Wednesday, January 28, 2015

The Finger Pointing Begins. The Joan Rivers Malpractice Lawsuit

You knew it would come to this. For all the talk about medical staff teamwork in the operating room, when the sh** hits the fan, each person is on his own, trying to save his own butt from the wrathful vengeance of the malpractice attorney. In the medical malpractice lawsuit filed by the late Joan Rivers's daughter, each doctor is now essentially blaming each other for the comedienne's untimely death last September 4th during a simple endoscopy.

During the official investigation following her demise, a note was found in the chart that was handwritten by the anesthesiologist, Dr. Renuka Bankulla, that said she tried to find the ENT surgeon who had performed the laryngoscopy and possible vocal cord biopsy, Dr. Gwen Korovin, when Ms. Rivers went into cardiac and respiratory arrest. However Dr. Bakulla couldn't find Dr. Korovin in the room to perform a cricothyrotomy to open up the patient's airway even though she was there only minutes prior to the arrest. The suit speculates the Dr. Korovin fled the room at the first sign of trouble because she was not credentialed to perform procedures at the Yorkville Endoscopy center.

The attorney for Dr. Korovin counters that she was in the room all along. In fact, the faithful doctor was the last person to leave the room when the patient was taken away by ambulance. Just because the anesthesiologist didn't see her doesn't mean she had left the room. However, Ms. Rivers's lawyer wonders why, when Joan wasn't able to get any air into her lungs, the surgeon didn't take over the airway and performed the emergency operation. Said Jeffrey Bloom, the attorney, "She's an airway specialist. Why isn't she stepping forward and saying 'I'll do it' or 'You do it'. Instead she obviously did nothing."

Naturally much more will come out as the lawsuit proceeds. More witnesses will be testifying as to the whereabouts of Dr. Korovin, including the testimonials from the GI doctor and two other anesthesiologists and nurses that were in the room when disaster struck.

This is an important lesson for all anesthesiologists. You may think you are good buddies with your favorite surgeon, going out and playing golf or fishing together. Maybe you send each other Christmas cards or your children play soccer on the same junior high team. But when trouble hits, that friendship will quickly dissolve into acrimony.

A few years ago, one of our anesthesiologists was working with a highly likeable orthopedic surgeon. The surgeon was always friendly and loved to tell corny jokes in the operating room. Everybody wanted to work him. Then one day, after a simple joint procedure on an elderly female patient, the surgeon wrote a narcotics order after she had already been transferred out of recovery and to the floor. The patient consequently had an unwitnessed respiratory arrest and died. The inevitable malpractice suit was filed and now the surgeon was blaming the anesthesiologist for oversedating the patient while in recovery leading to the arrest from a routine narcotics order when she went to her room. That happy face mask quickly disappeared when facing a multimillion dollar lawsuit. A tough education no anesthesiologist should forget.

Thursday, January 22, 2015

The ASA's New Sexist Home Page

ASA's new home page
With the start of a new calendar year, the American Society of Anesthesiologists has unveiled a brand new home page on their website. They are quite proud of it and hope you like it too. They even provide a convenient link to their web editor so you can express your amazement at the good use of your annual dues to keep their home page fresh and engaging. You know of course that dripping sarcasm is difficult to express on a written page.

So here is my problem with the new site. There is nothing wrong with the new design. It is less cluttered and more prominently offers links to pages that you are most likely to use, like the current news or log in page. But the contents on this particular page are beyond sexist. Their first feature of the year is a discussion on pain in women. I object to the society pandering to females when pain is a universal ailment. Everybody feels pain. Why is the ASA focusing on predominantly female problems like fibromyalgia? And now the ASA claims they have expertise in treating PMS?

What happened to the other half of the world's population that also experiences pain? When I get back from the gym after benching 250 pounds, I get a soreness in my chest and shoulders. What's the ASA's answer to that? After a long weekend trip in the Santa Monica mountains mountain biking, my knees and thighs are screaming for relief. Will the ASA also offer a rose oil rubdown as treatment? Men suffer pain too. We just don't bring as much attention to it as we probably should because, well, we're men. And we can take it.

The other part of the new home page that I find extremely objectionable is the lack of diversity being shown. The slide show that scrolls across the top of the page currently only features one kind of anesthesiologist. I'll give you a hint: none of them are men. All the anesthesiologists pictured are women, even though they make up a minority of the ASA membership. Is this the ASA's idea of membership diversification? Did I miss the memo that January is Women Anesthesiologists Month? The links associated with those pictures aren't even gender specific. They involve subjects like Practice Management and paying your membership dues, neither of which are gender related. Yet every single image is of a female anesthesiologist. Has the ASA been hijacked by the National Organization for Women?

Exclusion of men does not make the ASA more inclusive. The ASA should be embracing all anesthesiologists, not just the politically correct ones. I've never heard anyone complain that there are too many male anesthesiologists. Don't stir up a gender controversy when there is none to begin with.

The Ultimate Sacrifice

Dr. Michael Davidson
We like to think doctors are kind, selfless people, working tirelessly to help the sickest and neediest human beings with little regards for our own well being. Unfortunately, not everybody feels the same way. The shocking murder two days ago of Dr. Michael Davidson, a cardiothoracic surgeon at Brigham and Women's Hospital in Boston, once again underscores the precarious situation physicians face every day when dealing with people who may not be thinking rationally when confronted with severe illness, either in themselves or in a family member.

Dr. Davidson was shot in his own medical office by the son of a deceased former patient, Stephen Pasceri. He then turned the gun on himself and died of self inflected gun shot wounds. Police investigations have not yet revealed the reasons why Mr. Pasceri decided to shoot the surgeon. His family is equally baffled by the violence, stating they felt their mother received good care while under Dr. Davidson's watch.

Dr. Davidson was only 44 years old. He was essentially just getting started with what was supposed to be a long and brilliant career. When you take into consideration the extremely long road that's required to become a cardiac surgeon--medical school, surgical residency, cardiothoracic fellowship--it's clear that he had only been in practice a few years. It's tragic that so much sacrifice he took to become a surgeon could be so easily extinguished by a crazed individual with no regard for human life. He leaves behind three children and a wife who is seven month pregnant.

This isn't the first time a surgeon, was murdered by a disgruntled individual in his own office. Back in 2013, a urologist, Dr. Ronald Gilbert in Orange County, was shot and killed by a patient unhappy with his prostate surgery performed 21 years prior to the shooting. He was not the patient's surgeon but was unlucky enough to have been chosen by the gunman for retribution.

More commonly, doctors and nurses have to deal with verbal and sometimes physical abuse from our patients regularly. Any healthcare professional can easily rattle off instances where patients have swung at them with fists, or tried to kick them while lying on a gurney. We've been yelled at, spit upon, threatened with legal action, all while we're doing the best we can to heal the patient. Sometimes we wonder if facing these confrontations is worth the sacrifice to our own dignity and well being. The answer of course is yes, because taking care of patients is our ultimate goal, no matter how much we too have to suffer before they understand that.

Tuesday, January 20, 2015

My Easiest Cancellation Ever

Every anesthesiologist has been through this. A surgeon books a case for a procedure and we go evaluate the patient. We examine her and think, "Hmm, this patient probably shouldn't go to the OR. She needs more workup to evaluate and resolve some important issues." We then gird ourselves for the inevitable argument with the surgeon for why the case needs to be postponed. Inevitably we win the argument but they still fight anyway. Or they decide to find another anesthesiologist with looser standards for administering anesthesia.

However that was not the case the other day. The surgeon scheduled a case later in the afternoon. I dutifully went to the ICU, where the patient was located, to preop her. Most anesthesiologists have had the "Holy shit! They want to operate on this patient?" moment. And this was one of them. I could only shake my head at the audacity of the surgeon to even book this case. Did he even examine her?

A quick perusal of the labs revealed the patient had a hemoglobin of 2.9. Platelets were 6K. Not 600,000, or even 60,000. SIX THOUSAND. The patient was highly coagulopathic with an INR of greater than 4. How will the surgeon possibly stop any surgical bleed during the case? And worst of all, on her blood gas her pH was 6.9. And the patient is on dialysis. WTF?!

I called up the surgeon and calmly relayed my concerns. The surgeon replied that the ICU team was giving the patient more blood, though I didn't see any hanging at the moment. Well, they didn't want to give the blood too quickly because of the renal failure. Uh huh. Then I asked, if the patient is on dialysis, why is she so acidotic? Why hasn't the dialysis machine corrected the pH? Well, the patient is on a very expensive experimental drug that costs $20,000 per dose. The team didn't want to dialyze out the drug. Haha. That excuse was too funny to hold back my snort. So the primary team didn't want to waste $20,000 on a patient even though a pH of 6.9 is not compatible with life? This is so not happening. Case cancelled.

P.S. Subsequently the team tanked up the patient with blood to a more sane hemoglobin of 7. They also started a bicarb drip to bring the pH up to 7.3. They found an anethesiologist to do the case the next day after all these corrections were made. The patient then expired less than 24 hours after that. Don't we just love American medicine?

NIMBY And The Measles Epidemic

Huntington Beach High School in Orange County is doing the right thing. A student with measles was on the campus last week. Consequently the school has told all students who have not been given the measles vaccine to stay home until the end of the month. That is when presumably measles will present itself by then in these unprotected kids. Bravo.

Finally we are seeing some sanity in dealing with these parents who withhold essential vaccines from their children. What started out with an infected international traveler visiting Disneyland last month has now spread to four states and Mexico. This is the worst outbreak of measles in the United States since it was thought to have been eradicated in this country back in the year 2000. Most of these measles victims were not vaccinated by their selfish guardians.

Why selfish? Because not only are they irrationally paranoid about the link between vaccines and a host of other problems like mercury poisoning and autism, all of which have been debunked, they are counting on other people to vaccinate their kids so that they don't have to do the same for their own. The ugly mentality of Not In My Backyard is one of the main excuses these parents fall back on to justify their actions. You know how environmentalists love solar power and windmills to generate renewable energy until it is located near their own homes? The vaccine deniers think vaccines are great, but for other people's children. They are counting on the kindness of strangers to continue herd immunity and prevent the spread of any outbreak of communicable diseases.

Unfortunately so many parents in California, particularly in the affluent and so called educated neighborhoods, that this herd immunity has broken down. We've now seen measles and whooping cough epidemics where there should never have been one in the first place if all the children were properly immunized. Instead of pampering these parents, the state education board must enforce its own rules for childhood vaccinations. There should be no leeway with religious or personal exemptions to vaccinating school age children. If parents feel that strongly about not giving their kids the proper, and medically tested, vaccines, then they can just home school their own children. This madness has to stop before one child becomes permanently disabled, or even dies, from a totally preventable disease because of the ignorance of his parents.

Friday, January 16, 2015

A Desperate Cry For Attention--Physician Anesthesiologists Week

Which person is the anesthesiologist? You can't tell either?
I've been trying to avoid bringing this up because I think the concept is so insipid. But the ASA has been bombarding its members with daily emails to spread the word for their latest idea on promoting the virtues of anesthesiologists, the first annual Physician Anesthesiologists Week. Therefore as a dutiful member of the society I am going to publicize this event even though I think it reflects badly on anesthesiologists as a whole.

Why do I think this is a bad idea? It has all the hallmarks of a desperate cry for attention from an organization with an inferiority complex. It says, "Look at me! I'm relevant! I am a REAL doctor!" Is that the message we want to be sending out? Have anesthesiologists become so insignificant and replaceable that we need to promote ourselves as a brand, like laundry detergent? Perhaps.

When our group's leadership asked our hospital to place a Physician Anesthesiologists Week banner as a screen saver on all the computers in the place, the response we received was less than enthusiastic, "As a rule, we don't use our communications channels/publications to promote organizational weeks or months. For one thing, there are far too many of those. More importantly, our strategic purpose is to promote the work under way at [the hospital] for our patients. So I'm afraid that we cannot assist with promotion of the Physician Anesthesiologists Week."

In other words, they use their screen saver to emphasize events like OR Nurses Week or Radiology Tech Week, but they don't see the need to promote anesthesiologists. And I don't blame them. You don't see the surgeons or internists clamoring for a Physician Surgeon Week or Physician Internist Week. For one thing, the title is redundant. Everybody knows surgeons and internists are physicians. They don't need to repeat it before their profession. Unfortunately the ASA thinks anesthesiologists have become so anonymous that we can't afford to do that, "Hey people, I'm a doctor too!"

Then, there's the awkwardness of celebrating ourselves. We're supposed to be leaders in patient care yet this campaign gives off an image of desperation, like we don't really believe our own legitimacy. Surgeons know they are leaders in patient care and the patients know it too. There's no need to have a special week to celebrate their work. It's innate. You know how despots in totalitarian countries conduct parades to themselves to imply to their own people how powerful they are and we laugh at their insecurity? Yeah it's kind of like that.

To see how embarrassing and debasing this Physician Anesthesiologists Week is, guess who else wants recognition for their work? And it takes place almost immediately after ours. Coincidence?
I bet everybody here is a CRNA.

Thursday, January 15, 2015

Does The Flu Vaccine Work? Depends.

Public health departments have been preaching the virtues of getting the flu vaccine for years. Many workplaces, including medical offices and hospitals have been mandating that their employees receive the flu shot or risk getting terminated. This despite evidence that the vaccine's effectiveness may be little more than the flip of a coin.

Now comes another study that details how ineffective this particular year's flu vaccine really are. The Centers for Disease Control has calculated the vaccine effectiveness (VE) of the vaccine. In most years, the VE ranges from 10% to 60%. This year they have reported it is only 23%. That means that getting it will lead the receiver to have a 23% less likelihood of needing to visit a doctor for the flu compared to the unvaccinated person. Sounds pretty good, right?

But take a closer look at the numbers. The VE is highest in children ages six months to 17 years with 26%. For adults ages 18 to 49, the VE is 12%. Adults greater than 50 have VE of 14%. But here's the kicker. The VE in adults was considered to be too small to be statistically significant. In other words, the vaccine's ability to prevent a person from going to see a doctor for the flu was no greater than somebody who never got the shot.

Once again, why are we forcing medical workers to get a shot with dubious medical efficacy with loss of employment? I'm not against vaccinations for the population that has been demonstrated to be helped by it. I am on my tirade because of losing my loss of self determination. My body. My choice.