Tuesday, October 14, 2014

What The Deaths Of Michael Jackson And Joan Rivers Have In Common

Following the unexpected death of Joan Rivers, I am once again inundated daily with questions from concerned patients about the safety of anesthesia. Everybody comes in with wide eyed fears while family members produce a list of questions about how likely their loved one will die during a routine outpatient procedure.

This hysteria is similar to the events five years ago when Michael Jackson was found dead in his rented mansion after being sedated by an inattentive cardiologist. At that time patient anxiety was actually far more intense because of Mr. Jackson's notoriety and the widespread news of propofol's involvement.

However, my answer to questions about both Mr. Jackson's and Ms. Rivers's deaths are quite similar--in both cases an anesthesiologist was not present to give the sedation. We know for a fact that MJ was overseen by Dr. Murray in a private bedroom with absolutely no evidence of any anesthesia resuscitation equipment available, not even oxygen. Ms. Rivers's case is still under investigation so we only have gossip and heresay to tell her story. However all evidence point to Dr. Cohen, her gastroenterologist, as the primary procedurist in the room. He has strongly voiced his opinion that the use of propofol by a non-anesthesiologist is just as safe as when an anesthesiologist is giving the sedation. With such a strong advocate of DIY anesthesia as Dr. Cohen, it is unlikely that he let any anesthesiologist sedate his patients, especially for a procedure as "benign" as an EGD.

As you can see, in both tragic cases there was no anesthesiologist in the room when a crucial airway emergency occurred. When patients ask about these sensational events, they must be firmly told that an anesthesiologist would most likely have prevented the untimely deaths of these two celebrities. No amount of PR material from the ASA about physician anesthesiologists (how I hate that term) can compare to a face to face bedside education that an anesthesiologist can give to his patient about the safety of our craft. This is another golden opportunity to inform our patients about the frequently misunderstood practice of anesthesiology. Out of tragedy anesthesiologists can really shine and demonstrate to the public the indispensable skills we possess to safely guide a patient through his most vulnerable period.

Sunday, October 12, 2014

The Scariest Doctors I Work With

I've worked with angry doctors. I've worked with slow doctors. I've worked with funny doctors. But do you know which physicians worry me the most? No it's not the psychopath surgeon whose mother never taught him how to talk with his inside voice. Nor is it the befuddled old coot of a surgeon who meticulously labors through a case that would take half the time in the hands of a more competent physician. No the procedurists that worry me the most in a procedure room are...first year GI fellows.

Why do these young innocent physicians scare the crap out of me? It really is no fault of their own. Every doctor has a steep learning curve that has to be traversed before they can be the experts they will eventually become. Unfortunately for me, new GI fellows are acquiring their craft by obstructing the part of the patient I am most responsible for safeguarding, the patient's airway.

When these young doctors first grab hold of an endoscope, they literally don't understand the ups and downs of the instrument. They'll fiddle with the myriad of knobs and locks to try to understand how to aim the scope in all directions. They'll play with the various valves and buttons to determine how to suction or insufflate. It makes my sphincters tighten just anticipating what is about to happen.

Then the dreaded procedure begins. The fellow will sort of bend the end of the scope to what he thinks is the approximate curvature of the tongue and the oropharynx. He will pass the scope through the lips then...get completely lost. All he'll see on the monitor is a red or orange monochromatic screen. Unless he pushes really hard into the soft tissue in the mouth in which case he may see white as all blood under the mucosa is pushed away from the end of the instrument.

In the meantime my job is to preserve the patient's airway while sedating her well enough so that she doesn't jump off the table as the neophyte continues his lesson. If the patient starts coughing or moving, I'll get the much despised, "Anesthesia, patient's waking up!" and it will be my responsibility to keep the patient still with more drugs while the fellow continues to meander his way down the mouth.

Eventually he will advance far enough past the tongue to actually see the vocal cords. It is at this point, when the greatest danger to the patient is present, that most of them decide to pause to admire the view, as if they think they are ENT surgeons. They may blow air directly on the cords to keep open the space around the tip of the scope, which of course causes the cords to become irritated and the patient to cough. Once again I'll have to respond to "Anesthesia, patient's waking up!" as if it is my fault. Or worse, the tip of the endoscope may become smeared with saliva and the fellow decides he needs to wash it with a squirt of water, which again leads to coughing, or worse, laryngospasm. All of these reactions the patient is suffering somehow have to be mitigated by me or the doctor won't be able to continue.

Once he's had a good look at the cords, he will then proceed to enter the esophagus. He will try to enter through that tiny little space right below the arytenoids and through the upper esophageal sphincter. Here is where most of them baffle me. They will tell the patient to swallow the scope to open up the sphincter. How quickly they forget that I have to sedate the patient so deeply for them to get to this point that the patient is not able to cooperate to verbal commands. This step may take awhile as there is usually a slight bend in the UES before the scope will enter the esophagus properly. Once they have passed this point I can finally let out a quick sigh of relief as the airway is now at less risk of obstruction once the scope has passed.

I know they have to learn their trade somehow. And after a few thousand endoscopies under their belts, they will be one of the highest paid physicians in the country. But in the meantime I don't think patients understand what risks they are taking when they have GI fellows practicing their procedures on them. Maybe this is one of those times where a model simulation of an endoscopy, like simulations of airway intubation, can be both safe and effective. I'm sure getting tired of pushing more propofol just so the fellow can get the endoscope past the patient's uvula.

Friday, October 10, 2014

Rich People Doing Stupid Things

I've seen some pretty ignorant driving behavior here in Southern California. There are the women who put their mascara on while going down the road at thirty miles per hour, the applicator just millimeters from their eyeballs. Or the girls who decided they just needed to braid their hair with both hands at that moment while steering their vehicles with their knees. Texting while driving is practically ubiquitous these days. But when I saw this car on the freeway I had to do a double take.

People were all driving 50 mph+ when this BMW M6 convertible came zooming past. Now that isn't unusual for a car with an excess of 550 horsepower under the hood. But what shocked me were the three teenage passengers sitting in the back seat. They weren't really sitting in it so much as squatting on it. As you can see their heads and shoulder are way above the headrests. That's probably because this car's knee room is so cramped that they couldn't fit their legs back there. This car is more of a 2+2 touring vehicle, not a family transportation hauler. BMW calls it a 4+1 seating configuration, meaning the person in the middle of the back bench had better be tiny and willing to straddle a huge center tunnel running down the middle of the car.

Of course when you aren't sitting in the seats properly, you can't wear the seat belts either, which none of these three kids were doing. If this car ever got into an accident, those kids would become living breathing flying missiles shooting out of the vehicle at fatal speed. So now you have three children squatting in the back with their heads above the headrests and none of them wearing seat belts in an open top convertible. The potential for disaster is mind boggling. This just goes to show that just because somebody has lots of money, the retail price of this car is almost $120,000, doesn't mean they have much common sense, or any sense. I hope somebody recognizes this car and tells the driver to stop this insanely reckless behavior before innocent people are killed.

Wednesday, October 8, 2014

Binge Drinking Is Another Reason Why Children Shouldn't Copy The Behavior Of Their Sports Heroes



Here's another case of a professional athlete setting a bad example for their young admirers. While the child abuse case of Adrian Peterson and the spousal abuse by Ray Rice are worse, this binge drinking by San Francisco Giants pitcher Madison Bumgarner is potentially more dangerous. Most of us can't contemplate the violent behavior of the aforementioned football stars, but the Giants player's binge drinking will certainly be admired by many young adults, maybe even impressionable high school students. In this video clip, Mr. Bumgarner is seen chugging FIVE cans of beer simultaneously while his teammates cheer him on in the aftermath of their win in the National League Division Series. Is this celebration of a baseball game excessive? Will Mr. Bumgarner want to be remembered as the man who can drink five cans of beer at a time? How will he feel when his own children and other young family members watch this on YouTube, up there on the internet for all time? Will he be embarrassed? Or will he be like the hypocritical pot smoking parents who tell their kids not to do what they see their elders doing?

Excessive alcohol consumption is a serious issue in our country. Its economic cost is estimated to be over $200 billion per year in medical care and lost productivity. Seventy-five percent of that is directly related to binge drinking. Binge drinking is defined in men as taking five or more drinks within a two hour span. In the video, Mr. Bumgarner is doing it all in thirty seconds.

According to the CDC, ninety percent of alcohol consumed by young adults under the age of 21 are done by binge drinking. Think of the fraternity weekend parties, postgame keggers, and Greek nights on campus. But it's not confined to just college campuses. Ten percent of high school drinkers have binge drinked. These are precisely the fans who will be admiring the beer guzzling performance of Mr. Bumgarner.

For the same reason these young fans buy the shoes and other products endorsed by athletes, they will also try to emulate their actions on and off the field. At that youthful age they don't have the judgement to discern what's wrong and what's right. I don't have to go through the long list of potential complications from excessive alcohol use, including injury or death to oneself or others from drunk driving, hepatitis, pancreatitis, unwanted pregnancy and sexually transmitted diseases. This sort of behavior should not be an example of a celebratory display after a hard won game. Spraying each other with champagne is one thing. Drinking alcohol so quickly that it is running out the sides of your mouth and down your clothes should not be condoned by any athlete or their professional organization lest they want their own children to do the same thing.

Everything You've Always Wanted To Know About The Female Sex Organs And Were Afraid To Ask

This extremely clinical description of the female genitalia will surely take any romance out of the mystery of female orgasms. Hmm, required reading for high school sex ed and college fraternities everywhere?

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.