What A Great Idea

Researchers in Australia have developed a head up display for anesthesiologists to watch a patient's vital signs.  The display is linked to the regular patient monitors. A simulated picture of the anesthesiologist's view is shown above. This idea is a long time coming.  As any anesthesiologist can tell you, there are many times when it is critical to watch a patient's vitals signs but can't. 

The most obvious example is induction and intubation of a patient, particularly a difficult airway.  I can't tell you how many times during a difficult intubation that the only way to monitor the patient is by listening to the tone and the rate of the pulse ox while I concentrate on trying to secure the airway.  The only way to know if the patient is desaturating is when the tone gets down to the baritone level, or the nurse yells "Sat is 75%!". Another example is starting a pediatric IV in the OR.  After the child has been masked down, the anesthesiologist has to concentrate on starting a tiny IV, again compromising the ability to watch the patient's vitals.  A HUD would easily alleviate that issue.  Hopefully in the near future this technology will be another tool in our arsenal for ensuring patient safety.

How Much Do Anesthesiologists Make?

Here is the latest report from the U.S. Department of Labor's Bureau of Labor Statistics.  The numbers come from May 2009, the last reporting period available.  According to the BLS there were 37,450 anesthesiologists employed in the U.S. as of May 2009.  Their mean hourly wage was $101.80.  Their mean annual wage was $211,750.  Anesthesiologists who are in group practice made the most, with a mean annual salary of $221,010.  Academic anesthesiologists made the least money with a salary of $139,490.

The top five states that paid the most money were Washington, Oregon, New Jersey, New Hampshire, and Missouri.  The top five states that are the most crowded with anesthesiologists are Hawaii, Kentucky, Tennessee, Delaware, and Arizona.

You can also create a custom chart on the BLS website.  For instance, you can compare the salaries of California, New York, and Texas anesthesiologists.  Interestingly all three states employ similar numbers of anesthesiologists: 3450, 3220, 3620, respectively.  The mean annual salaries of all three states are likewise similar: $219,000; $220,000; $196,000, respectively.  However the bottom tenth percentile wage earners are significantly different.  The lowest tenth percentile of CA anesthesiologists made $50.53 per hour.  The lowest NY anesthesiologists made only $29.26 per hour.  Then comes poor Texas.  Their lowest rung anesthesiologists made $12.88.  Seriously?  An anesthesiologist that makes only $12/hr?  The mean annual salaries of the three states' anesthesiologists also show a similar discrepancy.  The bottom tenth percentile salaries of the three states are $105,090; $60,850; and $26,790, respectively.  Again, really Texas?  I can't imagine an anesthesiologist that makes poverty level wages.  But then again they may be a leading indicator of where medicine  and doctors' salaries are headed in this country.

When 500 Pounds Is Not Enough

We are constantly upgrading our numerous operating room tables.  They wear out quickly after years of nearly 24/7 abuse.  The old tables were rated for safe use up to about 500 pounds, depending on the model.  Check out the specifications from one of our new tables.  1100 POUNDS!  Imagine operating on a patient who weighs half a ton.  Picture intubating and anesthetizing a patient who weighs as much as a full grown horse.  The horror.

Our hospital has to be prepared for whatever comes through the door.  If a morbidly obese trauma patient is rushed into the ER, our facilities have to be capable of delivering the same quality of care as a normal weight person.  If the hottest bariatric surgeon in town wants to bring his enormous (pun intended) case load to the hospital we must be prepared to facilitate his laparascopic gastric bypasses and other weight reduction surgeries.  Therefore that means we have to supersize our equipment, everything from operating room tables, to transportation gurneys, to ICU beds, and CT's and MRI's.  The costs are exorbitant when purchasing the equipment.  Naturally all these expenses are then passed along to the insurance companies and patients.  Besides their numerous comorbidities, these are some of the tremendous costs of the obesity epidemic in America.

Would You Eat Cake Off A Naked Man?

I would say that this cake plate is certainly, uh, provocative.  This plate comes from a line of European china called Anatomica.  It certainly has an appropriate title.  Perhaps you can use these plates at your next anatomy themed party.  Imagine the possibilities...  You might even give your guests some hard earned anatomy lessons that you spent months agonizing over in medical school.  Won't they be impressed with your knowledge and acumen?  Though at 48 euros each I wouldn't let the party get too wild.

Bad Ass Anesthesiologist

Check out Anesthesioboist's blog.  She is totally Bad Ass. We need more people like her in our profession.

Patients That Make Me Go Hmmm

To paraphrase a famous movie quote, "Preop is like a box of chocolates.  You never know what you're going to get." While I try to read the histories of my patients on the next day's operating schedule the night before, sometimes that is not possible, especially the outpatient or add on cases.  Frequently the outpatients don't have their histories dictated in the hospital computer system but instead are brought in by the surgeons from their private office files. Or the surgeon's history only discusses the surgical symptoms, not the other 20 positive review of system pathologies I'm more interested in. Thus it can be dismaying when confronted with an "interesting" patient ten minutes before the case is supposed to start.

For instance, we receive many patients for outpatient EGD's.  On the schedule it just says "EGD" and I'm thinking, "Great a quick 5-10 minute procedure"  But then I see the patient in preop holding.  She is 450 pounds and stands 5' 2".  She is here for an EGD as part of her preop evaluation for her gastric bypass surgery in the future.  "Hmmm," I ponder. "Should I intubate her for a five minute procedure like the textbooks and the ABA would advocate or risk apnea and aspiration by giving a MAC anesthetic?" Weighty question indeed.

Then there are the patients who are allergic to literally everything.  Their list of allergies runs two pages in single space type.  You know it gets ridiculous when they list Benadryl, atropine, epinephrine, all tapes, and half of California's agricultural industries as allergies.  One patient said she was allergic to morphine, fentanyl, dilaudid, and demerol, practically my entire arsenal of post operative analgesics.  "Hmmm," I'm contemplating. "This is going to be fun when she gets to recovery after her surgery. I hope there is some analgesic property in the L.A. smog we're breathing today."

Then there are the patients who are exactly the opposite.  They are taking every narcotic known to man for chronic pain.  Frequently these are the patients scheduled for major back surgery. The spine surgeon has assured them that their back pain will disappear after he does his miracle work.  I'm standing there looking at the patient who is already in tears because she missed her pain medications 30 minutes ago and I think, "Hmm.  She is on Dilaudid 24 mg every 4 hours and has fentanyl patches covering half her body.  This before a single millimeter of skin has been cut. I better punt this to one of our Pain guys. This is why they get paid the big bucks."

Variety may be the spice of life, but in anesthesia all I want is a simple, predictable, stodgy Hershey's chocolate bar.

Obama Hates Doctors, and Medicare Patients Too

As if we need more evidence that President Obama and Congress despise doctors and the current medical care system in America.  The July issue of Anesthesiology News (subscriber log in may be required) reveals that one of the provisions of ObamaCare states that physician owned hospitals are forbidden from expanding their facilities after March 23, 2010 (yes it is a retroactive law).  No new physician owned hospitals are allowed to be built after the end of the year.  And doctors have to tell patients their financial interests in the hospital or face a fine of $1 million. Because of these new restrictive rules, 39 new hospitals that were on the drawing books have been cancelled.  Another 45 hospitals that are now under construction are not expected to pass certification with Medicare before December 31, 2010 leaving their owners and investors in a quandary.

Is there any more confirmation of antiphysician bias needed than this new law?  What other industry in America is forbidden from expanding its perfectly legal and legitimate business?  The restrictions on boutique hospitals are almost as onerous as those aimed at the cigarette industry.  Isn't it ironic the government would lump doctors into the same class of people as tobacco companies?  Never mind that thousands of jobs have been lost because of the scuttled construction projects.  No hospitals also mean thousands of nursing jobs, back office staff, janitorial services, IT services, and other positions that makes up a modern American hospital have disappeared.  There doesn't seem to be any rational reason for strangling physician owned hospitals. 

Some people say these small hospitals (in general they are all miniscule compared to the behemoths of the university and nonprofit hospitals) siphon away the best paying patients from the tertiary care facilities that have to treat the poor and indigent.  But in my view this is what's called capitalism.  I know capitalism is anathema to this socialist administration but competition will only make the big hospitals more responsive to their patients' needs. 

Is there a way around these restrictive new rules?  Yes there is and it involves denying health care choices to Medicare patients.  Forest Park Medical Center in Dallas was undergoing a $104 million construction project to expand its current 24 inpatient beds by 60 inpatient beds, adding 12 ICU beds and 14 operating rooms.  They are not scheduled to finish until August 2011.  Since it will be illegal under ObamaCare to open the new facility after December 31, the doctors at Forest Park have decided that they are going to stop accepting all Medicare and Medicaid patients, thus exempting themselves from the new law.  The biggest losers are the Medicare and Medicaid patients.  They have just been denied the choice of being seen in a state of the art medical facility by some of the most successful doctors in the Dallas area.  Instead they will have to seek their health care in the older more crowded hospitals that are deemed worthy of government approval.  The big hospitals also just got a giant influx of poorly reimbursed patients onto their daily census, thus weakening their ability to modernize their facilities and compete effectively against boutique hospitals.  Isn't it funny how capricious health care laws written by lawyers have unintentional consequences?

President Obama, we already knew you hated doctors and the medical system with your discriminatory taxes on "the rich" but you just raised a big giant middle finger at the poor and Medicare patients in this country too.