Wednesday, August 30, 2017

Dubious Milestone In Anesthesia

Anesthesiology has given the world great advances in medicine and healing. In fact, it was voted one of the highest achievements in the history of medical literature. Unfortunately, lately the only time anesthesia is mentioned is when it causes harm, or even death, usually in a sensational fashion.

Now anesthesia has entered the public discussion once again with the news of a prisoner execution in Florida last week. For the first time ever, the drug etomidate was used as part of the IV cocktail to cause the death of a convicted inmate. This news seems to be more widely covered in British media. They appear to be more fascinated with capital punishment than the Americans probably because capital punishment is outlawed in most of Western Europe.

Mark Asay, a white Floridian, was convicted of the racially motivated murders of two minority men back in 1987. After decades of litigation, he was finally put to death with a combination of etomidate, rocuronium, and potassium. This has caused an uproar besides the usual moral handwringing over the death penalty in general. The defense attorneys argued that etomidate is an unproven method for achieving death. They hired doctors who testified that etomidate can cause pain prior achieving its effects.

Meantime, the pharmaceutical company that manufactured the etomidate is objecting to its obviously non-FDA approved use of the drug. This is the reason that more drugs are becoming off limits for use in the death penalty. Previous attempts using pentathol, propofol, and midazolam have been thwarted because the penal system was unable to acquire the drug due to manufacturers' refusal to sell the product or the courts have deemed them cruel and unusual punishment and thus illegal.

Because of these difficulties with IV injections for capital punishment, some states like Mississippi are considering bringing back the old reliables like a firing squad, electrocution, or the gas chamber. That is probably the proper approach. Stop bastardizing anesthetics that were invented for medical purposes to somehow humanize an inhuman act. Centuries of human executions have given us plenty of methods to kill somebody for state reasons. Don't drag anesthesia into this mess.

Tuesday, August 29, 2017

The Next Statue To Fall May Be Of A Doctor


This is the slippery slope that we have been warned about. Ever since the violent clashes that afflicted Charlottesville a couple of weeks ago, statues of Confederate army generals and soldiers have been removed all around the country. Regardless of how the local citizens feel about them, politicians are so cowed by the possible outcry from loud activist groups that the memorials are being taken down without debate or consultation. It appears nobody has the spine to defend free speech, even hateful repugnant free speech, from an angry mob.

Now the righteous hordes have cast their indignant nets wider to tear down other commemoratives they find offensive. Annapolis removed a statue of former Chief Justice of the U.S. Supreme Court Roger Taney because he wrote the misguided Dred Scott decision, the one that affirmed slavery in the United States. Though a terrible decision in retrospect, it was representative of the thinking of 19th century America and a teachable moment for today's society. Now his figure won't be present to remind people of the mistakes we have made in the past and to avoid in the future.

The next unlikely statue to be beseeched by the PC crowd is of Dr. J. Marion Sims. He is called the father of modern gynecology and founded the first women's hospital in 1855. His statue in Central Park, New York is facing angry calls for removal. What was his unforgivable sin? In the early 1800's he experimented gynecologic surgeries on African American slaves, frequently without any anesthesia.

As one protester says, "At best, J. Marion Sims was a racist man who exploited the institution of racism for his own gain." Another decried, "Memorializing of imperialist slaveholders, murderers, and torturers like J. Marion Sims is white supremacy."

Already a statue of Dr. Sims in Columbia, SC is facing an uncertain future as Mayor Steve Benjamin has called for its removal. Says the mayor, "The most offensive statue I find on our capitol wasn't the (Confederate) soldier, it was J. Marion Sims." Looks the the doctor won't be welcome for long even in his native state.

So next time you nod your head in agreement with violent thugs who refuse to let a small minority of incorrigible racists express their right to free speech, just remember that the next target for censure might just be your own views. And there might not be anyone around to defend you anymore.

Texas Tough


Hurricane Harvey's terrible toll on Houston, seems to have brought out the best in humanity. There are numerous stories of strangers helping strangers escape the horrendous once in a millenium flooding that is ravaging south Texas.

I can't help but contrast the difference between the altruism of Texans and the helplessness of Hurricane Katrina victims in New Orleans. Back in 2005, Katrina slammed into New Orleans and unleashed a similar flooding when the flood dikes gave way, inundating the poorer, lower lying sections of the city. The city opened up the Superdome to house their displaced citizens.

Then the people appeared to get stuck there. Despite what looked like only ankle deep standing water surrounding the stadium, thousands of people were not able to leave and nobody seemed to step forward to help them. I'm glad that the self sufficient Texans are taking matters into their own hands and not waiting for the inevitable slow hand of government to come to their rescue.

Let's not even mention the histrionics that would blare through the airwaves if Los Angeles ever faces a real rainstorm. In this city of precious snowflakes who don't know how to drive properly even when the roads are dry, a forecast for a couple of inches of rain brings out mass hysteria with local news reporters. Dire warnings of dangerous mudslides and flooding are ubiquitous for days prior to even a single drop of rain falling. Then afterwards there are the usual recriminations about how the government wasn't prepared enough to help the people through the horrible tempest.

So God bless all the Texans who are helping each other out during this cataclysm. We're all pulling for you and hope you stay safe.

Sunday, August 27, 2017

The President And His Cocaine


This is why I find history so fascinating. Here is something I didn't know about Ulysses S. Grant, the eighteenth president of the United States. Grant, not known for being a sharp businessman before becoming president, was facing bankruptcy after he retired from public office. Mark Twain offered to write his memoirs so that Grant would not leave his wife a pauper.

However, Grant was facing an oral cancer that was growing more deadly and painful by the day. This was thought to be due to his penchant for cigar smoking and alcoholism. To ease his discomfort, his doctors applied cocaine to his throat to take away the pain. While he was initially able to dictate his autobiography to Twain, he later had to write it out since he was no longer able to speak.

He finished his memoirs just a few days before he finally died. The book turned out to be a best seller and his wife received a royalty check of $200,000. The general fought a good fight all the way to the end.

Checking Off The Bucket List


Last week, I had the opportunity to check off an item that was near the top of my bucket list. Unless you were living under a rock, you probably know that the Great American Solar Eclipse occurred over the continental U.S. from coast to coast for the first time in over one hundred years. I've seen several partial solar eclipses in my lifetime, but this seemed like my best chance to see a total solar eclipse. It took place during summer vacation so I could take my son to see it and the maximum totality would happen in the Midwest where I went to school so I had plenty of friends to visit. This was not going to be some solar eclipse in faraway places like the South Pacific or on a remote Asian country.

The problem with going to the Midwest is that the weather there is extremely unpredictable. For the seven days prior to the event, the weather forecast seemed to change almost hourly. Finally on the day of the eclipse, there were some ominous clouds in the western sky in the morning but we hoped for the best. We went to my friend's farm for a viewing party and eagerly chowed down on good down home barbeque while waiting apprehensively with our eclipse glasses.

Unfortunately about one hour before totality, the clouds started rolling in. They weren't particularly uniform, just patchy, but this could mean trouble. With about thirty minutes before the start of totality, it looked like the clouds were not going to cooperate. However there was a small patch of blue sky east of us that everybody could see. We all jumped into our cars and raced towards that clearing. It seemed like everybody else thought the same thing and cars were zooming through the small back country roads heading in the same easterly direction.

As the magic moment approached, we could tell that we were not going to catch up to the clear sky that lay tantalizingly close but still so far away. With about one minute before the start of totality, and the sun just a thin crescent, we finally had to admit defeat and had to find a place to park and hope for the best. I had brought my fancy camera with its extended telephoto lens and solar filter for naught.

Then it happened. The western sky turned very dark. Soon we too were enveloped in the eery twilight that caused the street lamps to turn on and the crickets to chirp their evening songs. The only natural light was way out along the horizon where the sun was not completely covered by the moon. As we kept staring up into the sky, it happened. The clouds just barely thinned out for a few seconds and we saw the eclipse and the corona. It was truly magical. Though it lasted for the briefest of moments, in retrospect I feel like I was mesmerized by it for a long time. My good friend and hostess was able to keep her wits together and took the picture that you see above. That is the only decent eclipse picture we got on our journey despite me lugging that expensive camera equipment halfway across the country.

The next time the clouds parted, the sun was already peeking out from behind the moon. Fifteen minutes later the rain clouds opened up and we were inundated with the typical Midwestern summer thunderstorm. But we had accomplished what we came to do. Grinning stupidly from ear to ear, we high fived each other for a job well done. We didn't get the best view of the eclipse, but we got a view of one which is more than I can say for many other people. As far as pictures go, there are plenty of pictures on the internet of the Great American Solar Eclipse that are far better than anything I could have produced. At least this one picture, and my all too brief experience with my first total solar eclipse,  I will treasure for a lifetime.

Wednesday, August 9, 2017

Wrong Priorities

At the risk of sounding like an old fart, I have to admit that we attendings frequently talk about our residents critically when they're not around. One common observation is that residents and fellows these days really aren't that into education. Surgeons complain their residents would rather round, or even finish writing patient notes, than enter the operating rooms. IM physicians gripe about residents who are nowhere to be found when an interesting case shows up at 4:00 PM. In fact, the hospital halls are pretty bereft of trainees after 5:00. Where are all the bright, intellectually curious young doctors these days?

A new poll just released by Medscape illustrates this problem. A survey of over 1500 residents asked them what were their biggest challenges during their training. The results are rather disheartening for those who had high hopes for the next generation of physicians.


As you can see, the number one concern that residents feel they are facing is "Work-life balance". By comparison, the reason they are in residency to begin with, "Developing the clinical skills required for the specialty", is down at a woeful fifth place. Really? Are our millenial physicians really such snowflakes? Is the medical field doomed when attaining knowledge lags behind worries about having the time to binge watch Game of Thrones?

In an era when medical information is growing exponentially, shouldn't this next generation be more troubled by whether they can keep up with that deluge of data instead of hoping they can get out in time to meet with their personal trainer?

Let's remember why medical residents are called that in the first place. Back in the day, they practically lived in the hospital for days at the time, thus the title of resident. Taking every third or fourth night call was common practice. Work-life balance was something you only hoped to attain once residency was finished, not striving for during the training itself.

Now we notice that attendings frequently stay at the hospital longer than our residents do. Critical decisions are made when most of the team have already left the building. This is the sad future of medicine. Shift work is being ingrained into the mentalities of our impressionable doctors. The days when the caring physician will stay at the bedside through the night will soon be history as work-life balance takes precedence over patient care.

Tuesday, August 8, 2017

Do Not Donate Money To The ASAPAC Yet

It's that time of year again. Like the Salvation Army's brigade of Santas and their red kettles who appear before Christmas each year, August marks the ASAPAC's annual donation drive, or Day of Contributing. This year it will occur on Thursday, August 10th.

But I'm here to tell you not to give any money on that date. Only a fool would give them any moolah this week. I'm not saying don't contribute to the ASAPAC. They are the most effective political action committee in medicine and one of the most effective in Congress. The more money we anesthesiologists give to them, the more the profession can effectively fight the encroachment of CRNA's, poor payer reimbursements, and other major concerns.

The reason I suggest holding off on giving to the DoC Thursday is because you will get nothing in return. Though the yearly event always reminds me of a public television donation drive, you will receive nothing for your generosity. PBS will give you a nice mug or towel, maybe even a book or DVD if you are generous enough. By comparison, the ASAPAC gives you bupkis.

What really got on my nerves last year though was that the goodies are given the weeks AFTER the DoC. In the past I've dutifully made my online contribution to the ASAPAC and urged others to do the same. Then I realized that if you wait just a few weeks, they will actually give you free stuff to show their appreciation. It's nothing significant, just little tchotchkes like pens or flashlights with the ASAPAC logo. But it's still better than nothing.

When I saw the gifts they were handing out, I emailed the ASAPAC to ask if I could have some of the items too, since I had JUST given them a few hundred dollars. "Sorry, no can do," was my reply. They were only for that particular fund drive. Giving to the DoC was purely out of the goodness of your heart. If you want ASA paraphernalia, you'll have to wait for a different event where they actually promise to give you things. Gee, thanks a lot. I feel like I just got shafted by my own professional society.

So please contribute to the ASAPAC. But you don't have to give them money on the arbitrary day of August 10th. They will take your money any day of the year. Just wait until they pass out ASA logo'ed hats or T shirts if you truly want to feel appreciated.