Tuesday, September 23, 2014

Syringe Labeling Rules Run Amok. The Double Wide Propofol Label

We are expecting shortly another facility inspection by The Joint Commission. Cue scary Psycho music. As per routine, our department heads are going around the operating rooms to make surprise inspections in each anesthesiologist's cart. At the top of the list is making sure that we have properly labeled our drug syringes.

But this year the rules have changed, specifically for propofol. In the past, one would slap a propofol label onto the syringe and write down the date and time the drug was drawn up along with the user's initial. Now that is no longer the case. Instead, the new rules want the date it was drawn up, the time twelve hours later when it supposedly will expire, along with the date of the expiration time and the user's initial. Consequently, in order to have space for all that information, our propofol labels has gone double wide compared to the other drug labels.

I asked my department why twelve hours when I've always been told that propofol should not be used six hours after it is taken out of the bottle. Their reply is that due to the ongoing propofol shortage, our pharmacy has determined that propofol is acceptable to use for up to twelve hours. What? With just a simple decree by committee, longstanding rules for drug use can be changed without further research and FDA approval? It makes me wonder how many other "rules" in medicine are not based on any scientific processes and were developed by a bunch of people sitting around a conference table.

Frankly this whole syringe labeling exercise is a total waste of time. Half my routine during morning setup involves sticking these small labels on small syringes and writing in teeny tiny letters on slippery rounded surfaces. It's not as easy as it sounds. Not all pens will write on these paper labels. And how many of us routinely write on a non-flat surface? The lettering wind up being so small and distorted that they are hardly legible. How is this helping patient safety? Doing this on dozens of small syringes a day wastes a good portion of my time before each case.

I never understood why we even label syringes. I have a colleague at an ambulatory surgery center who claims he has not labeled a syringe in a decade. He uses only four different drugs for all his cases. With a clever combination of different size syringes and needles, he knows exactly what each syringe holds without even thinking about it. He scoffs at our insane rules for syringe identification.

Besides, who really needs to know the content of a syringe? Yes almost all drugs look like water in the syringe so it's helpful to know what's in it. But as far as dating and timing the drug, who really needs that. If I find a filled syringe sitting around that I didn't make, of course I wouldn't want to use it. It would go instantly into the drug trash bin. If I drew up the drug and forgot to put a label on it and subsequently forgot what I put into the syringe, again it goes straight to the medication trash. If I'm the one using the syringe, why should I put my own initials and date and time for when it was first made? I know all that information already. Who are the labels really supposed to help?

But The Joint Commission is on its way. And since they have a near monopoly on this whole hospital accreditation scam and could potentially shut us down, we just have to grit our teeth and follow their rules, no matter how nonsensical they are.

Sunday, September 21, 2014

You Give Docs A Bad Name

Audacity hardy begins to describe this physician. In the latest article from the New York Times on who is to blame for the U.S.'s enormous healthcare costs (they usually blame the MD's), the paper writes about unexpected medical expenses following a hospital stay. This time, they document the difficulties of a young man who just had neck fusion surgery.

Even before they talked about the outrageous bill that blindsided this patient, they itemize the enormous costs of having surgery that were anticipated in advance: $56,000 from the hospital, $133,000 from the orthopedic surgeon, a relatively measly $4,300 from the anesthesiologist. I think most Americans would be shocked by these expenses, much less the rest of the single payer world. The man knew that his insurance company will only pay the prenegotiated reimbursements since these were all within his network. But then, much later, her received a bill for $117,000 from an assistant surgeon that he never recalled meeting.

The primary surgeon, Dr. Nathaniel Tindel, was eventually reimbursed $6,200 by the insurance company. The assistant, a neurosurgeon by the name of Dr. Harrison Mu, was out of the insurance network. Therefore he could bill for whatever he felt was his going rate. This despite the fact that he was duplicating the work that was already performed by Dr. Tindel. Dr. Tindel billed the insurance company $74,000 for removing two vertebral disks and $50,000 for inserting the hardware. Dr. Mu billed for the exact same procedures at a rate of $67,000 and $50,000, respectively.This sounds suspiciously like double dipping to me. Not a bad payday for about two hours of operating time.

I've seen these situations in the OR's before.When the economic times were tough a couple of years back, we had plastic surgeons scrub in and just stand around holding retractors until they were needed for skin closure. I'm sure they billed a pretty penny for that beautiful pencil thin scar. You have to wonder about any possible financial arrangements that were made between the primary surgeon and the assistant. After all, why share the work with another doctor if it is much cheaper to just use the PA or resident?

Another highly questionable aspect of this situation is that the patient denied ever meeting Dr. Mu. Was Dr. Mu's name on the surgical consent? Around here, if the name is not on the consent, the doctor does not touch the patient, period. That even applies to the surgical residents and fellows in the operating room. Anything else could be construed as an assault by the doctor on the patient.

The paper tries to justify Dr. Mu's actions based on his normal hospital practice, which is in Jamaica Hospital Medical Center in Queens. According to state records, his practice mostly involves trauma patients on Medicaid, which probably pays him about one percent of what he billed in this spine case. Therefore, even though Dr. Mu is the chief of neurosurgery at Jamaica Hospital, he has to find time to moonlight at other places to make ends meet.

In the end, the insurance company coughed up a $117,000 check for Dr. Mu. The patient, who was reluctant to pass the check along to the surgeon for fear of setting a bad example, ultimately mailed it to him rather than getting into a legal tangle with the doctor. And Dr. Mu will now be forever known to the world as the neurosurgeon who makes Gordon Gekko look like Mother Teresa.

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.