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Primer On Laparoscopic Gallbladder Surgery and Injury To the Biliary Tract

The biliary ducts carry bile from the liver to the small intestine. Bile aids in the digestion of fatty foods. The biliary tract begins as the left lobe duct and the right lobe duct which descend from the liver. These two liver ducts form at their bifurcation the common hepatic duct. As the hepatic duct descends toward the small intestine, the cystic duct which leads from the gallbladder joins the hepatic duct to form the common bile duct. The common bile duct descends into the small intestine. The ampulla of vater is the sphincter of tissue that controls the flow of bile from the common bile duct into the small intestine.

Cholecystectomy is the removal of the gallbladder due typically to gallstones or sludge formation. Most often a cholecystectomy is an elective or planned procedure though emergency cases occur. The gallbladder is removed surgically by clipping and transecting the cystic duct and the cystic artery so as to allow the gallbladder to be removed. The gallbladder is not a vital organ and if gallstones or sludge formation have occurred, it can be readily removed without a change in lifestyle or liver or biliary tract function.

An open procedure used to be the surgical method whereby the patient’s abdomen was opened and the biliary tract was examined in a traditional manner by the surgeon. In the late 1980s, laparoscopic surgery became the popular method of removal of the gallbladder. Laparoscopic surgery was touted as causing less pain to the patient and a shorter recuperative period.

Surgeons who were in active practice in the late 1980s oftentimes went through training which included proctoring at their hospitals by qualified and experienced laparoscopic surgeons. Medical students began laparoscopic training in medical school and were not required to undergo training after medical school.

Preceding removal of the gallbladder during laparoscopic surgery, trocars are introduced into the patient’s abdomen. The trocars allow for lighting, video camera illustration, surgical instruments and carbon dioxide insufflation. The abdomen is insufflated with carbon dioxide initially and video camera and surgical instruments are used to scan the abdomen for any abnormalities. The liver is lifted and the gallbladder is exposed. The gallbladder is grasped and a process of meticulous dissection begins to remove tissue and/or adhesions from the gallbladder and cystic duct so that accurate identification of the anatomy occurs. The better practice is to pull the base of the gallbladder to the patient’s right so that the cystic duct is perpendicular to the common bile duct. When the base of the gallbladder is not pulled to the patient’s right side then oftentimes the cystic duct aligns parallel to the common bile duct and this can lead to misidentification. A short cystic duct can contribute to misidentification of the anatomy. However, a short cystic duct is not an excuse since meticulous dissection will reveal the junction between the gallbladder and the cystic duct.

Because there are variations in the biliary anatomy, most surgeons agree that the safest practice is to perform a cholangiogram before a transection of any duct. A cholangiogram is a test where dye is introduced into the biliary system and outlines the system so that the anatomy is more readily identified. A cholangiogram is a safeguard for the patient since it helps to confirm that the surgeon has properly identified the anatomy and also the lack of any ductal injury. It also confirms that a gallstone is not obstructing the biliary tract below thereby eliminating a possible problem requiring re-invasive treatment at a later time.

Surgical journals reveal that many iatrogenic (“physician-caused”) injuries during laparoscopic cholecystectomies are oftentimes due to lack of experience. The Southern Surgeon’s Club reported that the new laparoscopic technique resulted in a learning period. The learning curve reflected a higher incidence of bile duct injury. The Southern Surgeon’s Club’s study found that within the first 13 cases of any participant’s experience, the bile duct injury rate was 2.2%, compared with 0% after the 13th case. During the initial 12 – 13 procedures the surgeon is on his “learning curve”. Another cause for injuries is the surgeon’s overconfidence resulting in failure to meticulously dissect and conclusively identify the biliary anatomy prior to transection.

The Society of American Gastrointestinal Endoscopic Surgeons (hereinafter “SAGES”) sets forth well-established principles for the prevention of injury during laparoscopic biliary tract surgery:

the cystic duct should be identified at its junction with the gallbladder;
traction on the gallbladder infundibulum should be lateral rather than cephalad (towards the “head”);
meticulous dissection of the cystic duct and cystic artery is essential;
gallbladder holes should be closed to prevent loss of stones;
the surgeon should not hesitate to convert to an open operation for technical difficulties, anatomic uncertainties or anatomic anomalies, especially in cases of acute cholecystitis (infection of the gallbladder);
liberal use of operative cholangiography is desirable to discover surgically important anomalies, clarify difficult anatomy and to detect unsuspected common bile duct stones;
all energy sources can cause occult injury.
Correct dissection exposes the cystic artery and the entire gallbladder infundibulum but not the common bile duct. The steps of dissection that will avoid confusing the common bile duct for the cystic duct are:
retraction of the infundibulum laterally;
initiation of dissection on the gallbladder (dissection should begin on the gallbladder and proceed along the cystic duct towards the common bile duct rather than vice-versa);
opening up all folds in the gallbladder;
stopping medial dissection when a sufficient portion of the cystic duct has been cleaned for cholangiography and clipping; and
application of the first clip to the base of the pedunculated gallbladder where it begins to taper to its stalk.

Because the cystic duct and cystic artery are the structures to be divided, it is these structures only that must be conclusively identified in every laparoscopic cholecystectomy. Accordingly, the cystic duct and artery should not be clipped or cut until conclusively identified. To achieve conclusive identification, Calot’s Triangle must be dissected free of fat, fibrous and areolar tissue and the lower end of the gallbladder dissected off of the liver bed. (The latter is an essential measure that precludes the possibility of injury to an aberrant duct.) At the completed dissection, there should only two structures seen to be entering the gallbladder, and the bottom liver bed should be visible. Note that it is not necessary to see the common duct. It is at this point that the surgeon has achieved the critical view of safety and the cystic structures may be occluded because they have been conclusively identified. Failure to achieve the critical view of safety because of difficulty of dissection as a result of inflammation or any other cause is an absolute indication for cholangiography or conversion to open cholecystectomy to define ductal anatomy.

If an injury is recognized early, it can be repaired by the surgeon and the patient stands a much greater chance of no resulting complications. Therefore, the standard of practice requires the surgeon to search for potential injuries prior to completing the surgery. The omission of cholangiography increases the odds of an injury failing to be recognized.

Injuries to the biliary tract can have a devastating impact on a patient’s life. Injuries that are discovered post-operatively should be referred to a specialized center with expertise in hepatobiliary surgery because the first attempt at repair is critical. The biliary ductal anatomy often has modest blood circulation when healthy. After an injury, a stricture or narrowing of the duct or lumen may occur due to inadequate blood supply and/or scar tissue. Further, studies show the probability of increased risk of stricturing after the initial stricture as well as increased mortality.

When a stricture occurs follows an injury, one effect is “back flow” pressure in the liver since the bile no longer flows to the intestine. If this pressure is not relieved, liver damage can result. One of the effects of prolonged stricture formation is dilation of the intra-hepatic ducts. (The extra-hepatic ducts are the ducts that flow out of the liver towards the intestine. The intra-hepatic ducts are the ducts within the liver.)

Repair of an injury to the common bile duct by the surgeon involves bringing up a loop of the small intestine and suturing it directly to the remaining duct. A Roux-en-Y hepaticojejunostomy is a surgical procedure often used to attempt to repair bile duct lesions or injuries high (towards the liver) on the bile duct. A hepaticojejunostomy involves removing a 8-10 inch loop of bowel from the small intestine, suturing one end closed, suturing a top portion of the loop to the remaining bile duct, and re-suturing the lower end into the intestine. Strictures also occur at the site of the anastomosis or the location where the remaining duct is sutured to the loop of intestine.

Cholangitis is infection or inflammation of the bile ducts. Since the ampulla of vater no longer is present in the injured patient, the sphincter of tissue that normally control the flow of bile from the common bile duct to the small intestine is no longer present. Therefore, the bacteria and other matter present in the small intestine can flow up the previously “sterile” biliary duct to cause infection possibly extending into the liver. Antibiotics are used to treat the cholangitis which is then usually resolved but may re-appear intermittently. Severe cases of cholangitis can be life-threatening particularly after several episodes due to the effect on the ducts and possibly the liver.

After a repair surgery, stricturing and re-stricturing occurs unfortunately. Many studies reflect that only 10-28% patients undergoing hepaticojejunostomy in these circumstances experience a stricture of the ductal anatomy. However, these studies arguably include “selection bias” of the physicians in choosing their patients reporting their results and the studies do not involve long periods of patient history review. Further, re-stricturing is more likely after an initial stricture. The author’s contact with experts reveals that strictures may occur as late as 20 years after the initial repair surgery. A minimum of 5-7 years is required in follow-up of the patient before a patient’s chances of stricture following a repair surgery diminish significantly.

Another option (other than surgical re-attachment higher on the duct) available to resolve the obstruction caused by stricture is a balloon dilation. During a balloon dilation, a catheter is inserted into the biliary duct above the stricture and a balloon is introduced. The balloon is threaded down to the stricture where it is threaded into or across the stricture prior to the ballooning which expands the duct allowing the flow of bile. The risks of the significant bleeding, infection and other complications of the balloon dilation procedure is approximately 11%. Further, repeated balloon dilations efforts and other necessary gastrointestinal studies increase the risk of scar tissue within the ductal anatomy at the anastomosis and at other locations where friction occurs.

In one patient’s case presently in litigation, the repair surgeon wrote in the Operative Notes that there was a 90% chance that the patient would completely recover from the repair surgery. Four months later, the patient experienced a stricture of the anastomosis or repair site, cholangitis, a balloon dilatation sequence involving two dilatations and repeated episodes of an apparent continuing peptic ulcer. Another result of the hepaticojejunostomy repair is that stomach acids no longer neutralize the bile as before. Rather, the bile acids directly flow into the intestinal loop and this can cause an ulcer as the acids inflame the intestinal tissue.

Another client’s experience began in 1990 when her bile duct was divided during a laparoscopic cholecystectomy. A cholangiogram was not performed and the injury was not diagnosed nor repaired until approximately 14 days later. This patient’s management has included two major surgeries (re-attachments) and numerous balloon dilatations of recurrent stricture. Therefore, the author suggests that an attorney practicing in this field of medical malpractice should not resolve his or her client’s case without an understanding of the significant and chronic risks facing the injured patient.

Tips for Requesting and Reviewing Medical Records

Whether your practice involves medical malpractice, personal injury, toxic tort or even family law you will at some point in time have the need to request medical records.

Most states have a section in the Rules of Civil Procedure covering specifics of request format, time to respond and charges for medical billing. Be sure to check your state code prior to preparing a request for medical records.

Below are some tips for paralegals and attorneys who will need medical records in order to substantiate a claim and answer discovery through production of medical records.

Interview the client to obtain as complete a medical history as possible. If they have billing records copy and retain those, as they will contain important contact information for health care providers.

Remember billing and medical records may not be maintained at the same facility and a separate request for each is needed.

Obtain the pharmacy billing records prior to and subsequent to the incident in question. Have the potential client bring these for the initial interview. They will contain a thumbnail sketch of the patient’s medical care prior to the incident in question, identify prescribing/healthcare providers as well as document medication taken (such as pain medication) to aid in supporting damages.

Many medical records, especially nursing documents are multiple pages with dates, signatures only on one page. It is suggested you request multiple pages be stapled in order, this is crucial for establishing dates/times and providers in a chronological order.

Often treatment and medications records are double-sided with initials/signatures and comments on the opposite side. Be sure to request double sided copies, or if single sided copies, request they be stapled together. These records may contain crucial information in a case.

As in any case of medical negligence or malpractice, the medical records are extremely important in proving the facts showing negligence, causation, and damages.

Obtain ALL of the nursing home, clinic, urgent care, emergency room, ambulance, visiting nurse, occupational therapy, speech therapy, physical therapy and respiratory therapy records and ALL doctor and hospital records.
Sometimes urgent care, ambulatory care clinics, emergency rooms, ambulances, nursing and various therapy services, etc., are independent contractors. Establish with the hospital or institution what care is provided by independent contractors and where to address medical records requests to ensure you are ordering ALL of the available medical records.

Even if all of the available medical records are not part of the alleged incident and hence are not subject to the medical review, they should still be obtained as reference material.

The records just prior to and after an alleged incident are especially important in providing documentation as to the person’s medical condition, the extent of the alleged injuries as well as an indication of any probable long-lasting complications that may now exist.

Key Point: Information is often obtained from seemingly obscure records, hence the need for ALL of the medical records.

Components of the Medical Record

HOSPITAL RECORDS

Hospital records include, but are not limited to:

Admission Information/Summary – documents date/time of admission, admitting diagnosis. Admitting physician and other basic admission information

Discharge Summary – documents condition at time of discharge, any post discharge instructions for lab tests, physician appointments and medications prescribed, as well as instructions for physical activity and other treatment modalities.

Admission History and Physical – documents condition at time of admission, usually performed by admitting physician, but sometimes deferred to a medical resident or physician assistant. There may also be a separate document, “Physician’s Admission History and Physical” in some health care facilities.

Physician’s Progress Notes – daily chronology of patient’s progress, often gives rationale behind change in treatment or medication and documents physician visits.

Emergency Room Records – documents condition upon arrival, chief medical complaint and may also include emergency room physician evaluation of any tests performed such as ultrasound, radiology and laboratory tests. Also recommendations for referral, admission and/or discharge are obtained here.

Consultation Reports (Physician and other professional.) documents evaluation and recommended treatment by physicians, and other health care providers asked to consult in reference to patient care.

Physician’s Orders – documents date and time of treatments and medications ordered by treating physicians. These are to be signed by the physician ordering, even if a telephone order or phone/verbal order given to a nurse.

Operating Room Records and Report (Physician, Nursing and Anesthesia Record) – documents procedure performed, surgeons, nurses and anesthesia personnel present during surgery. Also documents patient condition before, during and after surgery. Some hospitals document post operative care in the “PAR” (post anesthesia recovery) record.

Laboratory Reports – documents results of tests performed in the laboratory. Includes not only blood and urine tests, but also cultures of tissue and microscopic exam of tissue.
Graph Sheets – documents basic vital signs and other basic functions such as urinary and intestinal elimination. Some graphic sheets also document dietary and fluid intake.
I and O record – documents fluid and solid intake and output on a daily basis. Usually tallied on a daily basis, but may be recorded with each shift (two to three times a day)
Treatment Sheets – documents all manner of treatments such as wound care, hot and cold therapy not given in physical therapy, etc.
Medication Sheets – documents medications given. PRN medication is given on an “as needed” basis and may be listed separately from regularly scheduled medications.
X-ray/Radiologist Reports – documents radiologist’s impression of radiology tests. Will also contain name of ordering physician.
Physical Therapy Records – documents treatments/therapy given in the Physical therapy department as well as the patients response to therapy.

Speech Therapy Records – documents therapy given by speech pathologist.
Occupational Therapy Records – documents therapy given by occupational therapist. May be included as part of physical therapy records in some institutions.

Nurse’s Notes/Nursing Progress Notes – Chronological documentation of patient’s condition, physician visits, change in condition and treatments given as well as patient responses. Usually written in longhand, but more and more frequently are seen as a computerized record.

Nursing Care Plans – Each patient has a general plan of care, and the foundation is determined by the policy of the health care facility. However, generally the nursing care plan covers all treatments, medications and therapies ordered for the patient. Goals are also stated for patient care.

Interdisciplinary/Multidisciplinary Progress Notes (Not utilized in all facilities.) – documents progress of each therapeutic department in chronological order, rather than a separate progress note maintained by each department. May include notes made by more than one department, such as speech, physical and occupational therapies.
Other records found but not consistently maintained by all facilities may include:

  • Records/Treatment Logs
  • Treatment Records, Nursing Treatment Records (Sometimes in with the medication records; sometimes listed separately.)
  • Physical Therapy
  • Speech Therapy
  • Occupational Therapy
  • Rehabilitation Therapy, Restorative Services
  • Recreational Therapy, Activity Therapy or Service
  • Any other form of therapy records
  • Visiting Nursing or Home Care Nursing Records
  • Records from Independent Medical Laboratories

Records from Independent Radiology and Nuclear Medicine Services

Ambulance Records (EMS — Emergency Medical Service) – these records may be maintained by either an independent EMS service or a municipal fire department, or hospital EMS service.
Emergency Room Records (These are often not part of the hospital records, where the emergency room is operated by an independent contractor.)

In some situations, the records of emergency response personnel such as the local police and rescue portions of the fire department will also apply and will be separate from other EMS records, and a separate request for each entity will be required in order to obtain all records.

Building Your Medical Library

Whether your practice involves a client injury in the workplace, injury due to medical negligence, product defect, or toxic chemicals you will have a need to obtain and review medical records.

At times the terms used in the medical records can be confusing and the rationale for diagnosis and treatment is not clear. In other instances you wish to review a standard of care as it relates to your client’s diagnosis and treatment.

Below is a general listing of resources, both in text print as well as online which might be of benefit to your office.

We are all sensitive to the issue of overhead for the law office. Therefore, you may want to consider obtaining some of these books as library materials for a shared legal medical library established through your local bar association or in co-operation with other law firms in your immediate area.

Medical Abbreviations: 24,000 Conveniences at the Expense of Communications and Safety, by Neil M. Davis
Temple Univ., Philadelphia, PA. Annual pocket quick-reference guide to 24,000 meanings of medical abbreviations and 3,400 cross-referenced generic and brand drug names. Thumb-tabbed pages. Includes single-user access code to the Internet version of the book which is updated with 80-120 new entries per month. Softcover.

Laboratory and Diagnostic Tests with Nursing Implications (6th Edition)

Each test is discussed in seven subsections in the following sequence: (1) reference values/normal findings, (2) description, (3) purpose, (4) clinical problems, (5) procedure, (6) factors affecting laboratory or diagnostic results, and (7) nursing implications with rationale. Following the name and initials for each test, there may be names of other closely associated tests. Reference values/normal findings are given for children and adults, including the elderly. The description focuses on background data and pertinent information related to the test. The general purpose for each test is listed. Clinical problems include disease entities, drugs, and foods that cause or are associated with abnormal test results. The procedure is explained with a rationale for the test and with appropriate steps that the nurse and other health professionals can follow. Factors affecting laboratory or diagnostic results alert the nurse to factors that could cause an abnormal test result. The last subsection and most valuable information for each test concerns the nursing implications with rationale. For most diagnostic tests, nursing implications are given as “pretest” and “posttest.”

Alexander’s Care of the Patient in Surgery

ALEXANDER’S CARE OF THE PATIENT IN SURGERY, considered the standard in perioperative care for over 50 years, is a comprehensive reference for students and practitioners alike. Unit I covers basic principles and patient care requisites. Unit II details step-by-step procedures for over 400 general and specialty surgical interventions. The unique needs of ambulatory, pediatric, geriatric, and trauma surgery patients are discussed in Unit III. New features include highlighted patient education and discharge planning, sample critical pathways, expanded coverage of endoscopic/minimally invasive procedures, and internet resources. A new chapter, Surgical Modalities, addresses today’s technologically advanced perioperative environment.

Merck Manual Diagnosis & Therapy (Includes Facsimile of 1st ed. of the Merck Manual)

The most widely used medical text in the world and the hypochondriac’s bible, the Merck has the lowdown on the vast expanse of human diseases, disorders and injuries, as well as their symptoms and recommended therapy. It’s intended for physicians and medical students, but though the type is tiny and the language technical, the Merck’s a valuable volume for anyone with more than a passing interest in bodily ills.

Rosen’s Emergency Medicine: Concepts and Clinical Practice (3-Volume Set)

ROSEN’S EMERGENCY MEDICINE continues to be the premier source that defines the field of emergency medicine. It describes the science of emergency medicine and its application, focusing on the diagnosis and management of problems encountered in the emergency department. This stellar new team of editors has introduced many new features including a “Cardinal Presentations” section, chapter consistency, and more diagnostic imaging throughout. All existing chapters have been extensively revised, and reference lists have been edited to include more significant, up-to-date references.

Joint Commission on Accreditation of Healthcare Organizations. (CAMH) Comprehensive Accreditation Manual for Hospitals: The Official Handbook: Accreditation Policies, Standards, Scoring, Aggregations Rules, Decision Rules.
Oakbrook Terrace, IL, Joint Commission on Accreditation of Healthcare Organizations, 2001. CAMH, $350.00; CAMH and 1-year update, $565.00; CAMH annual subscription update, $245.00.

Cecil Textbook of Medicine (Single Volume)

Cecil Textbook of Medicine, 21 Edition CD-ROM provides rapid-access to the complete text, illustrations, tables and references. Review questions with answers are linked to the relevent sections of the textbook and complete drug monographs from Mosby’s GenRx are included. Plus, this CD-ROM gives you FREE access to Cecil Online! –This text refers to the CD-ROM edition.

Current Pediatric Diagnosis & Treatment

Provides clinical information on ambulatory and inpatient medical care of children from birth through adolescence, focusing on clinical aspects of pediatric care and their underlying principles. Emphasis is on ambulatory care, acute critical care, and a practical approach to pediatric disorders. This edition contains new chapters on developmental disorders and behavioral problems, substance abuse, allergic disorders, and fluid, electrolyte, and acid-base disorders and therapy, plus expanded illustrations.

Clinical Nursing Skills & Techniques

The 5th edition of Clinical Nursing Skills and Techniques offers new up-to-date content and improved features, in addition to complete coverage of more than 200 nursing skills, a nursing process framework for a logical and consistent presentation, and a convenient 2-column format with rationales for each skill step.

Critical Decisions in Emergency Medicine, reliable, relevant clinical updates/risk management. two lessons each month. Subscription for non member $244 a year.

Index of past issues found at:
Order by calling ACEP or going to and order online
ACEP – Foresight CEU Risk Management

Example:
Print monthly from online resource.
AMA – Medicolegal Forms with Analysis – Documenting Issues in the Patient-Physician Relationship.
Covers issues such as consent, informed refusal, ama, and others. Contains current forms and references to legal citations related to each issue discussed.

Other suggested Book Lists/Links

Brandon/Hill selected list of print books and journals for the small medical library

“Selected List of Books and Journals for the Small Medical Library” was published almost forty years ago, this series of selection guides has been heavily used and highly valued by librarians, nurses, health care practitioners and publishers. The Small Medical Library list was followed in 1979 by the “Selected List of Nursing Books and Journals” and by the “Selected List of Books and Journals in Allied Health Sciences” in 1984. In 2001, the publications were made available on the internet, promoting unrestricted access.

It was always the instruction of Alfred Brandon and Dorothy Hill, the original authors, that the selected lists would not be published under their names without their direct involvement which is why they retained copyright of the lists. With the recent retirement of Dorothy Hill, this longstanding project has drawn to a close.

Brandon Hill Journal Links

This list of Journals available in full text online was updated on a regular basis by the National Library of Medicine through May 12, 2003, This page is valuable in terms of information to online resources, but this page, “MLA Brandon/Hill Journal Links”, is no longer updated.

General Reference Internet Links

Medscape

Medscape is a multi-specialty Web service for clinician and consumers that combines information from journals, medical news providers, medical education programs, and materials created for Medscape. Here you will find a combination of peer-reviewed publications, a free version of drug information via the “First Data Bank File” and free Medline.

MD Consult

Founded by leading medical publishers that include Mosby and W.B. Saunders, MD Consult integrates peer-reviewed resources from over 50 publishers, medical societies, and government agencies. From this site you can obtain full text from respected medical reference books from a variety of specialties, medical journals, and MEDLINE. In addition you can obtain comprehensive USP drug information (beyond the scope of a PDR), as well as more than 600 clinical practice guidelines. This is not a free service, but for a small fee you can have access by the day, month or year. Also there is a free seven day trial membership.

Guidelines Clearing House

This site is a public resource for evidence-based clinical practice guidelines. NGC is sponsored by the Agency for Healthcare Research and Quality (formerly the Agency for Health Care Policy and Research) in partnership with the American Medical Association and the American Association of Health Plans. A medical term search will retrieve objective, detailed information on clinical practice guidelines. Results in a search will obtain: structured abstracts (summaries) about the guideline and its development, a utility for comparing attributes of two or more guidelines in a side-by-side comparison, syntheses of guidelines covering similar topics, highlighting areas of similarity and difference, links to full-text guidelines, where available, and/or ordering information for print copies and, annotated bibliographies on guideline development methodology, implementation, and use.

CPT Codes

This website gives users of CPT the opportunity to perform CPT code searches and obtain information about Medicare’s relative value payment amount associated with the codes. Searches can be performed using 5 digit CPT code numbers or key word(s) in the code description. Also you can order the CPT coding handbooks in paperback format. The codes are updated annually.

Utilizing the Power of the Web: Medical Resources for Attorneys

As a medical-legal consultant and Internet researcher I am asked every day to find authoritative medical literature references for a broad spectrum of topics. The information I am looking for may be used to support a claim, to debunk an expert theory, or to educate the attorney during the course of a case evaluation.

Changes in the way medical information is stored, accessed, and retrieved have created a wealth of health care information. The Internet provides free access to a great deal of the medical literature, either in full text or citation/abstract format.

Because anyone with access to the Web can establish a Web page, many medical sites contain little useful information, even though they may be visually appealing. For this reason, the quality of information available varies from very good to poor, and some sites even intend to mislead. It is important to search for peer reviewed information, from an authoritative source.

I. Define The Search

Before you start your search, be clear as to the specific type of information you are seeking. It may be a standard of care for a particular procedure, it may be the rate of occurrence for complications related to a specialized treatment, or it may be basic information defining a disease or particular injury. You must identify the main concepts in your topic and determine any synonyms, alternate spellings, or variant word forms for the concepts.

In order to define your search, you will need a grasp of basic medical terminology. The medical terms used in your search usually come from records showing a diagnosis or particular treatment. The terms may include the name of a medication or specialized medical equipment. It is a good idea to keep a medical dictionary and drug guidebook close at hand as references, because spelling of medical terms must be accurate in order to get relevant search results.

Because the Web is not indexed in any standard manner, finding information can seem difficult. Search engines are popular tools for locating web pages, but they often return thousands of results. Search engines crawl the Web and log the words from the web pages they find in their databases. Without a clear search strategy, using a search engine is like wandering aimlessly in the stacks of a library trying to find a particular book.

II. Performing the Search

Most of the major medical literature search sites have tutorials or help functions to assist you in customizing your search. It may take some time to learn how to master the specific commands and options offered by the various search engines, but it pays off by helping you avoid hundreds of hours fruitlessly searching.

Do not let the similarity between the appearance and function of medical search sites fool you into thinking they are all alike. They are not. They use different rules and procedures to analyze your queries and decide what results are seen.

If you have tried a query a few times and are not getting the results you are looking for, switch to another search engine. It is natural after searching for awhile to have “favorite” search sites.

In one way this is good, the more you use a particular site the more likely you are to master a particular tool. But, instead of relying on one search site for all your needs, try using several different sites on a regular basis. This way you will get a feel for which ones work best for specific types of searches. Over time, it will become automatic for you to select the “best” search site for each query from among the several that you know well.

Boolean operators (and, or, not) allow you to construct very precise queries that theoretically should give you very precise results. But this is not necessarily the case for two reasons.

First, search sites implement Boolean operators in slightly different ways. If you are going to use Boolean operators, be sure you understand exactly how each site implements them.

Secondly, despite the apparent simplicity, Boolean logic is anything but simple. A misused “not” or a poorly “nested” phrase can lead to wildly inappropriate results. For a good Boolean primer, with helpful illustrations and examples is Boolean Searching on the Internet from the University of Albany Libraries found.

Some search engines ignore certain words. They are never used to find a matching document, despite what amounts to a direct command when you type them into a search form.

These are called “stop words” because the search engine does not “search” when they are found in its index. This is because the stop words are either too common to generate meaningful results, or are parts of speech like adverbs, conjunctions, prepositions, or forms of “be” that mean nothing unless they are part of a phrase with more “important” nouns and verbs. If you use a stop word in a query you may get wildly irrelevant results.

How can you identify stop words? They are listed at the website: Most of the 300 Most Common Words in the English Language found.

Some search engines will tell you when they are ignoring a stop word at the very top of a results page.

Another problem for the net-searcher is whether to use capital letters in a query. Some engines are case sensitive, while others are not. As a rule of thumb, it is best to always use lower case letters when you search This will typically return results that contain both upper and lower case letters.

It is a good idea to bookmark or print out the information you find. It is easy to believe once you have found a page or site using a search engine that you will find it again. It does not work that way.

You may not get the same search results using the same terms if you repeat a search within an hour, let alone days or weeks later. The Web is in constant flux. Thousand of new pages are published to the Web every day, and thousands more moved to new “addresses”, or are removed entirely.

This means a particular “relevance” of a particular document for a specific search query also changes constantly, as it is compared to other documents added to or removed from the search engine index.

If you get stuck, and can not find what you are looking for on the Internet, do not stop looking. Sometimes your best bet for finding information is to log off and take a trip to your local medical library.

Libraries have many resources that are not available on the Internet. And, the librarians are trained experts who are usually more than willing to help you find what you are looking for. Effective searching requires a blend of learned skills, common sense, and a bit of clever intuition.

III. Where to Search For Medical Information

Medical Search Engines/Website Lists

Medical information on the Internet is growing and diversifying. Every month more information is added and it becomes more challenging to sift through the many sites to find the content you are looking for. Traditional search engines do not focus on medical sites, and therefore some very valuable sites are overlooked or not updated into the index.

To date, there is no all-inclusive engine for searching medical sites. Nor is there a single engine that adequately and throughly indexes just the most reputable sites. These are a sampling of sites that will search for and retrieve up-to-date, applicable and current postings from peer-reviewed sources.

National Library of Medicine

The NLM is a very large database and the efficiency of a search can be aided by a review of the MESH (medical subject heading) “trees” at http://www.nlm.nih.gov/mesh/

The mesh trees incorporate the specialized language of the NLM classification system. Failure to use the appropriate language will result in a null or irrelevant search. For example: the phrase kidney calculi should be used instead of kidney stones.

Medline (accessible from various sites)

MEDLINE is the NLM’s premier bibliographic database covering the fields of medicine, nursing, dentistry, veterinary medicine, the health care system, and the preclinical sciences. MEDLINE contains bibliographic citations and author abstracts from more than 4,300 biomedical journals published in the United States and 70 other countries.

The file contains over 11 million citations dating back to the mid-1960’s. Coverage is worldwide, but most records are from English-language sources or have English abstracts. Medline is free, and is accessible from various sites, such as Medscape, Pubmed, and Healthgate.

Pubmed

The PubMed database was developed in conjunction with publishers of biomedical literature as a search tool for accessing literature citations and linking to full-text journal articles at web sites of participating publishers.

Publishers participating in PubMed electronically supply NLM with their citations prior to or at the time of publication. If the publisher has a web site that offers full-text of its journals, PubMed provides links to that site, as well as sites to other biological data, sequence centers, etc.

User registration, a subscription fee, or some other type of fee may be required to access the full-text of articles in some journals.

PubMed provides access to bibliographic information which includes MEDLINE as well as the out-of-scope citations (e.g., articles on plate tectonics or astrophysics) from certain MEDLINE journals, primarily general science and chemistry journals, for which the life sciences articles are indexed for MEDLINE.

Medscape

Medscape is a multi-specialty Web service for clinician and consumers that combines information from journals, medical news providers, medical education programs, and materials created for Medscape. Here you will find a combination of peer-reviewed publications, a free version of drug information via the “First Data Bank File” and free Medline. At the present time there is no fee to set up a user account which gives access to full text articles.

Healthfinder

Healthfinder is a free gateway to reliable consumer health and human services information developed by the U.S. Department of Health and Human Services. healthfinder can lead you to selected online publications, clearinghouses, databases, web sites, support and self-help groups, as well as the government agencies and not-for-profit organizations that produce reliable information for the public.

MD Consult

Founded by leading medical publishers, MD Consult integrates peer-reviewed resources from over 50 publishers, medical societies, and government agencies. From this site you can obtain full text from many respected medical reference books from a variety of specialties, as well as information from medical journals, and MEDLINE.

In addition you can obtain comprehensive USP drug information (beyond the scope of a PDR), and many clinical practice guidelines. This is not a free service, but for a small fee you can have access by the day, month or year. Also there is a free trial membership.

Medical Matrix

Medical Matrix is a source for a wide variety of online resources that include major journals, textbooks, disease and conditions, and patient education. To access this site you must complete an online registration form and fees are charged for some features.

Medical World Search

Medical World Search can aid medical practitioners, researchers, or anyone with basic knowledge of medicine, to formulate an optimally precise query to search the World Wide Web and find exactly the information they need. The major goals of Medical World Search are to provide a search engine that operates over a selection of the most high quality medical sites on the Web and to facilitate searching by using a medical thesaurus that understands medical terminology and can thus search for related terms automatically.

Medical World Search has three components: the Web crawler, the indexer, and the query processor. The Web crawler seeks out medical sites on the World Wide Web, starting from some of the major entry points for clinical medicine, then retrieves them and stores them on Medical World Search’s disk system. The indexer recognizes medical concepts in the pages retrieved by the Web crawler, and generates a large index of all medical concepts and words in the Web pages; this index shows in which pages each concept and word appears. The query processor allows the user to specify his information needs and then attempts to match the query optimally to Web pages using the index generated previously. Results are ranked and returned to the user. There is a small annual fee charged for use of this service.

MD Choice.com

This site is founded by academic physicians. Their goal is to make access to the Internet’s vast health and medical information as efficient and reliable as possible for healthcare professionals as well as consumers. MDchoice.com has combined the content of several award-winning medical websites including NetMedicine.com, Physician’s Choice, and EMBBS.com (The Emergency Medicine and Primary Care Home Page). A panel of board certified physicians in the U.S. evaluate the Web’s medical content.

Guidelines Clearing House

This site is a public resource for evidence-based clinical practice guidelines. NGC is sponsored by the Agency for Healthcare Research and Quality (formerly the Agency for Health Care Policy and Research) in partnership with the American Medical Association and the American Association of Health Plans. A medical term search will retrieve objective, detailed information on clinical practice guidelines. Results in a search will obtain: structured abstracts (summaries) about the guideline and its development, a utility for comparing attributes of two or more guidelines in a side-by-side comparison, syntheses of guidelines covering similar topics, highlighting areas of similarity and difference, links to full-text guidelines, where available, and/or ordering information for print copies and, annotated bibliographies on guideline development methodology, implementation, and use.

IV. Where to search for information on Pharmaceutical Products

Institute for Safe Medication Practice

The Institute for Safe Medication Practices (ISMP) is a nonprofit organization that works closely with healthcare practitioners and institutions, regulatory agencies, professional organizations and the pharmaceutical industry to provide education about adverse drug events and their prevention. The Institute provides an independent review of medication errors that have been voluntarily submitted by practitioners to a national Medication Errors Reporting Program (MERP) operated by the United States Pharmacopeia (USP) in the USA. Information from the reports may be used by USP to impact on drug standards. All information derived from the MERP is shared with the U.S. Food and Drug Administration ( FDA) and pharmaceutical companies whose products are mentioned in reports.

Lawfirm Websites/Class Actions/Document Vaults

The lawfirm of Feldman & Rifkin, LLP has put together a good site of resources related to class actions and pharmaceutical related litigation resources. Another site link http://www.badproducts.com has a wealth of litigation resources including pleadings and exhibits. You can also do a search of the web and news services by using http://www.google.com for the drug in question.

Formulary Journal

Formulary is a monthly clinical journal for members of Pharmacy and Therapeutic (P & T) Committees (and others charged with drug management responsibilities) at hospitals, HMO’s and other managed care settings, PBM companies, and within the VA system.. This publication contains peer-reviewed clinical articles plus drug-related clinical news, drug-related regulatory news, meeting “pearl” reports, formulary trends, and clinical experience briefs.

The American Society of Health-System Pharmacists

Founded in 1942, this is the premier professional association for hospital and other health-system pharmacists. The Association publishes the IPA database, the American Hospital Formulary Service (the “Red Book”) and the American Journal of Health-System Pharmacy, as well as a number of books and continuing education publications. The site offers timely alerts on medications which have been recalled by the FDA or had warnings issued. The site also offers free MEDLINE access, as well as a directory of headquarters staff and the Association’s publications catalog. Information on purchasing publications is found at this website.

American Association of Pharmaceutical Scientists

The American Association of Pharmaceutical Scientists consists of more than 9,300 pharmaceutical scientists employed in academia, industry, government, and other research institutions worldwide. “Founded in 1986, the goal of AAPS is to improve human health through the development of better pharmaceuticals.” This site provides information about the pharmaceutical science profession, information for members, publications, and links to additional health and pharmaceutical sites.

The American Pharmaceutical Association

The American Pharmaceutical Association (APhA), the national professional society of pharmacists, was founded in 1852 and is the first established and largest professional association of pharmacists in the United States. The more than 50,000 members of APhA include practicing pharmacists, pharmaceutical scientists, pharmacy students, pharmacy technicians, and others interested in advancing the profession. The Association is a leader in providing professional information and education for pharmacists and an advocate for improved health of the American public through the provision of comprehensive pharmaceutical care.

International Society for Pharmaceutical Engineering

ISPE is the Society of choice for more than 13,000 healthcare technology professionals in more than 60 countries… ISPE [is] the leading global source of information, educational services, and forums providing knowledge and practical experience for technical professionals who develop, manufacture, regulate, and support healthcare products. This site includes a calendar of upcoming educational programs; information on ISPE publications; career development and student areas; contact information for affiliates and chapters; and Shared Interest Groups (SIGs) Bulletin Boards, plus information on Good Automated Manufacturing Practices (GAMP), Baseline Pharmaceutical Engineering Guides, and Clinical Trial Materials training tools.

Parenteral Drug Association

PDA is a non-profit professional/technical association whose mission is to support the advancement of pharmaceutical technology by promoting scientifically sound and practical technical information and education for industry and regulatory agencies. PDA is the recognized authoritative voice and leading technical organization in the field of parenteral science and technology. Through the development of technical reports, bulletins and responses to regulatory initiatives. Membership consists of over 9,000 individual and 250 corporate members worldwide. Conferences, meetings and open forums bring together pharmaceutical manufacturers, suppliers, users, academics and regulatory officials to discuss issues of mutual interest.

FDA – Electronic Orange Book – Approved Drug Products with Therapeutic Equivalence Evaluations

At this site you can search for drug information by active ingredient, drug applicant holder, proprietary name, or application number. If you have the trade name, search the Electronic Orange Book Rx or OTC section using the Proprietary Name search. This determines the ingredient(s). Then use the Ingredient Search for all approved products that contain the ingredient(s). The resulting list will provide approved products by dosage form and route. For each dosage form; route grouping, there will be a Reference Listed Drug (RLD) that is the innovator product. One or more strengths will have a Yes RLD. If there are approved generic products of another firm, the RLD will be No and all the products within the dosage form; route grouping will have a therapeutic Equivalence Code (TE Code). Products that have been discontinued are in the Discontinued Section and do not RLD or TE Codes. The OTC Section products are not evaluated for therapeutic Equivalence.

Information not found here can be requested from the FDA by going to CDER Freedom of Information Office

Pharmaceutical Research and Manufacturers of America

The Pharmaceutical Research and Manufacturers of America (PhRMA) represents the country’s leading research-based pharmaceutical and biotechnology companies. You can search medication/pharmaceuticals in development by disease, drug name, or company name.

Biotechnology Information Directory

This directory contains well over 1500 URLs of companies, research institutes, universities, sources of information and other directories specific to biotechnology, pharmaceutical development and related fields. It places emphasis on product development and the delivery of products and services. It includes a listing of pharmaceutical companies and their associated websites, as well as a link to the European mirror site.

Hardin Meta Directory of Internet Health Sources: Pharmacy and Pharmacology

As a “metadirectory” this site provides a “directory of directories” on a variety of medical topics. The section on pharmacy and pharmacology provides links to 20 different directories on the World Wide Web.

Virtual Library: Pharmacy

This general site also includes links to information on pharmacokinetics and pharmaceutical chemistry. Included are links to schools of pharmacy throughout the world, community pharmacy web pages, and job information for pharmacists. Maintained by the University of Oklahoma College of Pharmacy.

PharmWeb

This site is maintained at the University of Manchester (England), and is “mirrored” by over a half-dozen sites throughout the world. It includes extensive links to Internet resources of interest to pharmacists and maintains numerous discussion groups.

University of Sydney Department of Pharmacy — Pharmacy Internet Guide

This site includes a thorough and logically organized guide with links to pharmacy resources on the Internet. The guide includes an extensive list of email discussion groups and electronic journals of interest to pharmacists.

FDA Bulletin Board/World Wide Web site

Includes FDA Federal Register Notices, Drug & Device Approvals, agency press releases, FDA Consumer Magazine. A search form is available for searching the FDA web site for information on a specific topic or drug.

U.S. Department of Health & Human Services

The DHHS is the parent agency of the Health Care Financing Administration MedicareMedicaid), Food & Drug Administration, Centers for Disease Control, Agency for Health Care Policy & Research, Agency for Toxic Substances & Disease Registry and others. Links to the agency web sites, as well as grant, research and policy information are available from this central site.

National Institutes of Health

Links to CancerNet PDQ Drug Information, the full-text of Clinical Practice Guidelines, grant information, and NIH sponsored research in progress.

National Library of Medicine

The National Library of Medicine (NLM) provides no-cost access to MEDLINE, a database which provides citations to the primary biomedical literature. MEDLINE can be searched via the World Wide Web from this website using either NLM’s “Internet Grateful Med” search engine, or the “Pub Med” search engine. Pub Med also includes links to a small number of full-text articles available on the World Wide Web.

V. General Information Searching

Search engines rely on computer programs called spiders or robots to crawl the Web and log the words on each page. With a search engine, keywords related to a topic are typed into a search “box.” The search engine scans its database and returns a file with links to websites containing the word or words specified. Because these databases are very large, search engines often return thousands of results. Without search strategies or techniques, finding what you need can be like finding a needle in a haystack.

General search engines are good for finding information and sites on a specific topic. The search results generally will contain many irrelevant sites, and you will need to “sift” through your results to find information that is useful.

There are many tutorials for web searching techniques on the Internet. One particularly good tutorial, which you may download and print for reference is Bright Planet’s “Deep Content” tutorial.

This is an in-depth Web searching tutorial, organized to proceed from the basics to more advanced topics. It has 12 parts containing over 60 topics.

Listed below are some of the more popular general search engines.

VI. General Information Search Engines/Website Lists

Google

Google consistently turns up high-quality, highly relevant results. Google does well on specific queries such as American Pediatric Neurological Organizations, and broad-topic searches, such as Medical Professional Organizations. It’s also great at targeting a specific home page. Depending on your query, you may get stock quotes, or related news stories for example. My favorite feature is Google’s ability to view cached copies of results pages. When the page you want to access is no longer live, you can view a cached copy of the way it looked the last time Google crawled it. Google offers only basic query customization features, including phrase searching and foreign-language filtering. You can use plus or minus signs to include or exclude keywords, or you can head to the Advanced Search page for drop-down pick lists to construct complex searches. There is a similar page” feature as well as a translator for foreign language websites.

About

About.com uses “professional Guides” to research and collect over a million useful sites in over 700 topic areas. About.com is a great place to start a web inquiry as long as you’re not looking for anything to specific. Think of it as a resource library for popular subjects. Uses Sprinks (powered by the competent Inktomi) as a default search engine if it can’t find your query at about.com.

Dogpile

Dogpile uses a different concept to search the Internet than most other general content search engine. Rather than maintaining its own database of Web site addresses and their contents, Dogpile searches the databases maintained by the other general content search engines, such as Google, Ask, MSN-Search and Yahoo Search, as well as databases maintained by Usenet newsgroups, ftp sites, newswires, and business news sources.

Dogpile begins by searching the larger general content search engine databases and general purpose directories, and then gradually moves through smaller, more specific search engines. The user is permitted to alter the order of search, however.

Open Directory Project

The goal of this new engine is to produce the most comprehensive directory of the web, Similar to Yahoo, listings are organized by category and reviewed by editors. The ODP is a Web directory, not a search engine. Although they do offer a search query, the purpose of the ODP is to list and categorize web sites. They do not rank, promote or optimize sites for search engines. The ODP is simply a data provider.

WebFerret

WebFerret is free software that searches the internet for you. (This type of program is called a “bot.”) WebFerret uses several search engines, looking as deeply as you like to “ferret” out the pages you’re interested in. You can search the entire text of pages, their titles and descriptions, just their titles, or even just their URLs. What search features you select determines how fast WebFerret works.

In addition, WebFerret will eliminate duplicates by URL, title, or host. WebFerret will list the pages it finds by relevance, title, address or source, then you can save your search as WebFerret search results (an ASCII file or HTML). Since WebFerret is a small program, so it can work in the background.

VII. Summary

The Internet continually offers more opportunities to find information on medical and related topics. However, with the expanding resources comes a larger challenge for net-researchers to find the information they are seeking. The more experience the researcher gains the more proficient they become in finding pertinent data.

Janabeth F. Taylor, R.N., R.N.C. has a degree in Nursing from Oklahoma State University and a Litigation Paralegal Certificate from the University of Oklahoma Law Center. She was a nursing instructor for ten years and has been a medical legal consultant since 1990.

The American Trial LawyerÕs Association (ATLA) named Mrs. Taylor PARALEGAL OF THE YEAR 2002.

Mrs. Taylor is currently President/Owner of Attorney’s Medical Services, Inc. in Corpus Christ, TX. She provides litigation support for attorneys across the United States and specializes in case reviews and Internet information resources.