4 against). In children (over 1 year of age), proton pump inhibitors were found to be equally effective to alginates and ranitidine.

When looking at OBJECTIVE test findings, proton pump inhibitors were found to be equally effective in both infants and children compared with placebo, alginates, or ranitidine. For reducing histologic aberrations, proton pump inhibitors showed no difference compared with ranitidine or alginates.

Conclusion
If GERD symptom control is the main goal, proton pump inhibitors should not be used in infants. In older children, these medications are helpful but potentially no better than alginates and zantac which have better side effect profiles. As is true with most studies, more study is needed.

Reference:
Efficacy of proton-pump inhibitors in children with gastroesophageal reflux disease: a systematic review. Pediatrics. 2011 May;127(5):925-35. doi: 10.1542/peds.2010-2719. Epub 2011 Apr 4.

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What is the BEST Way to Disinfect a Toothbrush?

In my previous blog article, I discussed the debate over whether a toothbrush becomes "contaminated" leading to the practice of throwing them out after a strep throat infection. Although the answer is still ambiguous whether it helps or not, the fact that even NEW toothbrushes contain harmful bacteria brings even more confusion on what to do.

Going on the assumption that bacteria on a toothbrush is harmful and if a new or old toothbrush contain such bacteria, perhaps the best practice would be to disinfect toothbrushes on a regular basis.

Would toothbrush disinfection work best by...

• Microwave
• Ultraviolet light (examples in this list from Amazon)
• Dishwasher
• Listerine
• Crest Pro-Health
• Air dry
• 3% Hydrogen Peroxide

Although the ultraviolet sanitization method is perhaps getting the most attention due to the high-tech nature, researchers have found that though this method did significantly decrease bacteria load, they also have found this method to be the least effective compared to other measures.

Rather, the best way to disinfect a toothbrush is by rinsing the toothbrush with Crest Pro-Health mouthwash for 20 minutes OR having it go through a normal dishwasher cleaning cycle.  3% Hydrogen Peroxide was also found helpful.

Interestingly, Listerine didn't work much better than air-dry alone and ultraviolet light didn't do much better.

Bottom line?

Don't waste your money on ultraviolet light toothbrush treatments.

Rather, if you already use a dishwasher regularly, stick the toothbrush in there. If you already like gargling with mouthwash, get Crest Pro-Health which can also disinfect toothbrushes effectively.


References:
Disinfection of toothbrushes contaminated with Streptococcus mutans. Am J Dent. 2011 Jun;24(3):155-8.

Germicidal activity of antimicrobials and VIOlight Personal Travel Toothbrush sanitizer: an in vitro study. J Dent. 2010 Aug;38(8):621-5. doi: 10.1016/j.jdent.2009.08.011. Epub 2009 Sep 23.

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Pinterest for the Medical Office

For some time now, I've been struggling to figure out how to use Pinterest social media as it applies to a medical practice.

Pinterest is a pinboard-style photo-sharing website that allows users to create and manage theme-based image collections such as events, interests, and hobbies. Users can browse other pinboards for images, 're-pin' images to their own pinboards, or 'like' photos.

Pinterest is also one of the newest and hottest social media platform, especially among women and 20-40 years old demographic. As such, it behooves physicians and hospitals interested in social media to figure out how to incorporate Pinterest to their social media campaign.

For more interesting Pinterest statistics, check this webpage out.

BUT... given its visual and pictoral nature, it has been problematic when incorporating into something as privacy-ridden as healthcare.

How to use Pinterest for a medical practice and be successful without getting into trouble with HIPAA?

Not sure I have the secret, but I've ultimately decided that relevant medical infographics is the best way to go.

We shall see...

Check out our Pinterest page here!

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Find an ENT Doctor App

If you have an iPhone or Android, get the ENTLink App... You can search for an ENT by current location or by zip code. The search can be narrowed to a specific specialty area (laryngology, neuro-otology, rhinology, etc) as well.

Of course, you can search for the same information from the website.

Download the app for iPhone and Android.

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Azithromycin Increases Risk of Death Slightly... Well, So Does Tylenol and Ibuprofen

The media has made much fuss about a NEJM study suggesting a slight increased risk of death from taking azithromycin or z-pack. The more unhealthy you are, the higher the risk... no duh... (I would think the sicker you are, the greater the risk of death PERIOD... a sick person by definition is closer to death than a healthy person).

How slight? Compared to amoxicillin, about 47 additional cardiovascular deaths per one million courses of therapy.

Never mind the blatant biases found in the study nicely espoused on by cardiologist Dr. Wes in his blog. I should also point out that there's another study that did NOT find an increased risk of death with azithromycin.

Thinking you should never take a z-pack again due to this slight increased risk of death?

Well, good luck finding an alternative medication (of any kind) because they ALL have a potential risk of death.

Similar to z-pack, these other antibiotics also have an increased risk of sudden cardiac death:

• Avelox
• Bactrim
• Biaxin
• Cipro
• Diflucan
• Erythromycin
• Factive
• Floxin
• Foscavir
• Ketek
• Levaquin
• Sporanox
• Sulfa
• Tequin

It's not just antibiotics. These other common medications (not all-inclusive) also have an increased risk of sudden cardiac death:

• Benadryl (allergy)
• Pepcid (reflux)
• Albuterol (asthma)
• Prozac (depression)
• Serevent (asthma)
• Sudafed (decongestant)

The complete list can be found here.

Let's consider other popular drugs that also has an increased risk of death, though not necessarily from a cardiac trigger.

• ALL antibiotics due to a severe anaphylactic allergic reaction - Take Penicillin for example... about 300 die annually from penicillin allergic reaction in the US
• Tylenol causes liver failure - About 400 deaths per year in the US
• Ibuprofen causes internal bleeding - About 15,000 - 20,000 die per year in the US
• Alcohol related deaths - 75,000 deaths per year in the US
• Smoking related deaths - 443,000 deaths per year (one in five deaths) in the US

Never mind deaths from driving a car, accidental gunfire, drowning in a swimming pool, etc.

Life in general in the United States has a risk of death.

Source:
Azithromycin may up chance of sudden cardiac death. Heartwire 5/16/12
Popular Antibiotic May Raise Risk of Sudden Death. NYT 5/16/12
Azithromycin and the Risk of Cardiovascular Death. New England Journal of Medicine 2012; 366:1881-1890May 17, 2012
Use of Azithromycin and Death from Cardiovascular Causes. N Engl J Med 2013; 368:1704-1712May 2, 2013DOI: 10.1056/NEJMoa1300799

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Best Drops for Earwax Removal

It's about time, but some researchers actually put to the test to try and determine what is the best solution to dissolve/remove earwax.

The verdict was... WATER!

Better than mineral oil, liquid colace, and over-the-counter cerumenolytics (ie cerumol). Hydrogen peroxide was not evaluated.

How was this result determined?

Using guinea pigs, the researchers first tested whether each of these substances were safe should a hole in the eardrum be present allowing for the solution to enter the middle ear space. Colace was found to be the most ototoxic (meaning, potential for permanent hearing loss if a ear tube or a hole in the eardrum is present). Mineral oil and saltwater (normal saline) was found not to be toxic.

Next, they determined which substance provided the greatest degree of cerumen dissolving ability. Each substance was added to a cylinder filled with earwax for 5 minutes. They than determined how much weight was required for a 25G needle to fully penetrate through the earwax.

Water was found to provide far superior earwax dissolving ability compared to all other substances tested. Not surprising given water is considered the best universal solvent used to clean everything from dishes to cars to buildings.

What is the take-home message?

Given saltwater/water is completely safe for hearing even if there is a hole in the eardrum along with superior earwax dissolving ability, it seems to be a no-brainer to instruct patients with lots of earwax to use salt-water to get rid of earwax.

Reference:
Ototoxicity of intratympanic docusate sodium and mineral oil in the Guinea pig. Otolaryngol Head Neck Surg. 2012 Mar;146(3):455-60. Epub 2011 Nov 18.

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Nasal Hair Removal and Nasal Sores

It is not unusual that I encounter a patient who develops crusting and sores around the entrance to the nose where coincidentally nasal hair is found... in both men and women.

Other complaints/symptoms beyond crusting and sores include:

• Skin Splitting
• Pimple/Acne Formation
• Scabbing
• Ulcers

People often try applying lotion, neosporin, or cortisone cream... which does help, but not completely with recurrent flareups.

The most common triggers I find that lead to such recurrent sores are nose-picking and nasal hair removal.

The best thing is to avoid doing either... but... if one must...

Nose picking is pretty self-explanatory, but nasal hair removal does require some clarification.

People often use tweezers or even their fingers to pull the offending long nasal hair out for either cosmetic or annoyance reasons.

Yanking nasal hair out is not a good idea beyond the watery eyes it may bring. It causes micro-trauma to the surrounding skin and hair follicle that may lead to infection. Furthermore, just like any other place on the body where hair is removed, ingrown hair growth can also occur.

Aha! one might say... Use an electric nasal hair cutter! That's a good idea, but make sure it does not cut down to the skin for the same reasons as stated above. Also, ensure the blades are kept sharp to prevent hair pulling.

There are good nasal hair cutters and there are bad ones...

From personal testing of a variety of nasal hair cutters, I like the Groom Mate Platinum XL.

I'm sure there are other good ones, but it may also come down to personal preference.

Now, if there's an active recurrent nasal sore that's not healing, the best way to treat it is with prescription cortisporin ointment.

However, best to have a doctor to check it out as there are other more malicious reasons for a nasal sore including skin cancer.

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For a Physician, When is the Best Time To Tweet or Publish a Blog?

According to professional bloggers and tweeters, timing of content publication is important in order to maximize getting noticed and shared. From a general topics viewpoint (not healthcare specific; data taken from here):

• 4PM Eastern is the best time to Tweet
• Friday is the best day to Tweet
• 9AM Eastern is the best time to Facebook share
• Saturday and Sunday are the best days to Facebook share
• In the morning is the best time to blog
• Publishing a different blog article multiple times throughout the day is better than once per day

However, I've always wondered if such "rules" similarly apply to healthcare content as by their very nature, people tend to search a problem after seeing their doctor or seeing/reading it on the news.

Ever since I've been monitoring my website statistics starting in 2005, I've noticed some undeniable trends of "when" website activity occurs which presumably reflects "when" healthcare keyword searches occur.

For any given 24 hour period of time (graph shown below is for Nov 14-15, 2011), my ENT practice website got THE most activity between noon and midnight; peak activity being from noon - 3PM.

On a weekly basis (graph shown below is for Mon Nov 14 - Sun Nov 20, 2011), the greatest activity is Monday thru Wednesday after which web traffic drops off almost 50% by Saturday before bouncing back up 100% on Monday.

Such statistical fluctuations have been true for the past 5 years I've been tracking this stuff.

Now I certainly can't explain the "why" this phenomenon happens without more google analytics data from more healthcare websites, but I certainly can take advantage of this knowledge as it pertains to ENT problems (though I suspect that what is true for ENT is true of other health problems when it comes to web traffic).

How can I take advantage of this knowledge?

People are CONSTANTLY adding to the content found on the web, all vying for the attention of eyeballs. Being the first is important as it seems to me that google values original content (not copies that appear later), but just as important is "when" the content first appears as one would like to ride the wave of when healthcare keyword searches occur.

Overall, the holy grail is to come up with great original content, be the first to publish it, but publish it at the right time.

Great, Original Content

Good content is king and #1 in the priority of getting noticed. If your content stinks, being first and when you publish won't matter.

Be the FIRST to Publish

I can't prove it and I don't have supporting evidence for it, but it seems that google does prefer content that appears "first" over copies that appear later. The prime example is Associated Press articles that are syndicated and re-published over a wide variety of different newspaper websites throughout the world.

If google encounters the same exact article 100 times, how does it rank one over the other?

I suspect, it ranks based on two factors:

1) "Popularity" of the website publishing the content
2) Being the first to publish

Obviously, an individual only has control over timing. Take advantage of it.

WHEN to Publish

Though being the first to publish is important, the timing of when to publish is also extremely important. It's almost like surfing... You want to be the first to stake out a place to ride a wave... but you need to be where the waves are.

Given the dramatic... but consistent... fluctuations in healthcare web activity, it is better to wait and publish when people are actively searching. It is more likely to get noticed and hopefully shared, emailed, liked on facebook, tweeted, etc. Going viral is the goal all content publishers dream of.

So, WHEN is the golden moment to publish?

It is around 11AM on Mon, Tues, and Wed based on my limited data.


Conclusion

Now, do I even follow my own advice?

Not necessarily... I tend to go with the "be the first" rule regardless of the time, not because I feel it more important than the timing of publication, but it's just that I have so much other things to do (like taking care of patients), that if I come up with an idea to write about, I just publish it and not worry too much about timing.

BUT, if I do have a moment, I WILL tend to publish things timed between 11AM and 3PM during the week.

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Dr. Chang a Castle Connolly Top Doctor in America

In November 2011, Dr. Christopher Chang was added to Castle Connolly's list of Top Doctors in America. Apparently, he is the only Top Doctor in the field of otolaryngology within a 30 mile radius.

It's no surprise given patients travel from as far away as California and even the Philippines to be treated by Dr. Chang.

You can check out his listing here or on US News and World Report of Top Doctors.

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New Video on "Where" Snoring Comes From and Treatment

Our office has produced a new video describing "where" snoring comes from determined by a simple procedure known as sedated or sleep endoscopy.

At its most basic definition, snoring is noise produced from a vibrating mucosal surface in the upper airway.

Though snoring can be defined simply, the tough question is WHERE are these vibrating mucosal surfaces? Because unless one can define WHERE the snoring is coming from, successful treatment can't be pursued definitively.

An office exam performed while a patient is awake is suboptimal as the patient is awake... and not snoring. As such, it is an educated guess where the snoring problem is stemming from.

To this end, there are three main levels where snoring can be produced and the best way to localize a snore is to perform the exam while the patient is asleep (induced by anesthesia) and snoring!

1) Nose
2) Mouth
3) Throat
4) All of the above

Watch the video to see how each of these areas can contribute to a person's snore as well as treatment options.

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YouTube Ranks Fauquier ENT as Most Viewed for Medical Videos

I was informed that our practice's YouTube channel has been ranked as one of the most viewed channels related to medicine in the world!

As of Oct 6, 2011, our channel which contains 52 videos has received 198,064,840 views. We currently average over 500,000 views a day!

We far surpass other more "prestigious" medical organizations with a YouTube channel.

Mayo Clinic Channel Channel
4,936,943 views

University of Maryland Medical Center Channel

2,047,260 views

CDC Channel 

4,173,563 views

Massachusetts General Hospital (Harvard) Channel 

33,994 views

Children's Medical Center Channel 

318,688 views

Duke Medical Center Channel 

1,571,694 views

Medical University of South Carolina Channel 

699,002 views

UVA Health System Channel 

29,922 views

Stanford Medical Center Channel 

132,303 views

British Medical Journal Channel 

216,331 views

Penn State Hershey Medical Center Channel 

46,688 views

Scripps Health – San Diego Channel 

212,848 views

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