Tuesday, September 16, 2014

The Contradictions Of Voter ID Laws And Obamacare

The latest headlines about the travails of Obamacare concern the fact that hundreds of thousands of people will lose their newly acquired government healthcare insurance because they are unable to prove their eligibility by producing paperwork showing their citizenship or residence in this country. These undocumented insurance recipients will likely lose their plans or have to pay back to the IRS the subsidies they have been getting from the government to buy into the program.

I can't help but contrast this aggressive bureaucracy with the controversy surrounding voter ID laws. These laws were enacted to make sure that people who want to vote in elections can prove that they are really who they are and where they live. Yet this simple requirement has been struck down by liberal courts all over the country.

I find it difficult to believe that people can be so isolated from society that they can't produce one single piece of paper to prove their identity. You need a photo ID to do almost anything these days. Use a credit card? Show me your ID. Want to buy that six pack of Bud along with that carton of Marlboro's? Show me your ID. You want to receive free government handouts? ID please.

Ironically these special interests who want to allow virtually anybody to vote without identification are the same ones who endorsed Obamacare in the first place. Are they going to abolish this requirement for proof of identification to receive health insurance? Unlikely because they know that massive fraud will ensue and billions of tax payer dollars will be lost to people who are not supposed to receive this largesse.

Yet these same groups have no qualms of possible massive voter fraud, which is arguably more important than Obamacare itself. The outcome of elections determines whether legislation like the Affordable Care Act gets passed in the first place. When the political make up of the government can be decided by fewer than one percent of voters in close elections, it's unfathomable that we don't guard more closely this right that was won by the blood of our country's ancestors. If guarding the integrity of Obamacare is paramount, the least we could do to honor our forefathers is to do the same for our constitutional right to free and fair elections.

Monday, September 15, 2014

This Simple Drug Can Reverse The Effects Of Propofol

Propofol is dangerous! Propofol should only be administered by professionals well versed on its effects! Propofol should not be given unless the administrator is an expert on airway management! These are some of the dire warnings we anesthesiologists trumpet to anybody within hearing distance to limit its use by non anesthesia providers. The reason is that propofol has long been considered to have no effective reversal agent. Once a patient becomes apneic and unresponsive from being injected with propofol, it is widely assumed that only anesthesiologists have the skills necessary, mainly intubation, to treat the patient until its effects eventually dissipate. That is why we look with disdain at gastroenterologists and other physicians who think they too should be allowed to use the drug.

But what if there really is a reversal agent for propofol? What if this cure can already be found in every pharmacy in the U.S.? As a bonus, this miracle drug is dirt cheap too. How would that affect the balance of power between anesthesiologists and other physicians who have been trying to get into this patient sedation business for decades, inventing complicated and expensive systems like the Sedasys in order to usurp the monopoly held by our profession?

While doing some reading on this whole Joan Rivers fiasco, I came across an article published in Anesthesiology in the September 2000 issue. Its bold headline reads, "Physostigmine reverses propofol-induced unconsciousness and attenuation of the auditory steady state response and bispectral index in human volunteers." I couldn't help but gasp that this research paper of such potential consequence for the practice of anesthesia is not more widely publicized.

This is a rather simple experiment the researchers in Canada conducted, which makes it even more compelling. They asked several human volunteers to undergo a propofol sedation. Using a propofol infusion pump, they were able to achieve sedation defined as lack of motor movement when the blood level of the drug reached 3 mcg/ml. In eleven volunteers they injected physostigmine at a dose of 28 mcg/kg while in six they gave only normal saline. The reason physostigmine was chosen is because it is an anticholinesterase with the ability to cross the blood-brain barrier and has previously been shown to be able to reverse sedation caused by an anesthetic agent like halothane or a sedative like scopolamine or midazolam.

The volunteers were hooked up to a BIS monitor and an EEG with an earpiece to measure the person's response to an auditory stimulus. But the researchers also used such simple tactics as telling the volunteer to open his eyes or squeeze his hand. After the appropriate level of propofol was achieved, the pump was turned off and either physostigmine or NS was injected. The NS subjects showed no change towards recovery of consciousness. Meanwhile nine out of eleven given physostigmine woke up, as measured by the electronic monitors and also responsiveness to verbal commands.

To further prove that physostigmine was working inside the blood-brain barrier, the researchers also gave a separate group of volunteers scopolamine an hour before being given physostigmine. Scopolamine is an antagonist of physostigmine and sure enough, this group failed to regain consciousness with the physo.

Wow. What anesthesiologist hasn't been bedeviled by that one patient who just seems to take an abnormally long time to regain consciousness after anesthesia? One would think that this work would have more followup with greater numbers of patients and further refinement of the physostigmine technique. But doing a quick Google search only reveals one other recent study relating to these two drugs. It was published in the British Journal of Anaesthesia in December 2012 and involved a rat model. Somehow that feels like a step backward from the human volunteers used by the Canadians. Why aren't more scientists and anesthesiologists pursuing this research that could potentially save many lives?

I hate to be such a cynic, but is it perhaps that the ASA and other anesthesiologists have no vested interest in making propofol safer for other physicians and health care providers, ie/nurses, to use? Think about how many endoscopy and radiology suites would no longer need an anesthesiologist to give sedation if there was a quick and easy reversal for propofol. This could possibly cost the jobs of half the ASA membership.

However I'm a firm believer in patient safety first. That is why I have no qualms about bringing up this old article that could hold the key to dramatically improve the safety profile of anesthetics. I just hope nobody else besides anesthesiologists reads this post.

Sunday, September 14, 2014

The Murky Death Of Joan Rivers

I have tried not to comment on the untimely death of comedienne Joan Rivers last week due to the fact that the investigation into her demise at the Yorkville Endoscopy center in Manhattan is still ongoing. However, more details are starting to leak out about that fateful day and the story is starting to get more disturbing.

Ms. Rivers was scheduled to have a procedure performed at the center that day by her personal gastroenterologist, Dr. Lawrence B. Cohen, to evaluate a worsening hoarseness in her famously raspy voice. Ms. Rivers appeared to be in good health and spirits at the time, even performing the night before at a club.

Now it's not uncommon for GI docs to evaluate hoarseness. What does the GI tract have to do with poor phonation? Severe gastric reflux can produce acid that comes up the esophagus and potentially damage the cords. Therefore it's not unheard of for a GI physician to perform an endoscopy to look for evidence of reflux that might lead to vocal cord damage.

Up to this point I have no problems with the story. Then the whole episode starts to go awry. At first the news was that Ms. Rivers went into respiratory and cardiac arrest during the procedure. The first thing I thought of was laryngospasm, which is not uncommon during upper endoscopies performed with only conscious sedation or monitored anesthesia. An anesthesiologist present would have known precisely how to reverse the laryngospasm as that has been drilled into us since day one of residency training. However, it would have been unusual for Dr. Cohen to have used an anesthesiologist to give sedation to Ms. Rivers since he is well known in academic circles for looking with disdain at using anesthesiologists at all for endoscopies. He's one of those GI docs who feels he can simultaneously perform his duties of a gastroenterologist and an anesthesiologist without jeopardizing patient safety. So it's highly likely that Dr. Cohen was the one directing the nurses in the room to give IV sedation for the procedure, despite the claims of Yorkville spokeswoman Marcia Horowitz, who states that an anesthesiologist is always at a patient's bedside throughout the procedure and "immediately assumes control of the airway and assists with a patient's ventilation" if the patient is in jeopardy.

Ms. Horowitz says the center has three or four anesthesiologists working any given time to help with airway management. Yet they also say that succinylcholine is not available at the facility. Whaaa? I don't know of ANY anesthesiologist who will work anywhere without having access to at least one vial of succinylcholine at a moment's notice. It is precisely for emergencies like a laryngospasm that a rapidly acting muscle relaxant is most essential. So to claim that they have multiple anesthesiologists standing by with all the latest resuscitation equipment ready yet have no sux around doesn't make any sense at all.

Now comes the bombshell that Ms. Rivers had her vocal cords biopsied by an ENT surgeon who isn't even authorized to do procedures at Yorkville Endoscopy. In fact the surgeon was assumed by the center's staff to be a makeup artist for Ms. Rivers. Curiously, without knowing the identity of this person, they let her into the procedure room with her little black bag of equipment. If that's not the worst Joint Commission violation in the first degree, I don't know what is. First of all, did Ms. Rivers even know this surgeon or that she would be coming in during her EGD to possibly perform a vocal cord biopsy? Was the surgeon's name on the consent? Was there even a consent for vocal cord biopsy since the staff didn't even know the surgeon? Are the staff at Yorkville Endoscopy so intimidated by the GI doctors that they are afraid to raise questions about irregularities in the procedures?

The identity of this ENT hasn't been revealed, yet she could possibly be the worst ENT surgeon in the world. An ENT surgeon has looked at thousands of vocal cords during a lifetime of practice, including many airways horribly deformed by cancer. Therefore if Ms. Rivers went into laryngospasm, presumably the ENT would have just as much or more experience than the anesthesiologists in intubating her to reverse her hypoxia. One may assume that anesthesiologists have more experience with intubating the trachea, but many anesthesiologists who work at these outpatient ambulatory centers probably haven't intubated a patient in years. Even if the ENT had difficulty intubating Ms. Rivers, which they eventually did, the surgeon would have been the perfect person to perform an emergency tracheotomy to save her life.

So this raises the question of how Ms. Rivers was being monitored during her endoscopy. Did she have all the basic monitoring equipment in place according to ASA guidelines, including pulse oximetry? Even if she went into laryngospasm, there is usually at least a few seconds to get the endotracheal tube in place to prevent hypoxia leading to cardiac arrest and brain damage. The surgeon would have been in precisely the right location to quickly insert the tube. Yet it sounded like they didn't realize the patient was desaturating quickly until it was too late. 

So as you can see, a lot of this story doesn't make sense yet. The investigation into what happened in that procedure room will take months to complete and may never be completely revealed to the public. In the meantime, Dr. Cohen has lost his job as the medical director and procedurist at Yorkville Endoscopy. And I'm once again having to explain to my patients in preop why they won't suffer the same fate as poor Joan Rivers.

Saturday, September 13, 2014

Lineman For The County

I walk over to the ICU to pick up my next patient coming to the operating room. She is having severe GI bleeding and the doctors had been calling all day to the OR asking when we are going to bring her. When I walk into the room, the young patient looked relatively healthy, awake and alert and breathing room air. That's a pleasant surprise for an ICU patient.

Then I look at her monitors. She is in sinus tach going in the 140's with the last measured systolic blood pressure of about 100. I ask the nurse in the room who is getting the patient ready for the transfer about the heart rate. "Oh, it's been that way all day," she answers. What have they been doing to treat the tachycardia and hypotension? She replies, "the patient was given a 500 cc NS bolus and one unit of blood. The heart rate is now down from the 160's earlier." I see. The nurse also kindly volunteers that the ICU team gave her a small bolus of esmolol to try to bring down the rate but unfortunately the blood pressure bottomed into the 70's so they didn't try that again. The team's opinion is that the patient is very sensitive to beta blockers. I force myself from rolling my eyes.

I then ask her what kind of IV access the patient has. The nurse isn't quite sure since she had just started her shift. We look under the patient's blankets and find her lone IV, a delicate little 22 gauge catheter dangling on the back of her hand. Is this the only IV she's had all day? The only one that they're using to give fluid boluses and transfusions? "Yes," she says. "They were planning on putting in a central line later tonight." I couldn't help letting out a deep sigh of frustration.

What's her urine output been? "Oh, she doesn't have a foley catheter. But she is making urine. She just went on the bedpan." Does the patient have any more blood available in the blood bank? "Yes she has four more units ready and the team wanted to send one with the patient to the OR." Well at least they got something right though it would have been infinitely more helpful if the blood was given prior to the patient's procedure.

We quickly wheel the patient to the operating room. This mismanagement of a critically ill patient is going to take some work on my part to get her through the procedure. I proceeded by placing in her the appropriate monitors for somebody who is on the verge of hypovolemic shock. While I was getting the patient lined up, the OR phone rings. The circulating nurse picks it up and calls to me, saying the ICU resident needs to talk to me. Feeling no desire to talk to these incompetent boobs, I tell her that I'm busy resuscitating the patient and I can't come to the phone. She relays the message then hangs up. "The ICU resident is just asking if you could put in an arterial line and central line while you have her in the operating room." I gritted my teeth and tried to ignore that request while Glen Campbell plays in my head.

Saturday, August 30, 2014

Treat Your PONV Patients To A Propofol Sandwich

As any anesthesiologist knows, few things are more uncomfortable for a patient or time consuming for the anesthesiologist as dealing with post operative nausea and vomiting. The surgery and anesthetic may be a complete success but if the patient is puking her guts out in recovery, the goodwill that should have been earned gets flushed into the emesis bag. There are literally dozens of ways that have been attempted to eliminate or at least ameliorate PONV, which only goes to demonstrate how pervasive this problem is. I've been trying a technique called the propofol sandwich that has given me good success.

The propofol sandwich certainly wasn't invented by me. It has been extensively written about and researched. However, I was never taught this in my residency and only first read of its efficacy in a California Society of Anesthesiologists newsletter last year. Written by Orange County anesthesiologist Michael Reines, MD, he describes his technique, which he calls bookending, of finishing his cases by turning off all inhalational agents in the last 15-20 minutes of surgery and substituting small boluses of propofol to maintain amnesia. His goal is to use about the same amount of propofol at the end of the case as was used during induction and to have zero levels of volatile anesthetics in the patient's system by the time she wakes up.

Intrigued, I decided to try this for myself these last few months. This works best for predictable cases like appendectomies or lap choles where if you know the surgeon it is easy to guess how long it will take before the case concludes. It doesn't work quite as well in cases that can finish quickly and unexpectedly like ENT procedures. Unlike Dr. Reines, I use a propofol drip to maintain the sedation instead of giving small boluses. Giving small discreet aliquots of propofol at the end has demonstrated blood levels of the drug that is subtherapeutic and isn't adequate to prevent nausea. Running at a rate of about 100 mcg/kg/min, I can maintain good sedation during the last 20 minutes of surgery while allowing the gases to fall to zero before the patient emerges from anesthesia. The key is having as little volatile agents as possible in the patient by the time she awakens.

Why not just go with a total IV anesthetic using propofol for the entire case? Doing so runs the risk that the patient will take a long time to emerge from the anesthetic. Thanks to their insolubility, gases like desflurane and sevoflurane are expelled very quickly by the body whereas propofol can sometimes take longer than anticipated to metabolize, especially in the elderly or obese. By using a small infusion rate at the end of the case, there is less risk of the propofol accumulating in the patient causing a prolonged emergence. It is also less expensive to give a propofol sandwich than to administer TIVA.

How do I know that the patient isn't aware during the operation running on such a low dose of propofol? Anybody who has ever given sedation in the ICU knows that it doesn't take much propofol to provide amnesia. Also in MAC cases like GI endoscopies, experience has shown that very small amounts of propofol is all that's needed to maintain good amnesia. If you're truly concerned about possible surgical recall, you can first try the propofol sandwich by using a BIS monitor to give yourself some piece of mind. Just remember to keep the patient lightly paralyzed up until the end of the case or the BIS readings will jump with the patient's muscle movements.

With the propofol sandwich, I've found that my patients wake up much more quickly and smoothly than with trying to breathe off the inhalational gases. The patients also don't need as much paralytics to maintain muscle relaxation with propofol. Thus I can reverse the paralysis very readily. And my patients in general seem to have less complaints of PONV. Those who have a history of PONV say they still have some nausea but is less severe than with previous operations.

So try the propofol sandwich on your PONV prone patients. You might be pleasantly surprised by how rapidly they emerge with very little nausea. Then you'll get all the kudos from the patient, her family, and the surgeon for being such a terrific anesthesiologist. You have nothing to lose except your patient's emesis basins. You also might want to pass along where you got your new insight on treating PONV.

Friday, August 29, 2014

Incompetent IV Placement Botches Execution

The autopsy report on Clayton Lockett has been released. Mr. Lockett was the convicted murderer who was executed by the state of Oklahoma back on April 29. The incident made national headlines when the procedure took over 45 minutes to conclude. Witnesses reported that the prisoner was writhing and appeared to be vocalizing pain after the medications were given. At the time, a doctor stated that the IV had blown and they had to start a new one. Ultimately Mr. Lockett died but due to a cardiac arrest.

The autopsy now shows that Mr. Lockett did indeed pass away from the drugs that were administered, not an MI. However, the reason that death took so long was because the drugs had infiltrated into the soft tissue instead passing directly into his blood stream. And it appeared the prison staff tried REALLY hard to get an IV in. Examination of the body showed IVs were attempted in both arms, the neck, the right foot, and both groins. It seems that the femoral veins too were not successfully cannulated which led to the IV infiltration.

The drugs that were given also came to light. They included midazolam, vecuronium, and potassium. While the dosages that were administered were not listed, it would appear that an IM injection of midazolam may not have been sufficient to cause amnesia if they were giving him the usual IV dose. Vecuronium would also have taken a lot longer and need a bigger dose to work in the soft tissue, possibly causing the prolonged movements that were witnessed. And that potassium injection into muscle would have hurt like heck.

Perhaps before the next time the Oklahoma penitentiary system attempts another execution, they should read my advice on how to start a difficult IV. But then again, convicted murderers like these don't deserve much mercy after the harrowing crimes they committed that landed them on that executioner's table in the first place.

Thursday, August 28, 2014

The ASA Is Getting Desperate about CRNA's

I received this email from the ASA the other day. It breathlessly declared, "Nurse anesthetist care not equal to physician anesthesiologist-led care, comprehensive evidence-based review finds." I thought, Whoa! Did the ASA just discover the Holy Grail that will finally demonstrate the superiority of anesthesiologists over CRNA's?

So I dig a little deeper. The ASA is citing a study conducted by the Cochrane Collaboration, a "global independent network of health practitioners, researchers, patient advocates, and others..." The study is called, "Physician anaesthetists versus nurse anaesthetists for surgical patients." It is actually a meta-analysis of six different papers that tried to compare the quality of work of anesthesiologists versus CRNA's. The six articles combined had over 1.5 million patient records. None of these studies were blinded due to ethical and impractical reasons.

After reviewing all the studies, the authors felt that none of the papers could conclusively declare that anesthesiologists or CRNA's gave better care. Some appeared to give the advantage to the nurses while others favored the doctors. But all of them were too flawed to declare the results unequivocal. The studies did not properly account for the different acuity levels of patients that were treated by physicians versus nurses. The different practice locations of the two professionals, Level 1 trauma center vs. rural community hospital, were not adequately taken into consideration. There were large variations in how the papers treated the complication rates.

Ultimately the authors stated that there were just too many variables involved to make a strong statement. They concluded, "it was not possible to say whether there were any differences in care between medically qualified anaesthetists and nurse anaesthetists from the available evidence."

The inability to document the superiority of anesthesiologists versus CRNA's in the final result doesn't exactly conform to the screaming headline the ASA is trying to plaster all over the internet. Is the ASA becoming so desperate in its attempt to disparage the nurses that they will twist a scientific paper to justify its own personal beliefs even if the paper doesn't support that goal in any way?

As anesthesia technology and techniques continue to improve, that objective is going to get even harder. Through rigorous research conducted by physicians, we are constantly striving to improve the safety profile of our field. Then we magnanimously pass along this new knowledge to anesthesia and SRNA residents without prejudice because we believe patient safety is the number one goal of all anesthesia providers regardless of degree. So it's no wonder there will be very little documentable evidence of physician superiority, even though we can feel it through every fiber of our being. The ASA is going to have to try a lot harder than mischaracterizing a research paper to prove to its members that they are in fact number one.