Device that Allows Intubated Patients to Talk

Image by Calleamanecer in Wikipedia

There is nothing worse than to be very sick. It's even worse if you are intubated in the ICU (intensive care unit) being poked and prodded constantly. Traditionally, such sick intubated patients (if alert) will communicate by writing on a clipboard which is often frustrating to not just the patient, but also family members and healthcare professionals trying to care for the patient.

However, NEJM reported on the use of an electrolarynx to allow intubated patients to "talk". Electrolarynx is traditionally used by patients who have had their voicebox removed due to cancer (laryngectomy). Held similarly to a razor, a patient is able to talk by mouthing words while pressing the electrolarynx against the neck The electrolarynx produces vibrations within the throat that allows for speech sounds. See video below to see how it works.

Apparently, this device can also be used by intubated patients to communicate with caregivers. According to the article, speech by intubated patients occurred after only 2 minutes of instruction. Optimal placement of the electrolarynx was between the upper trachea and the sternocleidomastoid muscle. A video is shown in the article webpage demonstrating a patient who is intubated talking using an electrolarynx.

Electrolarynx can be purchased on Amazon.com.

Reference:
Speech in an Orally Intubated Patient. N Engl J Med 2014; 370:1172-1173March 20, 2014DOI: 10.1056/NEJMc1313379

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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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Ear Tube Placement in Kids WITHOUT Sedation (Starting at 12 Months of Age)

A recent report describes how using a relatively old technology, ear tube placement can now be performed in children starting at 12 months of age with chronic ear infections or hearing loss due to fluid buildup without the need for sedation of any kind nor aggressive restraints (ie papoose). Historically, ear tube placement in the office without sedation is typically performed starting at around 12 years of age using standard local anesthesia techniques. Any younger, a child could not be trusted to stay still during the procedure due to presence of some discomfort.

In any case, a Texan ear group reports how they accomplished this simple procedure at such young ages.

First, the ear canal is cleaned as much as possible of all earwax and debris. The ear canal is than filled with an anesthetic liquid (concoction of lidocaine, epinephrine, and sodium bicarbonate). Over 10 minutes, iontophoresis was than used to induce profound local anesthesia to the ear canal and eardrum. The liquid was than suctioned out and ear tube placement was performed with a reported 90% success rate (78 of 86 ears; 17 subjects were 3 years old or younger; 8 were 12 months old).

The key to success required 3 "new" elements.

• Iontophoresis device made by Acclarent. There are other iontophoresis devices in the market (Medtronic and Otomed), but none adapted for simultaneous bilateral ear canal usage that works within 10 minutes. Iontophoresis works by applying a gentle electric current in order to actively move charged drug molecules into the skin. In this particular case, positively charged lidocaine and epinephrine.
• Optimal anesthetic solution for iontophoresis. Dubbed "EMGIM", it contains 1:12,000 epinephrine with 3.3% lidocaine hydrochloride and 0.7% sodium bicarbonate. The solution is prepared fresh prior to use by combining 10 mL of 4% lidocaine hydrochloride with 1 mL of 1:1,000 epinephrine. After mixing the lidocaine and epinephrine, 1 mL of 8.4% sodium bicarbonate is added.
• Ear tube delivery device and placement system. Typically, a competent ENT can place an ear tube in about 10-20 seconds. However, when dealing with kids who may potentially move unexpectedly and operating within a very small ear canal space, a faster and more reliable way of placing a tube was required. Hence, this new device. [link]

Of course, during the actual procedure, age-appropriate distraction was needed to minimize movement, especially given aggressive restraint was not used.

Sounds great as sedation is something to be avoided if at all possible. However, there is one problem... the Acclarent iontophoresis device is NOT yet FDA approved contrary to what the report states (direct communication with Acclarent executives October 1, 2013). Hopefully in 2014. As such, beyond a research setting, this in-office technique is not yet available for use in the United States.

As an aside, there are FDA-approved iontophoresis devices for use in pediatric head and neck surgical procedures mainly for sub-cutaneous mass excisions and abscess incision and drainage. Check out Phoresor for such applications using lidocaine infused electrodes. It's even sold on Amazon.


References:
Otologic Iontophoresis: A No-Papoose Technique. Annals of Otology. Rhinology & Laryngology 122(8):487-491. Aug 2013.

In-Office Tympanostomy Tube Placement Under Local Anesthesia Using a Novel Tube Delivery Device. Triological Meeting Poster. Dec 2012.

Iontophoresis: a needle-free, electrical system of local anesthesia delivery for pediatric surgical office procedures. J Pediatr Surg. 1999 Jun;34(6):946-9.

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Compact EMG System for Targeted Muscle Injections

An EMG system (ElectroMyoGraphy) is a critical piece of equipment when it comes to targeted muscle injections in and around the neck, especially when you cannot see or feel the muscle.

This scenario is especially true when dealing with spasmodic dysphonia for which targeted botox injections are quite helpful. Given the muscles that need to be injected are contained inside the voicebox and not able to be seen and felt from outside the neck, accurate injection is quite difficult without EMG guidance.

Watch a video of this procedure using a traditional EMG system.

However, such traditional EMG systems are "overkill" in terms of technology and cost when all it is being used for is muscle placement.

It was with great excitement that a compact EMG device has been developed for just such a need when all that is required is needle localization for directed drug delivery.

Check out the MyoGuide made by Intronix Technologies based in Canada. The US supplier is Ambu.

I've been using MyoGuide for a few months now and am quite pleased with its performance. It pretty much does exactly what I want it to do... no more or less. There is both audio and display feedback, though I mainly depend on audio. It runs only on batteries.

For head and neck muscle injections, I find that a volume setting of 8 and vertical sensitivity of 6 works best.

My personal preference is using Ambu Inoject 35mm 27G needle for ADductor spasmodic dysphonia and the Allergan EMG needle for ABductor spasmodic dysphonia.

For those interested in trying out this device, there is a 2 week free trial.

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Does WaxVac or EarVac Actually Remove Earwax?

The EarVac or WaxVac is a device that purportedly suctions out earwax. Shaped like a miniature hair dryer, one simply needs to hold it up to your ear canal in order to suction out the earwax. Recently, they have been marketing this device heavily, especially through TV commercials.

Now, does it actually work???

Not really... In fact, British researchers tested it out against the humble ear curette (Jobson-Home Probe). With their test population, the WaxVac worked in exactly ZERO percent of patients. The ear curette worked 100% of the time to restore eardrum visibility and 88% for subjective hearing improvement for the patient.

Why would the WaxVac work so poorly?

Think of a handheld vacuum cleaner. Even for a regular vacuum cleaner, it will only suck up debris only when it is right on top of it. One can't "vacuum" out a bedroom simply by holding the vacuum cleaner at the bedroom door entrance or hovering it around in the bedroom. The vacuum needs to be placed DIRECTLY over debris in order to suction it out.

Well, the same goes for the WaxVac.

Even when the ear canal is professionally vacuumed by an ENT under the microscope, it only works with some earwax types... and doesn't work at all for other earwax types.

I also wanted to point out the danger of using an WaxVac which has the potential to create high negative pressures when sealed up against the ear canal entrance which could lead to eardrum perforation as well as permanent hearing loss (similarly to kissing ear syndrome).

As such, I personally do not recommend this product. However, should you decide to purchase it, I would strongly urge people to do their homework before buying this unproven device. Even if it did work, beware that the company seems to make their money by scamming people with shipping charges [link]. 

Reference:

A non-randomized comparison of earwax removal with a 'do-it-yourself' ear vacuum kit and a Jobson-Horne probe. Clin Otolaryngol. 2005 Aug;30(4):320-3.


Watch how earwax is cleaned at an ENT office video.

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Yet Another Sinus Dilation Device - AerOS Sinus Dilation System

Sinus dilation has become all the rage in the past few years to treat chronic sinusitis, especially since CPT codes for this procedure has become available as of January 2012.

The first company was Acclarent who coined the balloon sinuplasty term.

Next was Entellus who produced their simpler system (XprESS and FinESS).

Now, there is SinuSys who has produced a new way to dilate the sinus opening without use of a balloon like Acclarent and Entellus. It is currently pending FDA approval, but is used in Europe.

This new system is called AerOs Sinus Dilation System and utilizes an osmotic self-expanding technology. A "simple" two-step insertion and removal of the device is required. Once inserted, the device gradually expands via low-pressure osmotic pressure in about 60 minutes. At that point, it can be removed.

The device itself is 5mm in size and exerts pressure of 2.5 ATM. The diameter is 3mm before dilation that ultimately expands to 5mm.

Compare this with Acclarent and Entellus balloon devices which are inflated to 12 ATM pressure and expands up to 7mm in size (depending on the model).

My personal concern with this device is the small size of 5mm... the surgeon will have to be super-precise for placement, otherwise, it'll fall out or do nothing.

Also, I question whether a 2mm dilation will actually make any difference. Prior studies have established that 4-5mm ostia size really is the minimal efficacious opening size. Larger is better, especially when the uncinate process is still intact as it would be in pure dilation cases. More study is required.

In any case, when (or if) this new device becomes available in the USA is unclear. It's all up to the FDA now.

Reference:
Feasibility of an osmotically driven, self-expanding device for sinus dilation to treat chronic sinusitis. Poster Presentation

Assessment of the short term patency of the maxillary sinus ostium following dilatation with an osmotic device in a sheep model. Jerome E. Hester, MD, David Edgren, BS, Andrea Koreck, MD, PhD, Jason Fox, BS, Janie Mandrusov, PhD, East Palo Alto, CA USA (Annual Meeting of American Rhinologic Society, September 2012, Poster# P-7).

Treatment of Maxillary Sinusitis Using the SinuSys AerOsTM Sinus Dilation System. White Paper 

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CPAP + Oral Appliance (All-In-One) Device for OSA

A dentist colleague of mine informed me of a new device that combines CPAP mask with an oral appliance for patients with obstructive sleep apnea (CPAP Pro + Mandibular Advancement).

The unique benefits of this combo device are several-fold:

• No straps
• Keeps mouth closed
• Addresses tongue collapse that obstruct the airway by bringing jaw forward
• Can sleep in any position

This device does need to be fitted by a dentist. (For Virginia residents, Dr. Jason Woodside is familiar with this product.)

Of course, it is relatively new and we'll see if patients love this combo CPAP mask more than the traditional masks that have been on the market.

For those patients who do NOT have a problem with tongue collapse, but prefer the no-straps solution of the oral appliance, the company does make a mouthguard that fits only the upper teeth.

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New Medical Device to Cure Excessive Sweating

Everybody sweats, but some sweat more than others to the point where even constant anti-perspirant usage is insufficient.

Beyond botox which is painful and lasts only a few months, options have been few until now...

A new medical device called Miradry destroys sweat glands by heating up the junction between the second and third layer of the skin using microwave after sucking up secretions. Before the procedure, numbing injections are required.

A company study shows patients who used Miradry experienced an 82 percent reduction in sweat over 18 months. Patients may require the procedure to be repeated for ultimate sweat control.

So far, it is available ONLY for underarm treatment.

However, for those with excessive facial sweating, botox injections or robinul medication is still the only treatment, but who knows... perhaps Miradry will soon be available for the face/neck area at some point.

References:
Clinical Evaluation of a Microwave Device for Treating Axillary Hyperhidrosis H. Chih-Ho Hong, MD, Mark Lupin, MD et al; Dermatologic Surgery 2012; 38:728-735

A Randomized, Blinded Clinical Evaluation of a Novel Microwave Device for Treating Axillary Hyperhidrosis: The Dermatologic Reduction in Underarm Perspiration Study Dee Anna Glaser, MD et al; Dermatologic Surgery 2012; 38:185-191

Microwave thermolysis of sweat glands Jessi Johnson, PhD et al; Lasers in Surgery and Medicine 2012; 44:20-25

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New Oral Appliance for OSA (Only Needs Heat to Fit)

A new sleep apnea oral appliance can be fitted and used at home without going to a dentist called ApneaRx!

Oral appliances to treat obstructive sleep apnea (OSA) have an upper and lower component that fit into the upper and lower jaws. A mechanism within the device than allows for the lower jaw to be thrust forward to some degree which pulls the tongue and anterior airway forward thereby enlarging the airway and preventing obstructive apneas during sleep. It can also help with snoring.

Typically, such OSA oral appliances must be fit by a dentist and cost upwards of $300 or more.

Most patients or loathe to spend that kind of money if they are not sure if:

1) It will actually help
2) It will be something they can actually tolerate or use

That's where this new OSA oral appliance called ApneaRx comes in which is considered a "transition" device to try and see if oral appliances will work for a given patient before going with an expensive dentist-fit customized oral appliance.

In essence, the device is heated and bitten into for fitting. The device can than be adjusted in 1mm increments by squeezing from the sides.

If this device "works" for a patient, they can either continue to use this device, or now take the time and expense of getting a customized device from a dentist.

Best of all, you can get it on Amazon!

However, please be aware that there's only one size currently available which may be too large for 20% of patients, especially women. There will soon be a smaller version for those with a smaller mouth by the end of 2012.

Read brochure.

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Doctor Distraction Happens... It's Mandatory!

I admittedly snorted out loud when I read a New York Times article  earlier last week regarding increased physician distraction due to electronic devices, especially with the advent of the smartphone with its emails, text messages, calls, and other alerts that ping intermittently throughout a typical work day.

There is no question that electronic devices distract physicians as the article pointed out... But that's like complaining about a leaky faucet when there's a flooded basement and a hole in the roof.

The bigger problem that should be mentioned is hospital bureaucracy which probably creates just as much if not more unintended distractions for physicians and nurses.

What many patients and lay public may not realize is that there is a TON of paperwork that goes into the care of a patient. Regulatory bodies like the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) that accredits hospitals have made it mandatory in many cases though I suspect hospital administration often carries it a step above and beyond what is truly necessary.

What all this "mandatory" paperwork means is that nurses are calling physicians all the time just so they can check a box on a form... and there are a LOT of boxes to check.

Take a simple ear tube placement. A procedure that takes about 1-2 minutes to perform under sedation in the pediatric population.

It takes about 15-20 minutes to fill out all the nursing and physician forms (whether paper or electronic medical records). When the surgery actually begins, the nurse is too busy filling out even more forms rather than paying attention to the surgery... and often the surgery is already over... and the nurse is still busy filling out forms.

Talk about distraction... a registered nurse has been relegated to being a mere secretary rather than helping (or paying attention) in the care of a patient.

I recently asked a nurse how much time they spent on actual patient care versus how much time filling out forms during a typical shift.

It saddened my heart when I was told 60-70% of a nurse's time is spent on filling out forms (whether notes, chart documentation, medication reconciliation, etc) and only 30-40% on actual patient care. This time disparity was not always true in years past.

OR... ask any physician how many times they get called during a typical day because some form or paperwork was not completed or needs completion or just remind to get it completed by nurses who themselves are the main individuals who suffer under the crush of mandatory documentation in a hospital setting.

It is irritating to say the least to get a phone call during the middle of an operation, say dissecting a tumor off the facial nerve during a parotid cancer resection, by someone who wanted to remind me to sign off on a medication list on a patient I've already provided prescriptions for.

Another classic experience of mine was when the anesthesiologist had trouble intubating a patient who started to suffer a severe lack of oxygen. I was immediately called to the bedside and performed an emergency tracheostomy.

Of course, the nurse (well indoctrinated in form completion) involved in the case immediately instructed me to STOP performing the trach and to get consent as per the regulations... which is true 99% of the time... but never mind that. Heaven forbid we now can't check that little box that states "consent obtained prior to surgery." But in the interest of patient care, I did suggest that it would be better if the patient lived with an unconsented trach rather than died due to time spent obtaining consent.

Though electronic devices may be considered a "distraction" analogous to a mosquito buzz that comes and goes, one must not forget the avalanche of paperwork which is a much more pervasive and insidious distraction that DELIBERATELY takes attention away from the care of the patient. I understand the need for documentation, but at some point when the documentation itself dominates the majority of heathcare rather than the actual administration of care, there's something fundamentally wrong going on.

It's probably why medical missions are so gratifying to participating nurses and physicians where 90%+ of the time is in actual patient care.

Reference:

As Doctors Use More Devices, Potential for Distraction Grows. NYT Dec 14, 2011.

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Woman Survives Live Grenade Lodged in Face

A 32 year old Mexican woman, Karla Flores, survived extraction of a live grenade from between her jawbones. Apparently, she was minding her own business when she was knocked out after something hit her face. Read report here.

In the hospital, it was realized that rather than a stone as initially thought, it was a live grenade!

Due to fear of it going off, 3 volunteer doctors and one nurse surgically removed the live grenade in an open field under direction of two explosive experts from the military.

Due to airway compromise, a trach was first performed prior to extraction.

Bear in mind, that the doctor who removed the grenade did not wear any armor.

Read more on Fox News here.

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