Thursday, November 20, 2014

The Most Meaningful Job In Medicine Is...Not Anesthesiology

The website Payscale.com released an interactive chart on the most meaningful jobs in the country. They define meaningful as "Does your job make the world a better place?" Not surprisingly, Clergy came in as the most meaningful occupation one can attain. A full 97% of clergy reported that their work is meaningful, with 88% saying they have high job satisfaction. On the other hand, fast food cooks came in last, with only 22% saying they have a meaningful job and 45% reporting a high satisfaction.

While it's important to have a job that makes the world a better place like Clergy, maybe some of us prefer to have a high income AND a meaningful job--have our cake and eat it too. For that, you need to get your butt into medical school. Healthcare workers report the highest income and the highest meaningful numbers according to Payscale. On their chart, all the little yellow circles that are far to the right on the meaningful scale and trail up towards the top of the income scale are all healthcare providers. They include OB/GYN, Internal Medicine, Psychiatry, and Family Practice.

And ranked at the very top for medical workers are surgeons. Surgeons reported having the highest median income of all doctors. They arrive at a median income of $299,600 by including the salaries of high paying surgical fields like neurosurgery and orthopedics. About 94% of surgeons say their jobs are meaningful and 82% have a high job satisfaction. However, 79% say their jobs also come with high stress levels.

How do anesthesiologists compare on this chart? We come in at a very respectable number two. The reported median income is $291,300. Ninety-one percent of anesthesiologists say their jobs make the world a better place. Seventy-eight percent say they are highly satisfied with their jobs. Like surgeons, 79% of anesthesiologists report having a high level of stress at work.

So if you want to be poor and change the world, get yourself to theology school. If you want to be poor and inconsequential, apply to your local burger joint. If you want to be rich but unfulfilled, get yourself into law school (40% meaningful). If you want to have it all, be a doctor. But your mother already knew that didn't she when she made you apply to med school.

Sunday, November 16, 2014

When The Surgeon Asks For Cash...And Puts It In His Pockets

Here is some pretty contemptible news out of Torrance, CA. A young woman is suing her surgeon because he said her operation at a local hospital was not covered by insurance but if he paid her in cash he would do it at a surgery center that he co-owns. Sounds pretty shady, right?

Liza Lumanlan-Domingo had a fetal demise and needed to have the fetus removed. She is a nurse at Torrance Memorial Medical Center and asked for one of the staff surgeons, Dr. Steven Rosenberg, to do the procedure. Incredibly, Dr. Rosenberg told her that her insurance would not cover her surgery at her own hospital but he could do it at Pacific Coast Surgical Center, a facility in which he is part owner. Liza and her husband met Dr. Rosenberg at the surgery center at 7:00 AM on a Sunday and gave him $800 in cash which he puts into his pocket with no receipt returned.

She had her surgery the next day but started to bleed profusely. The surgeon asked her husband to run to the hospital pharmacy to buy $160 worth of medications that the outpatient facility did not carry. Eventually she needed to be transported by ambulance to Torrance Memorial for treatment where she stayed in the ICU for three days. Only later were they informed that her insurance would have covered her procedure at the hospital.

We hear these kinds of self-serving stories all the time. As more surgeons start building their own outpatient surgery centers, they siphon off the best patients from the very hospitals that they work in. Patients who have good health insurance or can afford cash are quickly whisked off to a posh aromatherapy infused ambulatory center while the Medicare/Medicaid/Uninsured patients are herded to the local hospital. Hospitals start losing money because of poor reimbursements while their staff physicians drive into the doctors parking lots in their Mercedes and Bentleys.

Should the couple have called the insurance company to question the denial of payments for treatment at the hospital that she works at? Perhaps. But maybe they were so emotionally distraught and they felt they had a surgeon whom they thought they could trust that they didn't want to go through the red tape of dealing with the insurance company. They just wanted to expedite the surgery for a quick closure.

One day, when all doctors in this country become government employees, these terrible stories of how avarice infected one of the most respected professions will serve as cautionary tales. We'll look back and wonder how we let the critical need for healthcare become a profit center that made a very few people very, very rich.

Friday, November 14, 2014

News Flash--Expanding Medicaid Enrollment Costs More Money

This story is both comic and tragic. State governments are now realizing that expanding the number of patients eligible for Medicaid is straining their budgets and the healthcare system. Hello! Obamacare allowed the states to expand their Medicaid eligibility rules to cover more people. Twenty seven states have done so. Now Medicaid covers 68 million people in this country while Medicare covers 53 million. In ten years it is projected Medicaid will be used by 93 million citizens. The Wall Street Journal has an article detailing the outcome of expanding Medicaid in New Mexico, the state with the highest proportion of Medicaid patients in the country.

Who will see all these patients? The primary care physicians who are expected to be the gatekeepers are already straining to keep up. Many have capped the number of Medicaid patients they will see in their practice. Dr. Holly Abernethy, a family practitioner in New Mexico, has to keep her Medicaid patients to less than 13% of her practice. Otherwise she will have to work a lot longer to keep her office from closing. As it is, she is making $150,000 per year.

In the meantime patients still need to be seen so they are gravitating to healthcare providers like nurse practioners. Jodi Padgett, an NP in New Mexico, has seen an influx of new Obamacare patients on Medicaid. She will accept up to 40% of her patients being on government insurance. She will be paid the same amount of money seeing a patient from Medicaid as Dr. Abernethy, about $80. Her income this year will be $130,000, almost the same as a medical doctor. But she too will eventually have to turn patients away to keep her business from bankruptcy.

Patients finally turn to the emergency room for their care when they run out of options. At a San Juan Regional Medical Center, ER usage is up about 9%. However, Obamacare cut back compensation to hospitals for uncompensated care, reasoning that more patients will have health insurance. This has decreased the government funding from $12 million to only $2 million. As a result, the local government has had to trim other programs like the local park and raise taxes.

The first hints of the consequences of Obamacare are now starting to trickle in. So far it doesn't look good. More patients have insurance but access to medical doctors may be limited. They may have to settle for being seen by nurse practitioners or physicians assistants. Hospitals are getting flooded by poorly paying patients while their funding gets chopped. Local governments have to raise taxes to make up for the lost revenue. And this is while the federal government is paying for 100% of the extra Medicaid expenses. What will happen in two years when the states will have to start paying for a portion of the Obamacare bill?

It's no wonder nearly half the states' governors have opted out of expanding Medicaid despite the federal government's enticement of 100% reimbursement. The crap is starting to hit the fan. Let these other states get splattered first with the excrement and see how they clean it up.

Thursday, November 13, 2014

When Male Chauvinism Turns Deadly

I've been following this horrible story out of India the last few days. Over a dozen women have died and dozens others become seriously ill after undergoing a tubal ligation, part of the government's attempt to rein in out of control birth rates in that developing nation.

Initially suspicion fell on the surgeon, Dr. R. K. Gupta. He reportedly performed 83 sterilization procedures in a span of six hours, though some witnesses claim it was as little as two hours. For all that work he received $100. That is a short day for him because he reportedly has done as many as 300 procedures in one day. The rules say no more than 30 sterilizations should be done at a time. However his breach of protocol didn't seem to affect his standing as the local government honored him last January for having performed 50,000 tubal ligations.

Patients describe the clinic as an assembly line. Each case was performed in a matter of minutes with only local anesthesia. There was little regard for patient discomfort. With such a fast turnover, there was little time for proper sterilization of the surgical instruments. Dr. Gupta reportedly dipped his equipment into a pool of disinfectant just long enough for one patient to be taken off the procedure table while another one was put on. While that may be the standard of care over there, that would be a "Saw" horror movie here in the U.S.

Now there are reports that other women have fallen sick after receiving sterilization. Fingers are now being pointed at possibly tainted samples of ciprofloxacin and ibuprofen that each woman is given after the surgery.

Regardless of the cause of these women dying after attempting to control their reproduction, it is very sad that so few Indian men will do the same thing. Up to 37% of Indian women have their tubes tied, the highest in the world, versus less than 1% of men with vasectomies. Vasectomy is a safe, outpatient procedure that really can be done in just a few minutes with a much lower risk for major complications like sepsis or organ injury. The Indian government even offers higher cash incentives for men to undergo sterilization. Men receive 2,000 rupees ($33) while women get $1,400 ($23) for going through a much riskier and invasive operation.

A husband of one of the victims was interviewed after receiving $3,300 as compensation from the state. He complained it will do him no good now as he has three children to take care of on his own. Perhaps he should have sucked it up as a man and gotten a vasectomy instead having his poor dead wife suffer because he couldn't bear the thought of having his scrotum cut.

The Most Self Loathing Anesthesiologist In The World

I usually don't like to comment on the opinions of other anesthesiologists, much less dump on them. After all their opinions are their own and why should I try to refute their beliefs. But I just read an opinion piece in the widely seen and respected site KevinMD. Written by Dr. Shirie Leng, it is so outrageous and preposterous that I felt I needed to make a counterpoint.

Titled, "Anesthesiologists have to start to truly care for patients," Dr. Leng, a former nurse, starts off by stating that anesthesiology is for people who don't like to relate with patients. She describes the interaction between a patient and an anesthesiologist as thus, "He reviews the information the surgeon and nurse have compiled in the patient’s chart. “Hi, How are you?  I’m your anesthesiologist.  Anything to eat or drink today?  Any problems with anesthesia in the past?  No? Great!  I’m going to put your IV in and then we’ll get going.”

I don't know about Dr. Leng, but my bedside manners are much friendlier and more refined than what she depicts. If that is how she talks to her patients, I wouldn't want her to be my anesthesiologist either. While my time with patients are constrained by necessity, that doesn't mean I can't have a meaningful exchange with them and their families. As a matter of fact I have patients who ask for me by name whenever they need to come back for another procedure. All good anesthesiologists have been blessed with the appreciation of grateful patients. Maybe Dr. Leng just hasn't had the privilege of being loved by her patients if she thinks that's how patients see us.

Naturally this drivel has generated quite a bit of publicity for herself, the way a bad wedding video can go viral for no other reason than that it was bad.  So she wrote a response post on her blog with a blatantly backhanded compliment of anesthesiologists. I'm not going to bother linking to that nonsense since I don't believe I want to give her any more exposure than she already has. But let's just say she doesn't appear to love any anesthesiologist except maybe herself and her anesthesiologist husband.

For any medical students out there contemplating anesthesiology, obviously don't believe everything you might read about this profession. Talk to an anesthesia attending that you respect and get their perspective. I bet he or she can regale you on how crucial a good anesthesiologist is for patient care. We truly save lives every day. As for me, I feel lucky every day that I work in a job I love. I wouldn't have it any other way.

Tuesday, November 11, 2014

What Really Happened At Yorkville Endoscopy?

The release of the Health Department's inquiry into the death of Joan Rivers has certainly shed some light on the event last August at Yorkville Endoscopy clinic. While the following is merely speculative, and we may never know exactly what occurred in that procedure room, we can certainly use some analysis of published data to try to draw a clearer timeline of what led up to her demise.

For months, most anesthesiologists, including myself, thought for sure that Ms. Rivers went into laryngospasm during the case. This is because most of us have seen it happen during a routine endoscopy. Then word came out that there was an ENT surgeon involved who may have been examining her vocal cords without prior consent to look for a source of her hoarse voice. This really put the laryngospasm theory into overdrive. We all slapped our foreheads with our palms and went "Duh! What do you expect will happen when you touch the cords during a sedation case?"

The official report from the Health Department doesn't paint such a clear cut picture. First of all, as it turns out, an anesthesiologist was present during the procedure. I guess Dr. Cohen will use an anesthesiologist for his VIP patients after all. The report also throws the whole laryngospasm theory in doubt. In the document, it helpfully lists Ms. Rivers' vital signs from preop up to when she went into cardiac arrest at five minute intervals. After looking at the data closely, it seems more likely she did not go into respiratory arrest at all before the cardiac arrest.

We know that she had perfectly normal vital signs in preop at 8:44 AM: BP 118/80, HR 62, O2 sat 100%. The patient went into the operating room at 9:00 AM. Then we get to see the vitals as they occurred during the procedure. 

9:12 AM: BP 117/60, HR 71, O2 sat 92%
9:16 AM: BP 92/54, HR 56, O2 sat 94%
9:21 AM: BP 89/44, HR 54, O2 sat 97%
9:26 AM: BP 84/40, HR 47, O2 sat 92%

The report does not indicate what time the procedure started. However it does say that Dr. Korovin started first with a nasolaryngoscopy before handing the patient over to Dr. Cohen for the EGD. The endoscope was removed from the patient at 9:28 at which time Dr. Korovin attempted to perform a second nasolaryngoscopy. At about 9:30 was when Code Blue was called.

So let's assume that the first VS was the baseline before the patient entered the room. Judging by the drop in blood pressure and oxygen saturation at 9:16, she had probably already started receiving some sedation with propofol. The electronic anesthesia record noted that propofol was given at the following times: 100 mg @ 9:21.45, 100 mg @ 9:21.46, 50 mg @ 9:21.48, and 50 mg @ 9:21.50. This is a total of 300 mg of propofol pushed in five seconds.

The anesthesiologist claims that those quantities are mistakes. The patient had only received 120 mg of propofol for the whole case, which she wrote in an addendum to the record later that day. She told the investigators that she accidentally double clicked the computer for the 100 mg boluses and really meant to click on 20 mg bolus instead of double clicking 50 mg boluses.

One thing about electronic medical records--just because you click on an event doesn't mean it actually happened at that time. You may have been too busy with your responsibilities before realizing you forgot to enter it on the computer. You then finally document it even though it happened a few minutes prior. Even though the anesthesiologist may appear to have first bolused the propofol at 9:21.45, it is conceivable that this was a slow bolus given over several minutes but not charted until that time. If we presume that the hypotension seen at 9:16 was already the beginning of the sedation, then the drug was not entered into the computer for five minutes. At that point the anesthesiologist documented 100 mg at 9:21 even though it may have been given over several prior minutes.

Why was her O2 sat only 92% at 9:12 even though the rest of her vitals were normal? This maybe an instance of bad oximetry data. There are many reasons for a sat monitor to pick up an erroneous reading. Perhaps her fingers were cold. Maybe she was shivering. Or maybe somebody was moving her arm. The computer will record whatever number it sees at a particular time without regard to its accuracy. It is up to the user to write a note explaining the false data in the record.

As the oxygen saturation started to drop during the procedure, the anesthesiologist says she turned up the oxygen flow and applied jaw thrust to open up the airways. The anesthesiologist's statement that she kept the O2 sat greater than 90% is true based on the recorded data. But unfortunately that was not Ms. Rivers' problem.

I've seen many laryngospasms during an endoscopy. On nearly all of them, the O2 saturation drops first because the patient can't pass any air. Then the body starts fighting like mad to open up the airways. This results in a severe tachycardia that doesn't slow down until the cords open up or the O2 sat drops so low that the heart becomes ischemic, leading to bradycardia, a most ominous sign.

But Ms. Rivers' problem doesn't seem to be hypoxia. Her sat never goes below 90. Instead we see hypotension and bradycardia first. This is most likely due to a depressed cardiac output. If the CO drops, the O2 saturation eventually falls too as the heart can't pump enough blood for adequate oxygen exchange in the lungs.

What could have caused her heart to fail? Right at the top of the list is propofol. That is why propofol is such a dangerous drug. If not used judiciously, it can cause severe cardiac depression and hypotension, sometimes fatally. In an elderly patient, the impaired heart function can be quite profound. While I want to give the anesthesiologist the benefit of the doubt and agree that she didn't give 300 mg of propofol to an 81 year old in a span of five seconds, which would no doubt lead to a catastrophic bottoming out of her blood pressure, even 100 mg of propofol if pushed too quickly can cause a severe decreased cardiac output.

Another possibility is a strong vasovagal reaction. This is especially true with something as stimulating as a laryngoscopy. If the patient is not sedated adequately, the stimulation from the procedure can cause the BP and HR to drop in some people. This usually goes away once the stimulant is removed by withdrawing the scope. Respiration again is not impaired but the sat may fall because of the decreased blood flow to the lungs and tissue.

Could she have suffered a pulmonary embolus? A PE can cause acute hypotension and bradycardia as the right heart workload suddenly increases. But a PE also usually causes severe hypoxemia, especially for one that leads to death like a saddle embolus. The medical examiner's report also failed to mention a PE as the cause of her death.

An acute myocardial infarction? Maybe. But it would be awfully coincidental for her to suffer an MI right at the time she was getting a procedure done, though it wouldn't be outside the realm of possibility.

If laryngospasm is no longer the likely cause of Ms. Rivers' death, it also explains why she had a hypoxic brain injury. It is easy enough to treat laryngospasm, especially with an anesthesiologist and an ENT surgeon at the bedside already. If it can't be broken with positive pressure ventilation, then give a muscle relaxant to open up the cords and intubate the patient. None of that should take so long as to cause brain ischemia. However if she had heart failure, the low cardiac output would starve the brain of oxygen leading to its death. She sent into cardiac arrest at 9:30 and was not fully resuscitated until 10:00. That is a full thirty minutes of suboptimal blood flow and oxygen exchange to the delicate brain tissue. Thus the brain dies.

Therefore the most likely reason that Ms. Rivers died that day was her heart failed. Either she went into such a severe vasovagal reaction during the laryngoscopy that they couldn't revive her heart or the anesthesiologist felt she needed to give so much sedation to perform the laryngoscopy (Anesthesia! The patient is moving!) that it irreversibly impaired her heart function.

That's just my two cents.

Joan Rivers. The Health Department Report Shows Major Violations.

New York's Health Department has released its findings on the events leading up to Joan Rivers' death at Yorkville Endoscopy last August. It gives a fascinating reading on how celebrity and unprofessional behavior of physicians can interfere with the best laid plans to protect patient safety.

Basically the report states that Yorkville Endoscopy failed in its responsibilities in these four areas:

1. Have a process in place to assure that only authorized personnel are permitted in the procedure room.
2. Have an effective process in place to assure that only credentialed physicians can perform procedures.
3. Ensure that informed consent is obtained for all procedures that will be performed and
4. Ensure a "Time-Out" (a preprocedure protocol for verification of the correct person, procedure, and site) was called to confirm each procedure to be performed.

Essentially, all these deficiencies point back directly at the ENT surgeon, Dr. Gwen Korovin. The report states that Dr. Lawrence Cohen, the gastroenterologist, wrote that Ms. Rivers needed an EGD to evaluate for gastric reflux and hoarseness in her voice. However, two nasolaryngoscopies were performed by Dr. Korovin, as confirmed by the anesthesiologist. The first one was performed before the endoscopy while the second one was done immediately afterwards. The Interim Medical Director and the Vice President of Clinical Operations both confirmed that Dr. Korovin had no privileges to perform procedures at Yorkville. Ouch.

The endoscopy technician said she had never seen Dr. Korovin before. During the Time Out, there was no mention of a nasolaryngoscopy to be performed on the patient. Dr. Korovin's role in the procedure room was not brought up during the Time Out. There was also no consent for Dr. Korovin to do a procedure or Ms. Rivers to have a laryngoscopy.

The report clearly documents the downward spiral that took place in the room. Ms. Rivers' baseline vital signs were: BP 118/80, HR 62, RR 16 O2 sat 100%. During the course of the procedure, the vitals steadily deteriorated:

9:12 AM: BP 117/60, HR 71, O2 sat 92%
9:16 AM: BP 92/54, HR 56, O2 sat 94%
9:21 AM: BP 89/44, HR 54, O2 sat 97%
9:26 AM: BP 84/40, HR 47, O2 sat 92%

Two minutes later, a Code Blue was called. Even the type of cardiac arrest is in dispute. One note, called the Cardiac Arrest Record, indicated that the patient became pulseless at 9:30. Meanwhile, a different page called the Endoscopy Code Blue Record said that the patient went into ventricular tachycardia with a pulse. In either case, there is no indication that she received the proper resuscitation protocol per ACLS.

Much of the events mentioned came from the GI tech and administration staff, as the physicians in the room have all essentially lawyered up and refused to give any incriminating statements. However the anesthesiologist was cited for two major violations. As part of her routine preop exam, she failed to mention the height and weight of Ms. Rivers. This could easily have led to an overdose of propofol if the correct weight is not used in calculating the rate the drug was given.

A second misstep was in the documentation of the drugs given during the procedure. In the computerized anesthesia record, the anesthesiologist said she gave a total of 300 mg of propofol. Yet in an addendum she said only 120 mg was given. When asked about this discrepancy, she said that she only administered a 100 mg bolus of propofol followed by a 20 mg bolus later. The computerized record showed she gave boluses of 100 mg, 100 mg, 50 mg, 50 mg all within five seconds of each other. Those other boluses, she said, were accidental double clicks on the computer for 100 mg. She couldn't explain how she double clicked 50 mg boluses when she claimed she only gave 20.

There are no statements made to the Health Department from the GI physician, Dr. Cohen, himself. I'm sure the anesthesiologist's statement that Dr. Cohen took a cell phone picture of the patient while she was asleep will not help his case. He probably has some very expensive lawyers right now telling him to just shut the f*** up for now.

What a tragic end to a brilliant comedic career.