Medicare Sleight of Hand

The New York Times has a nice article about the fraud in Medicare savings the new health care bills in Congress are perpetrating. Medicare will cut reimbursements to doctors, hospitals, and nursing homes by $500 billion over the next ten years. In addition, they plan on raising taxes on the wealthy and medical device makers, taxing expensive health care plans, or raising Medicare withholdings from your paycheck.

Together this is supposed to "save" Medicare by delaying its date with bankruptcy court by all of nine years. But wait. Since this is the federal government, they can't have all this extra money sitting around waiting to be handed out in the future. So using the same savings they are trumpeting, they are going to use it to subsidize health insurance for 30 million people.

So this is the conundrum Medicare and Congress are dealing with. You can't use the money to save Medicare in the future if the money is being spent today to pay for health insurance for the uninsured. Try explaining that to the voters back home. Of course by the time Medicare is truly in trouble, most of the current members of Congress who voted for these "reforms" will have passed on or retired (synonymous with Congressmen).

Medicare=Bernie Madoff

How is Medicare equivalent to Bernie Madoff, the perpetrator of the biggest Ponzi scheme to date?

1. Early participants made off with the most benefits.

2. People are promised fantastic, virtually unlimited, returns for their investment, no matter how little money they actually put into the program. (Free single payer health care for everyone!)

3. An ever greater number of people have to be recruited to pay into the program to keep it running.

4. Money paid into the program is supposedly kept in a "trust fund" for future benefits but in reality has already been paid out to current users.

How is Medicare different from Bernie Madoff's Ponzi scheme?

1. Madoff's scheme was bought by investors voluntarily. Medicare is forced onto every working American.

2. There is no clawback of money and benefits from early users of Medicare

3. No prosecutor is going to come in and arrest the federal government for running the world's largest Ponzi scheme.

Miracle, or Excellent Resuscitation Team

In news that's all over the internet today, a woman who appeared to have suffered a cardiac arrest during labor with her baby born limp and lifeless were both revived successfully. This is being credited to an act of God.

Mike Hermanstorfer [husband of the patient] credits “the hand of God.”

“We are both believers ... but this right here, even a nonbeliever — you explain to me how this happened. There is no other explanation,” he said.

I suspect that the real explanation for reviving the mother and child should be credited to the resuscitation team. Probably led by the anesthesiologist and the perinatalogist, the team acted professionally during an extremely stressful situation and performed their jobs as expected, all while the husband was watching their every move. Their professionalism extends to their modesty. They could have easily announced their achievement all over the net. Instead they allow the news media to continue the illusion that only God was able to help the poor family. After all, they are medical doctors, not politicians. So congratulations to the medical team at Memorial Hospital in Colorado Springs. One more family will be having a happy new year thanks to you.

Listening To Your Patient

I walked into preop to see my next patient. He was a centenarian, weighing all of 120 pounds. He had been cared for by his family at their home and it showed. The poor man was literally all shriveled up. He had horrible contractures of all extremities. Needless to say he had a nasty decubitus ulcer too. Why was he coming to the OR? He was scheduled for an EGD and feeding tube placement.

When I saw this poor man, I thought "Why?" He was nonverbal and confused. Of course he could not consent himself for the procedure so the family signed the order. While I don't normally advocate euthanasia, I thought this case would have been ideal. This poor man was not living. He probably hadn't lived in years. He was merely existing.

Under anesthesia, the patient did very well. That's one thing I have noticed about centenarians; they have relatively healthy cardiovascular systems. Otherwise they would have died a long time ago. The endoscopist performed the EGD and passed the nasojejunal feeding tube. It was not without difficulty as the tube kept wanting to slide out when he tried to withdraw his scope. When it was finished, the tube was taped to his nose. That's when the nurse noticed that most of the tube was curled inside the patient's mouth--the patient had used his tongue to pull it out. So the doctor passed the endoscope back down into his stomach. This time to ensure that the tube would not come out, it was clipped to the jejunal mucosa. He again withdrew the scope. The patient was then taken to recovery.

In the recovery room, the nurse noticed that most of the tube was once again curled up inside the mouth. Despite the patient's diminished mental state he had used the only defense mechanism he had, his tongue, to remove the feeding tube. Needless to say the endoscopist was extremely frustrated. He said he'll need to go talk to the family about placing a more permanent PEG tube so the patient can't pull it out. I thought, "Man, listen to your patient. He is telling you exactly what he wants and needs." He is scheduled for his gastrostomy tube next week.

Driving After Anesthesia

In the "Why didn't I think of that?" department, a new study appears to debunk the concept of having a driver available to take a patient home after outpatient surgery. In a study led by Asokumar Buvanendran, MD, he uses an computerized driving simulator to replicate the driving experience of patients before and after surgery. (Anesthesiology News, October 2009. Free registration required)

Current guidelines for outpatients are based on older, longer lasting anesthetics like diazepam and halothane. Consequently patients have always been advised to have somebody drive them home. If they did not have a driver, the case most likely would be cancelled. But what is the cognitive ability of patients now that mainly short acting anesthetics like propofol and midazolam are used?

In Dr. Buvanendran's study, a patient was tested in preop for fifteen minutes on the simulator. The patient then went to surgery. Afterwards, when the patient was cleared to go home from PACU, he was tested for another fifteen minutes. As it turns out, patients in postop actually had fewer accidents than they did preop.

Will this study change ambulatory surgery guidelines? Unlikely. In Canada, there are at least two malpractices claims that were brought by patients who were seriously injured in auto accidents after driving themselves home from outpatient surgery. Maybe as another condition for discharge from the PACU, all patients should play a course of Gran Turismo to see if they are mentally competent to go home.

Malpractice Advice

Words one shouldn't say to a patient or his family when there is a medical complication.

1. YOU signed the consents for surgery and anesthesia.

2. Are you receiving counseling? You need to get over it.

3. These things happen and you may never know what went wrong.

4. I knew there was a problem when I heard the alarms.

5. I have no idea what happened--go ask a specialist.

6. I guess I can squeeze you in for a meeting but I'm very busy.

7. I don't have to share the M&M and QA investigations with you.

8. I didn't tell the resident to begin surgery alone.

9. Medicine is an imperfect science--I did nothing wrong.

Sage advice from a mom whose child died during surgery and has never been told the etiology.
www.taskforce.org/JustinHope/YJustinsHOPETASKFORCE.ppt.

The New Token Minority

I saw a commercial for the Golf Channel today and was struck by the total disappearance of Tiger Woods. His complete banishment from the golf world is astonishing. Here is the man who single-handedly raised the profile of the sport into a respectable TV viewing event. He is the highest paid athlete in history. He made it cool for kids to want to learn golf. Adults paid hundreds of dollars to go see tournaments where he was playing and ignored those where he wasn't. Yet Tiger's philandering now makes his previous golfing appearances inadvertently portentous and laughable.

Take for instance this article about Tiger in Golf Digest in January 2008, "The Year of Living Dangerously. Learn what really happened inside his camp..." Indeed. Only now we now he's been "camping" for many years before that. A year later in the January 2009 issue of Golf Digest there is a cover story of Tiger entitled "Tiger's Comeback. There's a reason he's smiling." Seems like he had at least 10, or is it 14, reasons to smile, I've lost track of how many.

To keep the magazine from further embarrassing itself Golf Digest has removed Tiger's monthly advice column. Tiger's appearances on billboards all around our city has been pulled off. There are more jokes about Tiger Woods than anyone can count. To prevent the Golf Channel's commercial from looking like a lineup of middle aged white guys, there is a new token minority prominently featured, the exciting young player, ranked #39 in the world, Anthony Kim. Good luck Tony. You've seen the perils of success and hope you learn from it. And that advice isn't from any of Tiger's Golf Digest columns.

What Price Height?

How much would you sacrifice to make your child taller. Would you stick acupuncture needles into your child? How about spending hundreds of dollars per month for dubious herbal and hormonal treatments? In South Korea there is a whole industry that revolves around making children taller, or at least they claim to. Some of the equipment resemble medieval torture devices, like a treadmill with a harness that stretches your spine and relieves pressure on your legs as you exercise. Many of the children reported are barely in kindergarten.

But can you blame the parents? The usual qualities that women seek in a mate are described as "tall, dark, and handsome". Notice that "intelligent" is not considered a desirable trait. Studies have shown that taller people are more likely to find a spouse than shorter people. It is widely known that taller people are more likely to make a higher income and to get promoted more easily than their vertically challenged counterparts. Of course you can find very successful shorter people, like Robert Reich, or Prince. But they usually have to work much harder for their achievements. And short people who do succeed are often denigrated as having a Napoleon syndrome.

So even though we may look at these Korean parents as desperate, maybe they are only doing what is logical. It's surprising that there aren't clinics like these here in America. When children in middle school are able to dunk basketballs, there is a great deal of pressure for everybody else to keep up by any means necessary, thus the proliferation of steroids and hormone abuse in sports.

Merry Christmas Everybody

I thought I'd leave you some videos of my favorite Christmas songs. Hope everybody has a great Christmas and safe New Year!

Merry Christmas Nebraska!

And may the three chumps of California receive lumps of coal in their Christmas stockings. Yes I'm referring to you, Speaker Nancy Pelosi and Senators Barbara Boxer and Dianne Feinstein. While you three ladies have been so eager to pass health care reform, signing on before the bill was even written, the wiser senators of other states have been able to milk the system to the benefit of their constituents.

The master of this manipulation is Nebraska Senator Ben Nelson. Who knows how sincere he was about preventing federal funding of abortions but now that the Senate bill is in its final form and people have actually read it, everybody can see what sweet heart deals he has secured for his state. They include the provision to provide Nebraska with federal funding for 100% of their Medicaid expenditures in perpetuity. Yes the rest of the country will have to pay for Nebraska's Medicaid users forever and ever. Bravo Sen. Nelson. For your concerns about the life of the unborn, you were bought off with billions for your small state.

Meanwhile California will have to come up with another $3 billion to cover the increased number of users of MediCal that is written into the federal bill despite the fact that California is broke, facing another $20 billion budget deficit this year. Our illustrious leaders, presiding over the largest state in the nation, did not have the clout to bring home anything close. We have more elderly than there are people in Nebraska. Heck we have more illegal aliens than the population of Nebraska. Hospitals all over the state are closing their doors because of all the charity cases they have to give. All these people rely on the government for their health care and we could not get one cent extra. Again that was all due to California's Congressional "leaders". The California Congressional delegation, the largest in the country, did not have the fortitude or creativity to demand extra money for their poor broken state. Because states like Connecticut and Louisiana have senators that expressed "concerns" about the health bills, they were able to bring home the pork. Now Californians will have to pay higher federal taxes for the people of Nebraska and other small states and pay higher state taxes because our state government is broken and our Congressional leaders could care less about a "local" issue.

So here's to you Sen. Nelson, Lieberman, Baucus, Landrieu. You held back your votes and now your states will reap the rewards. And to the California delegation. Your Pavlovian acceptance of any liberal agenda has now hurt the very people you are supposed to represent. With more representation like yours, California is becoming the Mexico of the U.S.

Stretching and Coronary Artery Disease

In the New York Times, the Wells blog writes about a simple way to determine if one has the potential for coronary artery disease. They write about a study that shows in people over 40, the ability to touch your toes while sitting on the floor with legs outstretched correlates with flexibility of the coronary arteries. If somebody is too stiff to touch the toes, they probably also have stiff arteries, increasing the likelihood of coronary artery disease.

They also note a small study that shows increasing your flexibility by stretching can help decrease stiffness of the coronaries. I guess I shouldn't make fun of pilates as a nonexercise anymore. Sign me up for some yoga classes! So next time you're in preop, you can ask your patient to touch his toes while sitting in bed as a quick and dirty way to determine the risk of CAD.

Christmas, The Most Envious Time Of The Year

Christmas is almost here and Santa has come early for...the surgeons. Yes it's that time of the year when the surgeons flaunt all the gifts they receive from their patients while the anesthesiologists get bupkes. It annoys the heck out of me to see them brag about the presents from patients who are grateful their surgeons "saved" their lives while the party actually responsible for keeping them alive through the procedure gets to share a muffin basket with the rest of the "staff".

The surgeons are clueless about the resentment they cause their anesthesia colleagues. One guy went into great details about the $200 per person sushi dinner he received in Beverly Hills. Another one bragged about the dinner he ate at a private mansion, catered by the staff of one of Wolfgang Puck's restaurants. He said the paintings in the house were "exquisite". You'd think the person who made the procedure tolerable for the patient would get an invitation too. Maybe the anesthesia was too good; they forgot all about the person administering the anesthesia. We got a box of cupcakes instead. Gourmet cupcakes, but cupcakes nevertheless.

They receive boxes after boxes of $300 bottles of alcohol, clothing from Nordstrom's or Neiman Marcus. One person said he received such a huge tower of Harry & David's goodies that he can't finish it all at home. Well, I thought, you could at least bring it to the hospital to share with everybody. After all, there was more than one person in the room when the procedure was underway.

The only time they've shared with anesthesiologists, and the staff, is when they receive cheap See's chocolates or unwanted gifts. The nicest gift I ever got was when the surgeon received, another, Nordstrom's tie and he didn't want it so he gave it to me. Gee thanks a lot. I'll just put this next to the 50 other ties I never wear. When does an anesthesiologist ever wear a tie?

Some people say that the anesthesiologist not being acknowledged is the greatest complement to us. You can bet if there was a problem with anesthesia, you know something like recall, lost airway, or cardiac arrest, they would remember us very well. There would be no sushi dinner on Rodeo Drive for Christmas, more likely a piece of paper with a lawsuit on it. So enjoy that last red velvet cupcake. Sometimes it's better not to be remembered than to be remembered at all.

Ain't That A Kick In The Head

A man in Enshi, China taught his monkeys to do taekwondo as an attraction outside a shopping mall. When the monkeys rebelled, hilarity ensued, at least for the bystanders.

The Slow-Mo Game

We are in the middle of a procedure when the OR phone rings. The nurse on the other end says they are ready for the surgeon to come assist in their room. The surgeon promptly announces that he is needed for assistance in the other room and he will be back to finish his line up in an hour or so. WTF! How inconsiderate to the OR staff for the surgeon to schedule himself in two rooms at the same time without letting anybody know. I was beyond pissed. This called for the Slow-Mo Game.

In the Slow-Mo Game, the idea is to slow down the OR proceedings as much as possible without being obvious about delaying the case. Because if there is one thing surgeons hate, it is to sit around the OR lounge with nothing to do, wondering when he can get his case started. This is a very passive-aggressive maneuver. I only do it to surgeons I don't like. And you can't do it often or you'll get a reputation for being a "slow" anesthesiologist. But it gives me some level of personal satisfaction when I see the aggravation it causes the surgeon.

When the surgeon returns from the other room, he immediately wants to get his next case started. Normally I would have seen the patient already but in this case I announce I'll go preop the patient now. This is where Slow-Mo works the best. If there is one thing you can't be faulted on, it is taking your time to conduct a thorough history on a patient. The time between a patient and his physician is sacred. No one, not even the surgeon will dare to intervene in your interview. I introduce myself to the patient and start my exam. Does she speak English? Damn, she does. Can't slow down the preop to wait for a translator. I review the chart page by page. Consent? Check. H+P? Check. Labs? Check. EKG? Oh, oh. The EKG is over 6 months old. Call for another EKG stat.

Now let's go over the review of systems. Remember the H+P's you used to take as a medical student, the ones that took about two hours to perform? You can do something similar here. Any CP, SOB? What's your exercise tolerance? Uh huh. Any productive cough, fevers, chills? Abdominal pain? Rectal bleeding? Melena? N/V? How about PONV? What has worked for you in the past for PONV? Allergies? What reactions do get with these meds? And please be specific. This can go on and on. Out of the corner of my eye I can see the surgeon starting to pace.

Now let's do the physical exam. PERRLA? Jaundice? Open your mouth and say aaah. Any dentures or loose teeth? Filling? Where. Oh back there? It's not loose or will fall out right? No neck rigidity? Flex and rotate your neck for me. Any neck pain or stiffness? Good. Let's listen to your heart. Hmm. You have a slight murmur. Has anybody every talked to you about it? Yes? Did you see a cardiologist? Yes? And? No intervention necessary? Did you ever get an echo or stress test? Yes? Do you know the results? No but the doctor said everything was okay? Now let's listen to the lungs. Listen to all four quadrants. Front and back. Big breath in and out. Good. Abdominal exam. No pain. No masses. Extremities without edema? Any radiculopathy, neuropathy, or weakness? Good. Good.

It is time to start the IV. I need to go to the IV cart to assemble my IV bag. Walk slowly to the IV cart. Put together the line. Come back and exam for arm veins. Ooh, you've got small veins. Have you been a difficult stick in the past? Yes? Okay we'll give it our best shot. You know it doesn't help that you're dehydrated because you've been NPO all day. Tourniquet up. Pat pat pat. No, let's try here. Pat pat pat. Don't actually stick the needle in the patient multiple times to Slow-Mo because that is cruel and unfair to the patient. Get the IV on the first shot. Thank you doctor, that was great. I didn't feel a thing. That's what I'm trained to do ma'am. Now let's go over the anesthesia consent. Explain in great detail what will happen under anesthesia. Don't forget to discuss ALL the potential complications. That's informed consent right? But reassure the patient that the chance of a serious complication with anesthesia is miniscule.

By now this could be going on for 20 to 30 minutes. The surgeon is tearing his hair out. Don't push your luck too much. If you think you can get away with it, finish writing up your H+P before letting the nurse bring the patient into the room. Once in the room take your time putting on the monitors. Do a lot of chit chat with the patient while doing this. Once the monitors are in place, start drawing up your drugs. I normally draw up the drugs between cases but in the Slow-Mo game I draw it up now. Can't be accused of delaying a case by drawing up my anesthetics, right? Now do a nice gentle slow induction. Don't want any sudden adverse changes in the vitals now, do we? The surgeon at this point is ready to pour on the skin prep by himself. Tube the patient in your usual competent way, sit back, and watch the surgeon's frustration in silent amusement.

There you have it. The Slow-Mo Game. Use it sparingly and you will get great satisfaction out of annoying the hell out of the inconsiderate surgeon.

How iPhone is Destroying Our Economy

In this astute article, John C. Dvorak discusses how the iPhone is ruining our economy. Seems like the only reason to get an iphone is to waste time, killing worker productivity. He notes the parallel between the growing popularity of the iphone and the deterioration of the economy. How many of you out there have pulled out your iphone at work to surf or play games or Twitter instead of doing the job at hand? At the end of the article you can see all the iphone and Apple cultists lash out as usual in defense of their icon and their supreme leader Steve Jobs. Is it a coincidence that when people use their iphones, they hold their heads in a bowing position, as if in servitude and bondage to the electronic device? The evil iphone will enslave us all yet.

How Not To Go Christmas Shopping

Through great personal anguish and sheer stupidity, here are some lessons I've learned about how not to go Christmas shopping with the family.

5. Don't go shopping in the early afternoon on the busiest shopping day of the year. By the time you find parking, you and your spouse will be at each other's throats.

4. Don't go shopping if the kids are hungry or it interferes with their nap times. They will be grouchy and uncooperative. Guaranteed to ruin your shopping trip.

3. Don't spend too much time at the first store you enter. There is a tendency to shop enthusiastically at the first store, where everything looks inviting and you have all the energy in the world. But very soon the kids get bored and whiny and you have less stamina to shop other stores.

2. Don't shop when your wife is having PMS. Enough said.

1. This is a cardinal rule for you guys out there. Don't let your wife catch you looking at another woman, no matter how much younger and hotter she is than the wife. Nothing good can come of this, even if it is all "innocent."

There you go. Now go out there and shop til you drop to turn this country's economy around. Your president will love you for it.

Losers

Congress passed a bill preventing Medicare from slashing reimbursements in January by 21%. Instead it will maintain the current payment rates for another two months while they figure out how to fix the flaws in the SGR. President Obama is expected to sign the bill. Doctors across the country are relieved.

What a bunch of bull crap. While medical inflation is rising at twice the rate of consumer inflation, we are happy we are getting paid the same? It is actually a wage cut when inflation is factored in. Even our local utility workers are getting raises of 3% per year for the next three years. No wonder doctors are such losers.

Where To Go Get Drunk Then Drive

Recently, a Los Angeles police officer was celebrating his payday by getting drunk at the bar in the LA Police Academy. He then got on his motorcycle, tried to drive home, and crashed. Luckily nobody else was hurt but he left behind a wife and five children. That police break laws they swear to enforce is not news, but the fact that the LA Police Academy has a bar serving liquor on its premises surprised many people.

The bar is called the Los Angeles Police Revolver and Athletic Club. Apparently it was routine for police officers to spend their paychecks every other Wednesday at the club by boozing it up before going home. Of course nobody at the LAPD thought there might be something wrong with this situation. When asked what the department was going to do to prevent this from happening again, the former deputy chief said they were transferring responsibility of the bar to a third party. This would shield the department from liability. How comforting. If somebody gets killed by a drunken officer, the department won't get sued, the bar vendor will instead. So this weekend, if you want to get plastered and not get arrested at a sobriety checkpoint later, head on down to the LA Police Revolver and Athletic Club. Guaranteed nobody will be performing a breathalyzer test before you get into your car. If you get stopped just say you were supporting the LA Police Academy by patronizing their liquor establishment.

Telebation

Telebation is a term coined for a remote intubation with the aid of telemedicine. This was first demonstrated at a small community hospital in Arizona which required an urgent intubation for a patient with severe COPD. The physician on staff was not comfortable with his intubation techniques so he set up a telemedicine conference with the University Medical Center in Tucson. With the use of a video laryngoscope, an attending in Tucson was able to visually assist the intubation and secure the airway before transport to a tertiary care center.

The outcome in this situation was favorable, but it raises some troubling questions. First, was the intubating physician ACLS certified? If he was he should have been familiar with the intubation technique. He would also have learned the other modalities of securing an airway, including the use of the Combitube. The Combitube was designed for scenarios exactly like this, when there is a difficult airway or when the user is not experienced with intubations. This small community hospital has the funds for a video laryngoscope and telemedicine equipment; it must or should have other intubation aids available.

How long did it take to set up the telemedicine conference call? If this was an emergency intubation, how would the small hospital have dealt with the situation? What would have happened if the remote user lost the airway? Video laryngoscopy is helpful but it is no panacea. There have been many times where even with the use of video I was only able to get a Grade 3 view, essentially no view of the cords. What would have happened then? Again it goes back to knowing how to use other equipment like the Combitube or the LMA.

The use of telemedicine here also promises interesting possibilities. If we can treat a patient remotely by telling somebody else what to do, does that mean anesthesiologists can work from home? Imagine hiring some medical student, or even a premed student to sit in the OR for you. Using telemedicine you can have him intubate the patient for you. You can then electronically monitor the patient's vitals and tell the student what meds to give. At the end of the case the student will show you the train of fours and then you tell him to reverse and extubate the patient while you are sitting at home in your PJ's watching CNBC on your 52 inch LCD. This would be even cheaper for the hospital than hiring a bunch of CRNA's.

Gloves Gloves Gloves

Our hospital uses a profusion of gloves. As you can see from these pictures, they come in all sizes, colors, and textures. Most are latex free, some are not. Some provide better grip when wet. Some have better grip when dry. Some people have dermatitis with one kind so they have to use another.

Therefore we are not able to standardize on a particular type and have to buy a whole rainbow of colors of gloves. This is your health care dollar at work.

Please Don't Wash Your Hands

I saw this sign posted in a Chinese fish market. It's kind of gross to think people will actually think about washing their hands in a tank full of clams and then go handle produce and other goods. It's no wonder people get hepatitis and other infectious diseases. Ironically, I think the sign is there more to protect the clams than the customers.

Surgery Without Anesthesiologists

Another aspect of the story in the New York Times about a heroic 43 hour surgery really bothers, no angers, me. Besides the enormous expense of this procedure for questionable long term benefits, on a more personal note this article barely mentions the anesthesiologists involved in the care.

Toward the end of the surgery, when the liver was reimplanted, the operating team encountered some serious difficulties:

The liver bled profusely. Transfusions could barely keep up. Over the next few hours he needed 30 pints of blood. But even as the bleeding abated, his blood pressure and body temperature dropped, and his blood turned dangerously acidic. Drugs to correct one problem made others worse. He was sinking into a vicious cycle that could kill him.

Who was there giving all the transfusions, and the pressors, and other life saving maneuvers to try to salvage this 43 hour operation and the patient's life? There is not a mention of the work of the anesthesiologists at this critical juncture in the operation. It's as if all those interventions happened by magic. There is a single quote from an anonymous anesthesiologist in the entire article. Of course he, or she we will never know, is talking about the surgeon, describing him as having "soft hands." Blech.

On the 8th photo of the slide show, they actually described what the anesthesiology team was doing during the operation:

During surgery, anesthesiologists transfuse blood and other fluids and drugs, and monitor the patient's heart, breathing, blood pressure and blood chemistry, in addition to administering anesthesia.

That sounds like a pretty generic job description, something I do every day. That gives no indication of the exhausting work that must have been going on behind the drapes keeping this patient alive. Even the surgeon's PA had a picture and was mentioned by name in the article. But the team actually responsible for keeping the operation going is only shown as a single arm hanging up albumin and PRBC. Anybody can slice and dice a body into pieces. It is up to the skill of the anesthesiologist to make sure the patient survives this "attack" and wakes up afterwards in relative health and comfort. But thanks to writers of the New York Times, the public will continue to be ignorant of the vital roles we play.

Why Medicine Is Bankrupt

The New York Times has an incredible article about a 43 hour surgery for excision of an intraabdominal liposarcoma encasing the patient's internal organs. The surgery involved removing the tumor en bloc with the liver and other organs that it had invaded, excising the tumor, then reimplanting the liver.

The surgery was estimated to cost over $300,000 but I imagine ultimately it will cost at least $1 million after including postop care. The patient is described as a business owner who feels, "I've got too much fun ahead of me." My guess is that the patient has very good health insurance if he feels he can have an operation that expensive and still have enough money afterwards for "fun".

Isn't it ironic that right now there is so much debate about the cost of health care in this country yet the NY Times (We must have a public option) is glorifying a surgeon who performs an operation like this? Unless this patient is paying for everything in cash, you and I will ultimately pay for this. It is people like this who will cost the rest of us much higher insurance premiums and tax dollars. How can we have a rational talk about saving health care dollars when there are patients who refuse to accept a situation and are able to find doctors who will treat them, no expenses spared? And how did they convince the insurance company to pay for this? When these companies hire people to deny requests for a $10 lab test, they approved a million dollar operation of questionable medical value? It is no wonder no rational conversation about health care expenses is possible in this country.

When To Get A Cardiology Consult

Z, walking down the hall minding his own business.

Gastroenterologist: Hey Z, I've got a quick consult for you.

Z: Okay

GI: I've got a 95 year old patient from a nursing home here for a PEG placement. Her troponin level is elevated. Her primary care doctor says it is only a troponin leak. Do you think the anesthesiologist for her case will want a Cardiology consult?

Z: Yes

GI: I thought so. Thanks.

Z, thinking "Duh."

Elevated Troponin Level After Oral Sex

From a case report in Obstetrics & Gynecology.

A 29 year old pregnant woman was taken to the Emergency Room unconscious one hour after having oral sex with her partner. Cardiology was consulted for elevated troponin levels. It was determined the patient suffered from an air embolism after having air insufflation of her vagina leading to a troponin leak.

There you go. Make of that what you will.

What's It Like To Be In Primary Care

In a post in KevinMD, Dr. Ed Volpintesta describes his typical day as an internist. It sounds like a nightmare. Granted he has been in practice for 35 years so no longer takes night and weekend calls, inhouse patients, pediatrics, or GYN. He doesn't come in until 8:00 AM and leaves by 4:30 PM. Doesn't sound half bad does it? But then he describes an endless parade of phone calls, pharmacy refills, geriatric medicine, grief counseling, etc... And how much of this work is actual billable work? Makes me so glad I'm an anesthesiologist. I'm sure this article will further dissuade more medical students from primary care.

Christmas Party

How long does it take to finish off twenty boxes of pizzas and buffalo wings? In the case of our department Christmas party about ten minutes.

Petri Dish Cookie

Thanks to Not So Humble Pie, we have the perfect dessert for the Microbiology department Christmas party.

Burka Barbie

For the little girl who dreams of growing up illiterate and being forced into marriage with a total stranger. At least these burkas are of Italian design.

Alternative Christmas Trees

In the Wall Street Journal today, there is a hilarious article on alternative Christmas trees. Why spend $200 on a standard green dead or faux tree when you can recycle your trash to make your own personal statement? It is "green" in an ecologically correct way. There are pictures of trees made from coat hangars, Mountain Dew cans, and even beer bottles. Read it and you'll never look at a toilet brush the same way again.

From ROAD to RAPERS

I've mentioned before about the acronym for specialties that medical students are seeking out for their exquisite lifestyles and ginormous pay packages, ROAD (radiology, ophthalmology, anesthesiology, and dermatology). Of course the term ROAD is used in a condescending and derogatory manner by other specialties.

Now here is another acronym that includes anesthesiology. Again, it is used in a patronizing tone by other doctors who are not privileged enough to be included. Courtesy of the Happy Hospitalist, now we have RAPERS (radiology, anesthesiology, pathology, ER, and surgery). It represents the fields whose doctors are free to eat all the food in the doctors lounge before anybody else has the opportunity to get any.

Hilarious, and oh so true if my hospital offered free food for doctors. I have to brown bag my lunch every day. Of course one reason for that is that I rarely have time to go down to the cafeteria to buy lunch. Plus I'm cheap. By bringing my own food, I can nosh discretely in the OR without fainting from hypoglycemia. But I've been at other hospitals that do have free lunches for physicians and the anesthesiologists there were usually first in line. Their reasoning is that they have to eat first so they can give lunch breaks to all the CRNA's they are supervising. Sweet life those lucky anesthesiologists.

A New Public Option Pt. 2

In the previous blog entry, I pointed out the Senate is working on a plan to let the general public enroll in a health insurance plan similar to what federal employees get in the FEHBP. The Urban Institute wrote a study critical of how that might be achieved. Here are my interpretations of those criticisms.

The study said that Democrats in Congress and President Obama object to the fact that the public who would enroll in the FEHBP may not be able to afford the plans, therefore they would receive higher subsidies than what federal employees get. And that is JUST NOT FAIR. I guess these policy wonks really don't live in the real world. Here, when we buy insurance, healthy people pay more to subsidize sicker patients who actually use their insurance plans. That's what's called risk pooling. And my tax dollars have been subsidizing Medicare enrollees ever since I started working.

The Urban Institute also said there is a misperception about how generous the FEHBP benefits really are; they are not the Cadillac plans many people think. They are no more generous than the plans that large private employers offer. Well thank you very much. Not all of us are lucky enough to work for large private employers. Most people who would enroll in an FEHBP-like plan would be poor or self employed, like myself. We don't have the luxury of generous benefits. We choose the cheapest plan we can afford. So being allowed to enroll in a federal plan would be a huge step up for most people.

Other nit-picky objections in the study include that the FEHBP is not really a public option; it is a subsidized plan to buy private insurance, such as Blue Cross. Okay, I can live with that. They can call it whatever they want.

They are concerned that many people who are not happy with their current private insurance would move to this new plan if it became available. Well yeah. That's called competition. Isn't that what Congress wants to give health insurance companies?

The people who move to a federal plan would be the sickest and poorest enrollees, potentially burdening the new plan with higher costs. Again that is called risk pooling. A federal plan would have one of the largest number of customers to spread the risk. And isn't one of the reasons we're talking about health care reform is because of all the horror stories of people without health insurance becoming bankrupt and destitute because of their health care expenses?

Finally all these new sick enrollees would create a burden on the Office of Personnel Management, the federal department that determines the benefits offered in the FEHBP. I say that is their job. If they are unable to handle an influx of new enrollees, then fire them and find somebody who can.

It seems like the Senate may be onto something here. This could potentially please both sides of the aisle. We have a quasi Public Option to satisfy the Democrats while Congress would be forced to use the same health insurance plans as the public which would appease the Republicans. Let's hope no distracting sideline issues like federal funding for abortions and religious spiritual treatments trip up this progress.

A New Public Option

In the Senate's desperate attempt to pass health care reform, some senators are putting together a new plan. The plan calls for the public to enroll in health plans similar to what Congress and other federal employees get in the Federal Employee Health Benefits Program. This is an idea that many people have been clamoring for.

In the FEHBP, all federal employees and their families are accepted, regardless of any pre-existing medical conditions. The plans are portable nationwide. So if an employee gets transferred from Washington to Kansas City, he can keep the same plan. The plans are also portable across different jobs, as long as it is a federal job position. Even after an employee retires, he can keep the same plan with the same premium, something everybody else can only dream about. Right now, when a person retires from a company, the private insurance premiums are so expensive that nearly everybody enrolls in Medicare. Currently half of the people enrolled in FEHBP are retired. There is also choice, with ten different plans for federal employees to choose from. Most people, if they have a choice, only have two to three from their companies. Federal employees pay 25% of the insurance premium for the cheaper plans, with the government (you and me as taxpayers) picking up the rest. For higher priced plans, the employee pays a larger share.

Sounds perfect right? A nationwide portable health insurance plan, no denials for pre-existing conditions, and multiple plans to choose from. What could be easier than explaining to the public that they would get the same health insurance benefits as their Congressman, rather than the current labyrinthian proposals on the table. According to a study by The Urban Institute, there are some risks to allowing the public to enroll in health insurance plans similar to the FEHBP. Some of the downsides noted in the study don't seem justified, and I'll explain why.

Originally this was going to be one entry. But it got so long that I decided to split it into two sections. You can read part two tomorrow.

When Relatives Stay For The Holidays

This is what happens when relatives and their small children move in for the holidays. Good thing Thanksgiving and Christmas only come around once a year.

I Got Spanked

As every doctor eventually learns, don't ever cross the nurse in the hospital. You will be truly sorry if you don't remember this lesson each and every day. I just got back from a painful meeting with my chairman. He said a nurse complained about my behavior a few days ago. He wanted my side of the story.

I told him I vividly remember the details of that encounter. I was in a particularly grouchy mood that day, which I won't go into. I gave the nurse an order which she promptly disregarded. That set off my short fuse that day. I promptly marched up to her and "talked" to her very loudly. Unfortunately I didn't have the sense to do that in private but in front of the whole OR. Well guess what? For her act of insubordination, I get written up and could eventually be investigated by a Well Being Committee and sent to Anger Management class. The nurse? Well she gets to play the victim of the crazy out-of-control doctor. Any complaint about her now will seem petty and vengeful.

My chairman was sympathetic. He's heard this all before. His advice? If I feel I might be losing control, go to a dark closet and scream my head off to myself before doing something that I will come to regret much later. He said, sounding quite Shakespearian, the world is a stage. We have to go out on that stage and perform to the expectations of our audience, whether they be the patients, the nursing staff, other doctors, the janitorial service, our spouse, our children, our friends, etc. We cannot let our guards down. Of course he was right.

The relationship between doctors and nurses is pretty one-sided, and it's not to the advantage of the doctor despite what nurses may think. We've had physicians here fired because of complaints by a single nurse. But nurses are almost impossible to get fired by the complaints of a doctor. I had a severe case of remorse after that angry encounter and I barely made a peep afterwards. But the damage was done. I've been written up, for the first time ever. My reputation has now been carved into stone. The nurses on that ward will always remember me as the anesthesiologist who cannot control his temper and screams at poor innocent nurses.

Men, Time To Bend Over

The Senate passed the first amendment to the Healthcare Reform Bill. The amendment, sponsored by Sen. Barbara Mikulski, forces insurance companies to provide screening tests for women's health issues at little to no cost. Another win for another interest group.

Let's count the winners so far in America's health care debate. As just mentioned, women will now get virtually free screening exams courtesy of insurance premiums paid by all. The elderly in Medicare are sacrosanct, as exemplified by the Senate's vote tonight to leave all Medicare benefits untouched, despite the pledge by Congress to cut $500 billion from Medicare spending. Veterans are protected with free health care from the VA. Poor to middle class children are covered by SCHIP. Poor and disabled adults are covered by Medicaid. Illegal immigrants get charity care in county hospitals and the emergency room.

Who are the losers so far in this debate? It is the hard working middle to upper middle class men in America. It is these men, the most productive members of American society, who have been left out to dry. We are the ones who earn most of the income from which Congress will redistribute to everybody else. We are the men who spend so much time at work to make sure our families are well taken care of that we miss our own physical exams, our own screening tests for prostate or colon cancers, our own dental and eye exams. Nobody in Congress dares to mention the inequity of it all. While it is compassionate to offer free health exams for women, it would be completely sexist if the same bill applied only to men.

So men, get ready. The rubber gloved finger of government is about to become a fist.

Uvula Piercing

While doing some research on intubation injuries, I came across this lifestyle procedure, uvula piercing. It is not very common but unless you ask you never know. Hopefully you would catch this when you ask the patient to open his mouth to evaluate for Mallampati classification. We've been surprised in the OR when the patient, upon being undressed to get ready for their skin prep, to find body piercings anywhere from the nipples to the genitals. Facial piercings are also very common. Besides the ears, I've seen piercings in the eyebrows, nose, lips, tongue, chin, cheeks, and forehead. Just about the only thing on the face that can't be pierced is the eyeballs.

Check out this blog on how a uvula piercing is performed. Notice the recipient's earlobes. One of our OR techs has something like that. It is usually filled with a large colored disk, not hanging as a giant loop. Also note the anxiety on his friend Marty's face in the background as he is getting pierced. All this raises the question of WHY? Probably the only explanation is because it can be done. Ah, the insanity of youth.

Dude, are you working out?

I walked into the operating room to see if my colleague needed a break after a long night on call. I hadn't seen him in about a month and I was immediately struck by how BLOATED he looked. His scrub shirt looked like he was hiding the Incredible Hulk underneath. His neck seemed to have gained four inches in circumference. I asked him the polite way of asking somebody if they've been gaining weight, "Dude, have you been working out?" He said no. He does have a home gym in his garage but basically what he has been doing finally is eating on the job. He said he was tired of feeling cold, hungry, and dehydrated all the time in the OR.

We have a large number of anesthesiologists in our group, over fifty. There is just no way to give everyone fifteen minutes for a lunch and pee break. So each person is on his own. My friend began to worry about his health. While the nurses give each other breaks (it's in their nice little contracts) and the surgeons can leave anytime during a case to go to the bathroom, anesthesiologists are stuck in the OR all day or in too much of a hurry to get their next case started to give a break to themselves. This has led to several anesthesiologists here getting kidney stones, some requiring surgery. Some have nearly passed out and needed an IV bolus to keep going.

I was on call a few weeks ago and I worked nonstop from morning until the following morning after 2:00 AM, with no breaks in between cases. As soon as one case was finishing, the OR scheduler would page me and tell me to go set up another room as the surgeon was here and the patient was ready in preop, just waiting for me to get the case started. It went on like this for nearly eighteen hours straight. This is the reason many anesthesiologist will bring a snack into the operating room, usually something discreet like a power bar and bottled water. It's not like we're bringing in take out from McDonald's but we do need to rehydrate ourselves. And everybody in the OR knows this. I've never been reprimanded for snacking in the operating room. The nurses sympathize with our plight and the surgeons know that anesthesiologists snacking in the room allows for quicker turnover as no lunch break is needed between cases.

So despite the fact that JCAHO highly frowns on eating in the OR, we stealthily munch away behind the drapes. My friend realized that nobody was going to look out for his well being in the operating room. He now brings fruits and other snacks with him to work. He has gained twenty pounds since he had this revelation. And he feels 100% better.

Muppets Performing Bohemian Rhapsody

Ingenious. Bohemian Rhapsody is a song that will outlive us all.

Anesthesiology, Best Job in America?

When my wife's friends ask her what I do for a living, they all give knowing glances when she says I am an anesthesiologist. It is the look of understanding, with a tinge of envy. They know I have good job security along with excellent pay. For you see, seems like everybody has seen the poll where anesthesiology was named one of the top jobs in America.

I had heard about this poll but had never actually seen it, until now. The poll was conducted by Money magazine and PayScale.com and came out in early October. No, anesthesiology did not get the absolute top ranking for best job in America--we came in at number 11. However, we did rank number one (woohoo!) in median salary, at $292,000. We came in right above OB/GYN, who earn $222,000 and psychiatry at $177,000. Incidentally, CRNA's came in at number four with a median salary of $157,000. I love their job description of CRNA's, "Like the anesthesiologists to whom they report..." I bet that just annoys the hell out of them.

Anesthesiologists also rank highly in top pay, coming in at number two. By their methodology, the top pay in a profession is the 90th percentile on the pay scale. We just lost out to securities traders (don't we wish we could all work for Goldman Sachs?) but again top OB/GYN and psychiatry. Surprisingly attorneys came in only at number six, with the 90th percentile making $262,000. The stories we hear of money grubbing lawyers driving around in their Bentleys only apply to a very small elite. Medicine is much more egalitarian. Most doctors make roughly the same amount of income with much less variability; hardly anybody makes the millions of dollars top lawyers in large law firms can make. But we also don't have new doctors working as glorified clerks like many new law graduates have to endure when they first go into practice.

So overall, anesthesiology ranks number eleven. We get dinged for having a high stress level, which is true. But compared to general surgeons and emergency physicians, who have similar compensation levels, the stresses of anesthesiology is much more tolerable. I also don't see a listing for the other ROAD specialties (radiology, ophthalmology, and dermatology). It would have been interesting to see how these high pay and low stress fields rank relative to anesthesiology. But I can recommend wholeheartedly to any medical student that anesthesiology is a terrific field to specialize into. You can have the high pay, job security, and relatively lower stress levels compared to primary care doctors and surgeons. Plus you'll be the envy of all your spouse's friends. Hard to top that.

When DNR Doesn't Apply

My patient coded on the OR table. It's something every anesthesiologist dreads but is as inevitable as the sunset. My patient was undergoing a procedure in a last ditch effort to prolong his life that was racked by a self-inflicted end stage chronic condition.

He had already made his intentions clear when he made himself DNR/DNI. He came to the hospital with severe anemia. The primary physician tried to convince the family to give the procedure a chance to save him. The family was ambivalent. He then told them the patient wouldn't need to be intubated. They relented. When I saw him, I knew there was no way the procedure could be performed without a protected airway. The primary team then told the family the patient will be intubated for the procedure but will be extubated when it was finished. The procedure was performed and the patient subsequently coded on the operating room table. He was defibrillated and revived. He was then transferred to the ICU intubated. Over the next week he had multiple lines placed. Pressors were eventually started to maintain his blood pressure. The patient ultimately succumbed to ARDS one week later. He died the way he had hoped to avoid, a painful, artificial death.

Doctors like to blame patient families for sticking the ICU with a ward full of 90 year old grandmas with no hope of going home but refusing to "pull the plug." But are doctors complicit in denying patients their dignity when they pass away? In reality many doctors give families false hopes, always going for that one last OR procedure, one last CT scan, one last PEG tube. It's hard enough for families to let a loved one go, but when doctors tell them that they might be able prolong life, even if it is of questionable quality, what family wouldn't want everything possible?

And what is the role of anesthesiologists? We are frequently requested to perform anesthesia for procedures of dubious merit. Is it ever right for us to say no? That would just make the surgeon your enemy far into the future and the family wouldn't believe you anyway. They trust the surgeon who has been in family meetings with them, not the anesthesiologist they just met five minutes ago. When a family member does ask me what I think about the procedure, all I can say is that the surgeon feels it is justified. My input is not really being asked for; they just want a confirmation of their concerns. I'm also not privileged to witness all the complex family interactions that may be present that led to the procedure being performed. It is a difficult position for anesthesiologists. At best we take a deep breath, cross our fingers, and prepare for the worst, which was what happened here.

How to Solve the Primary Care Shortage

With health care reform promising to insure forty million more people, there is already hand wringing about who will see all these new patients. As anybody who has been to a doctor's office knows, the wait can be interminable. There is such a shortage of primary care doctors in this country that drastic measures have been suggested, including increasing the salaries of primary care physicians, lowering the salaries of specialists, or offering free medical education to any medical student willing to go into primary care for a certain number of years.

There is one way to increase the number of available primary care doctors in this country but one dares not speak of it in polite company. I will show you studies, from the AMA even, to prove my hypothesis. The solution to providing more primary care doctors is so simple, yet so politically incorrect. Are you ready? Here it goes. The solution to finding more primary care doctors is to stop admitting women into medical school. What?! Gasp! How dare you! That is the most piggish thing I've ever heard!

Okay, chill. I never said the solution was going to be practical or even feasible. Some of my best friends are female physicians, terrific doctors they are. But I also know many female doctors who have slowed down their practice to go on the mommy track. Or they decided they just weren't feeling well enough to work that day and could somebody please cover for them since coincidentally they are supposed to be on call that day. Or they just have to get out by 4:00 PM to make their Pilates class.

Let me show you the statistics to prove that having more male physicians will lead to more patients being seen with not too much effort. The statistics come from the federal government's own agency, the U.S. Dept. of Health and Human Services. They published a report called The Physician Workforce: Projections and Research into Current Issues Affecting Supply and Demand. There is a separate page devoted to female physicians. Most of the data cite the AMA as the source.

The report says that in 2005 nearly half of medical students are female. They may be more than half by now. Female doctors tend to go into the primary care fields and OB/GYN. Whereas only 4% of orthopedic surgeons and 14% of general surgeons are female, 52% of general pediatricians and 31% of internists are women. Female doctors are attracted to fields with flexible working hours and office based settings. Their salaries tend to be lower too, with average female physicians making $149,000 per year while male physicians make on average $206,000. Even when adjusted for specialties and work experience, men make $38,000 more than women.

But women work less than men. Female doctors work an average of 49 hours per week while male doctors work 57 hours a week. Women also tend to work fewer weeks each year. Female physicians take longer to see each patient, on average 2 minutes longer than men. So if you have an office of 30 patients, that is 60 minutes of extra time that women need to see all of them. Therefore increasing the number of female doctors has not alleviated the primary care shortage that one would expect.

The problem with female physicians being less productive is not isolated to this country. In this (chauvinistic) blog from the United Kingdom, the author notes a study that says 60% of female doctors drop their practices after ten years. He questions the value of government money that is used teaching so many female medical students who eventually waste their medical knowledge. Would that money have been put to better use to teach male medical students who will go on to a lifetime of productive medical caring and teaching? Who is hurt when so many well trained doctors drop out of the work force? It is the patients who suddenly lose their primary doctor when she announces she is "retiring" at the age of 36 to start a family. It is the patient who now has insurance but can't find a doctor to take care of her or has to wait two months for the next appointment. When you have 40 million more people show up at your doorstep, how high do you think the primary care doctor burnout rate will get?

By having more male doctors, productivity goes up. More patients are able to get an appointment. All that government money used to teach medical students will be placed with doctors who have longer medical careers thus amortizing the cost of the education. With longer careers, there is greater knowledge and experience, hopefully preventing simple medical errors common with all new doctors. Let's see, more male doctors equals more patients seen each day, with more hours worked each week and more years of productive work and fewer medical complications. Sounds like an easy solution to the primary care physician shortage. Logical? Yes. Doable? Hell no. We are never going back to the 1950's again in regards to workplace inequality. But this goes to show that the answer could be so simple, with the government's and the AMA's own studies to back it up. Now we have to do the hard thing: find more money to increase the number of medical school graduates and pay primary care physicians higher reimbursements so more will choose that field. And don't forget to let them out early so they can make their core strengthening program.

Why Surgeons Hate Anesthesiologists

I bumped into one of my partners in the Recovery Room. She appeared quite exasperated and peeved. I asked her what's wrong. She said she just had an argument with her surgeon when she cancelled one of his cases. The patient was scheduled for an elective shoulder arthroscopy in the beach chair position. He had multiple medical problems and was seen by a multitude of consultants for preop clearance.

Among the patient's many medical conditions, he complained of ataxia. A carotid duplex showed carotid stenosis. The consultant's note simply said the patient needs to have this addressed before his shoulder surgery but to go ahead and do a gentle intubation to prevent neck extension if the surgery was felt to be urgent. Nowhere in the consult was there a mention to cancel the surgery until the carotid artery stenosis was corrected. My friend was perplexed. She called up the consultant to ask about this unhelpful consult. The doctor told her that the surgeon was very aggressive and refused to listen to his verbal recommendation to cancel the case. Therefore he only wrote in the precautions and left it up to the anesthesiologist to cancel if she felt strongly about it.

Well she did feel strongly about the patient's safety. The surgeon would want deliberate hypotension with systolic blood pressures in the 90's during the procedure. Hypotension combined with carotid stenosis and the patient's symptoms of ataxia spelled c-a-n-c-e-l for her. She talked to the surgeon, who was furious. He pointed to all the preop clearance notes he had gotten for the patient, none of which recommended cancellation. The patient was likewise unhappy. He had taken time off from work to have his surgery done and made arrangements for after-surgery care. He wanted an immediate second opinion, which was impractical for this nonemergent operation. My partner stood her ground and cancelled the case.

Ultimately anesthesiologists have to worry about one thing only, and that is the patient's health and safety. Preop clearance notes can be worthless. If an aggressive surgeon does not like a conservative consultant, he'll refer all his future cases to somebody else who will approve his cases. It is up to the anesthesiologist to be the gatekeeper into the operating room and stop any elective surgeries that can cause serious harm to the patient. That is why surgeons hate anesthesiologists.

Great Wealth Transfer of America

How is this country going to finance the health care reforms so that we may have universal health insurance? Nobody wants to increase the trillion dollar deficits that the federal government is facing into the foreseeable future. According to an AP poll, the majority of Americans are in favor of taxing the "rich." Mary Path Rodthaler, who was interviewed for the poll, may be typical of most Americans. She says, "You know, I mean, why not? If they have that much money, it should be taxed." Never mind that the vast majority of the "rich" work their butts off for their income. Fifty seven percent of those polled like the idea of increasing taxes of those making over $250,000 per year with only 36 percent opposed. With the health reform bills subsidizing health insurance for those making up to $88,000 per year, well into middle class territory, the government is desperately trying to find ways to finance this enormous new subsidy. Welcome to the great wealth transfer of America, 21st century edition.

So let's count the ways the government is attempting to raise revenue to pay for this wealth transfer. I've only listed a few that I can think of. I'm sure there are other schemes that I have missed, what with the health care reform bills in Congress changing almost daily.

There is the simple accounting gimmick. The taxes will go up almost immediately, in 2010. But the universal health benefits won't kick in until 2013. Therefore Congress is budgeting ten years of revenue for only seven years of benefits. It's not until after 2019, which they fail to take into account for now, will the deficits really explode. Look how long it took Medicare to bankrupt the country.

Let the Bush tax cuts expire in 2011. That will immediately raise the marginal tax rate from 35% to 39.6% without Congress lifting one finger.

At the same time, the capital gains tax will jump to 20%, again without the cowardly Congress having to vote for a tax increase.

Add a surcharge of 5.4% to the marginal tax rate of individuals making over $500k or families making over $1 million. This will raise the highest income tax bracket to 45%.

Increase the Medicare withholding tax. Currently the Medicare tax is 2.9% split between employer and employee. Of course business owners and the self employed like most doctors have no illusion of paying only half the Medicare tax. We pay the whole darn 2.9%. Congress is proposing increasing the tax by 0.5% on both employee and employer contributions, to 3.9% for those making over $200,000.

Add the 5.4% surcharge not just to the payroll incomes of the rich, but also their capital gains, interest, and dividend incomes too. That will raise the tax to 25.4% after the Bush tax cuts expire.

Charge medical device makers a 2.5% tax of sales. But don't penalize the companies that supposedly cater to the poor and blue collar and contribute to our health crisis like fast food restaurants and beer makers.

Levy a tax on expensive insurance plans, the one tax that the Congressional Budget Office thinks will actually "bend the curve" on rising health care costs? Are you kidding? Don't you know union members, who are the ones most likely to have these Cadillac health plans, aren't rich? They shouldn't be forced to participate in this wealth transfer. Plans to tax individual insurance plans costing over $8000 for individual or $21,000 for a family plan are opposed by liberal Democrats.

For people who snicker that only the "rich" will be affected by all these tax schemes, remember that these income brackets are not indexed to inflation. One only needs to look at the Alternative Minimum Tax, the original millionaire's tax, to see what will happen. Today the AMT ensnares millions of tax payers, down into the sub $100K income brackets, because it is not inflation adjusted. The same thing will happen with taxes to pay health care reform. And conveniently the widening net of tax collection will happen around 2019, when the current universal health insurance bills start to explode.

Acknowledged By The New York Times!

Okay I'm just tooting my own horn a little bit here. I was reading an article by Pauline Chen, the New York Times' physician columnist. She was bemoaning the worsening shortage of primary care doctors because more medical students are choosing the ROAD fields. She defined ROAD as "radiology, ophthalmology, anesthesia (my emphasis), and dermatology." Well that immediately got under my crawl. As you readers may remember, being called "anesthesia" has always been one of my pet peeves. Pauline Chen is a liver transplant surgeon; I'm sure that's how she addresses her anesthesiologists in the OR. However I felt I had to immediately correct this professional slight.

I wrote a letter in the comment section reminding Dr. Chen and the NYT editors that anesthesiology is a highly respected medical and scientific field. We are not just "anesthesia." And to my surprise, they acknowledged that I was correct (see Comment #182). They corrected the article to read "anesthesiology." Hooray! A small victory for anesthesiology and anesthesiologists everywhere. Though few people will read down to Comment #182, thousands of people will now read that article and see "anesthesiology," a medical specialty at least equal to radiology, ophthalmology, and dermatology, not just anesthesia. I done good today.

Cruel and Unusual Punishment?

Ohio has now become the first state to use a single drug method for executing prisoners. Their previous three drug method was stopped by the Ohio Supreme Court for being cruel and unusual. This moratorium on capital punishment came about when the execution of Romell Broom was halted because a vein could not be found to start the IV. He was reportedly stuck 18 times before the procedure was called off. His lawyer argued in court that being poked with a needle 18 times was inhumane. They said that the three drug execution could cause severe pain and suffering if the initial dose of thiopental did not adequately sedate the prisoner. The prisoner would then suffer severe pain when paralyzed and potassium was injected to stop the heart. The state will now use only thiopental for executions, using a dose 2 1/2 times greater than normal to put the prisoner to sleep and slowly watch him go apneic and hopefully die in his sleep.

There are so many flaws with this. First of all, the only painful part seems to be getting stuck multiple times trying to get an IV. But this is no different from what many hospital patients suffer every day. These prisoners frequently are IV drug abusers so they have few accessible veins. Remember that prisoners are placed on death row because of the inhumane despicable acts they committed. Mr. Broom raped and murdered a frightened 14 year old girl. He now complains that getting stuck with needles is inhumane? His victim did not have the luxury of being sedated when she was tortured and killed.

The lawyers also argued that prisoners would feel pain if they were not adequately sedated. But how would anyone know? Nobody is arguing that the three drug cocktail is ineffective. This raises the old philosophical question about trees falling in the forest and nobody is around to hear it. If the prisoner dies from a lethal injection but isn't around to complain about the pain during the injection, did he really have pain?

Is a single overdose of thiopental adequate for an execution? It's only used routinely in veterinary euthanasia. All other state executions add a paralytic and potassium to stop the respiratory and cardiac functions. Many of these prisoners have histories of IV drug abuse. That's why their veins are difficult to find. It might take a larger dose of pentathol to cause death than they calculate. Since these prisoners have bad veins, there is also a high likelihood that their IVs may infiltrate upon injection, causing excruciating pain as the pentathol is forced into the musculature. Will that lead to another moratorium on executions?

It seems like our society coddle these murders. They commit atrocious acts and yet expect to be treated like some hospital patient. The lawyers and judges need to watch the History Channel to remember what real cruel and unusual punishment was: dismemberment, disembowelment, burnings, drownings, beheadings, etc. I believe this one drug method will ultimately fail as a prisoner will wake up from the seeming "lethal" dose of pentathol and complain that he suffered during the execution.

California Doctors

The Medical Board of California's end of the year newsletter has a table listing reasons doctors were disciplined by the Board. The most common reason cited was Negligence, resulting in 21 licenses revoked or surrendered. But the most common outcome for Negligence was either Probation or Public Reprimand. Other unfortunate excuses for disciplinary action by the Board includes Inappropriate Prescribing, with eleven licenses revoked or surrendered, Sexual Misconduct with four, Mental illness with six, and Self-Use of Drugs or Alcohol with nineteen.

The quarterly newsletter also lists the physicians who have been disciplined within the past three months by name and the cause of the action. For the sake of privacy and brevity I won't list the names here but you can read them for yourself as this is public information. Just follow the link above. Most of the causes for Board intervention are vague, like "gross negligence" or "repeated negligence." But there are some real eye-openers.

There were several cases of driving under the influence of alcohol. One doctor received a "Misdemeanor conviction for dusturbing the peace" and got a Letter of Reprimand. Another doctor was disciplined for "failing to meet the standard of care when inadvertently inserting a PEG tube into a patient who was not scheduled to receive one." That's another Letter of Reprimand. Another doctor received the LOR when he "Committed unprofessional conduct and made false representations by sending an e-mail to 4 individuals containing negative and untrue statements about 2 physicians while pretending to be the spouse of a patient." Would love to hear the backstory on that one. One doctor surrendered his medical license when he pretended to be a board-certified physician. Several lost their licenses for insurance or Medicare fraud.

Then there are the really disturbing ones. One doctor received a three year probation for a "Misdemeanor conviction for attempted unlawful sexual intercourse with a minor more than 3 years younger than himself." Doesn't say if the minor was his patient, just that he's a pedophile. Another doctor received probation for "performing physical examinations on 3 female medical students that made them uncomfortable." A Letter of Reprimand was issued to one doctor who "Committed unprofessional conduct by inadvertently touching the breast of a female patient during an axillary examination; failing to explain what was being examined and why; failing to document the performance of the examination; and making an inappropriate comment to the patient." Hmm. I thought all doctors by now have figured out that when examining the female anatomy, there should be a female nurse in the room. And finally, a physician received a 2 year probation for being "Convicted of assault with a deadly weapon." Could be anything from a syringe of potassium to a hit and run with his car. Doesn't say.

There's a lot more in the newsletter that I won't get into, for lack of time and space. But it shows that doctors are all to human. The public may like to put physicians on pedestals but we are just like everybody else, with all the frailties and insecurities of other people. The lessons for doctors to learn include: document everything, don't drink and drive, make sure the proper consent is in the chart, have a female nurse in the room for a female patient, and don't have sex with a minor. That should keep you from about 90% of disciplinary actions by the Medical Board of California.

Statistics on California Doctors

The Medical Board of California publishes a newsletter every quarter. For their end of the year issue, they print some interesting statistics about physicians in California. For instance, did you know there are 99,900 licensed physicians in California, with another 27,536 doctors who hold California licenses but don't live in the state? The county with the most licensed doctors is, you might guess, Los Angeles County with 27,556. The county with the next highest number of doctors is San Diego County with 9,428. The counties with the least number of doctors is Sierra County, with ZERO doctors, and Alpine County with 1 doctor.

There were 6,437 complaints against physicians received by the Board. Of those 5,303 wer closed by the Complaint Unit. Four hundred fifty cases were referred to the Attorney General and twenty-seven were referred for criminal action. The Board received a total of 811 malpractice reports against physicians. There is another list of malpractice settlements broken down by specialty. The field with the most number of malpractice settlements per physician was Neurosurgery, with 16 settlements for 541 neurosurgeons in the state, or 2.95%. The field with the next highest number of settlements per physician was Vascular Surgery, with six settlements among 228 vascular surgeons or 2.63%. The top five fields with the most malpractice settlements per physician were Neurosurgery, Vascular Surgery, Plastic Surgery, Orthopedic Surgery (do you see a pattern here?), and Neonatalogy/Perinatal Medicine.

The field with the least number of malpractice settlements reported was Oncology, with one case among 1,965 oncologists or 0.0509%. The next lowest was Neurology, with one case reported in 1,516 neurologists or 0.0659%. The five fields with the lowest reported malpractice settlements per physician were Oncology, Neurology, Physical Medicine/Rehabilitation, Psychiatry, and Pulmonology.

The fields that traditionally were thought to have a lot of malpractice complaints did surprisingly well. Emergency Medicine had the seventh most number of malpractice settlements per physician. General Surgery came in at number eight, and Obstetrics was in the top ten at number nine. Anesthesiology performed in the middle of the pack, ranking number fifteen, with 27 malpractice settlements among 4,781 anesthesiologists or 0.564%. All the research into providing safe and effective anesthesia has paid off well for us anesthesiologists.

Tomorrow, some more interesting reading from the Medical Board of California.