Monday, November 30, 2009

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 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.

Sunday, November 29, 2009

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.

Friday, November 20, 2009

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.

Thursday, November 19, 2009

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.

Wednesday, November 18, 2009

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.

Tuesday, November 17, 2009

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.

Monday, November 16, 2009

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.

Sunday, November 15, 2009

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.

Saturday, November 14, 2009

The Cookie Diet

I bumped into a colleague the other day who I hadn't seen in a few months. I complimented him on how good he looks. I asked if he had lost some weight, which obviously he had. He said he had lost 26 pounds in the last eight weeks. Wow, I said. That's great. What is your secret? Exercise, Atkins, Miami Beach? No he replied. He's been on the cookie diet. Gee, I thought to myself. Maybe I should try that too.

As some of you long term readers may remember, I recently restarted my exercise program. I've been going to the gym about twice a week now for about eight weeks and I have actually gained weight. While twice a week doesn't sound like much, it is 200% more often than I was going before. I accept that fact that I always gain a little weight when I start exercising again, hopefully due to the buildup of muscle mass, ha ha.

But this time I think I'm just not as disciplined on the diet side. With two small kids around and a good wife who makes great homemade meals, there is always food lying around the house. Thus it can get deadly when I get home late from work, starving so much that I could eat my own foot, and there are leftovers and junk food within easy grasp. The late hours also aren't conducive to a regular exercise routine. Therefore I snarf down my late dinner, put the kids to bed if they're still up, then collapse in bed to get ready to leave the house by 6:00 AM the next day. On weekends, the trips to the kids' favorite restaurant, Home Town Buffet, certainly don't help either. (I'm partial to their fried chicken, steak, and pasta with alfredo sauce.)

So this cookie diet sounds very tempting. Basically you consume less than 1000 calories a day. With that kind of intake, I think anyone can lose weight. The tricky part is weaning off the diet back to normal foods. That has always been my downfall. I'm trying to swear off any more fad diets and unsustainable diets. So I'll continue for now to exercise. Though I'm not losing weight, I feel better about myself after I come back from the gym and hope that I get some cardiovascular benefits out of it.

Friday, November 13, 2009

Mercedes SLS AMG Gullwing

Another car for my future midlife crisis.

I have always been a fan of the 1954 Mercedes 300 SL Gullwing. I loved that car even while in high school. While others had posters of the Lamborghini Countach or Ferrari Daytona on their bedroom posters, I have always dreamed of owning a Mercedes Gullwing someday. Alas I knew I would never earn enough money to own one of those million dollar originals. Now Mercedes has updated the Gullwing so that I can own one for a minimum of 200 freaking thousand dollars. Alas, like back in high school, that might as well be a million dollars.

People have the mistaken image of doctors as fat cats driving around in their Rolls Royce on their way to Per Se to dine on imported truffles and caviar before jetting off to Paris to watch an opera. While doctors are relatively well off, we're not Bill Gates or Warren Buffett rich. We may not be worried about where our next meal is coming from but most doctors live paycheck to paycheck, saving just enough for our mortgages and children's college educations. When the federal government talks about raising taxes on people making over $250,000 it directly affects people like physicians, who make just enough to have to pay higher taxes but not enough to not be bothered by it. If somebody is making a million dollars a year, they probably have enough to cover the extra tax payments. But a physician who makes $250k will have to cut back in order to pay the higher taxes.

So even though I'm making a very decent income, the Mercedes SLS AMG Gullwing is still a pipe dream, just like the Porsche Panamera. It's nice to dream about but for now I'll be getting into my seven year old Honda Accord to get to work.

Wednesday, November 11, 2009

My cellphone rings...

My cellphone rings. "Dr. Z. Where are you?" I look at my alarm clock. Shit! My first case was supposed to have started ten minutes ago. What happened to the alarm? Have the kids been playing with it again? Nope, just plain overslept. Do I have time for a shower? No. I'll just put on extra deodorant today. Good thing I got a short haircut last week, less of a grungy matted hair look. God I smell like my gym's locker room, a decidedly musky rancid odor. Shave? No time for that either. Guess I'll go with the lumberjack look today. Got to brush my teeth though. Throw on my scrubs. Got my wallet, my keys, my beeper, and my evil iphone. Out the door we go.

God I hate commuting at this hour. So many crazy drivers trying to get to work. Oh crap I forgot to change my underwear. Oh well just another reason to slow down and not get into an accident. C'mon lady! The light turned green five seconds ago. Stop applying your makeup and move it. And can you try driving with at least one hand on the steering wheel please? Stay calm. Turn on some soothing classic rock on the radio. Nobody at the hospital will give a shit if you die while trying to get to work. Man look at this line of cars trying to get into the hospital's parking lot. So this is what it's like when people come to work during normal working hours. Damn it. Why is there always some idiot who suddenly realizes he can't find his ID badge just as he pulls up to the parking gate? Got lucky today. Found a spot that's not a day hike away from the door.

One of my partners has graciously started my case for me. Thanks man, I owe you one. No problem, it happens to everybody. Is it just me or is he standing a little further away from me than normal? Okay now I'm good. I am in my element. I rearrange the anesthesia cart to the proper way, MY way. Check the patient. No twitches. Good. Sit back. Everything's good.


10:00 Hey I'm doing okay. I thought that late night case last night would wipe me out. But I'm doing okay after only four hours of sleep. This is going to be easier than I thought.


12:00 God why do the nurses and surgeons get breaks but not the anesthesiologists? I'm dying here. If OSHA knew the working conditions of anesthesiologists they would declare it a dangerous occupational hazard. I'm fading, fading... Where is my power bar? I need some rehydration but I don't want to have to run to the bathroom later. I'll just sit here and swallow my saliva instead.

13:00 "Anesthesia! Patient's waking up!" Huh? Oops. Sorry. Where is that syringe I drew up? There. No more twitches for you! Jesus I got to stay awake, I mean alert. Get up off your chair and walk around. That'll do the trick.

14:00 There is a God; this wretched case is finally wrapping up. Call preop. We're closing in here. Is my next patient ready? Really? The OR scheduler moved my next case to another room? Is she going to put anything else in here? Thank God. I have to remember to buy her something for Christmas this year.

Early out for once. So that's what the sun looks like. I won't have to take my Vitamin D supplement today. Gee it feels strange to be driving home with all this traffic. Hey buster do you mind not throwing your freaking cigarette ashes all over my car? Smokers are so disgusting. They think the world is their ashtray. Whatever happened to ashtrays inside cars, not that anybody would use them anymore. Just toss it out the window.

Get home in time to take a nap before the kids come back from their afterschool activities. I really need one. Then it's dinner time, play time, reading time, and finally bedtime for everybody. Try to recharge for another day. Only twenty more years until retirement. Got to remember to set my alarm clock really LOUD tonight.

Tuesday, November 10, 2009

Don't call your patient a C.O.W.

In our rush towards electronic medical record keeping, perhaps we haven't fully examined all the possible consequences. At our surgery center the patient's history is entered in preop holding on a computer workstation that is placed on a rolling cart. When the patient is taken to the operating room, this Computer On Wheels follows the patient in, thereby ensuring continuity of the patient's records.

One day as a rather portly patient was brought into the operating room, the circulating nurse yelled, "Bring in the C.O.W.!" I guess the patient took offense to that remark. She remembered enough about that incident to write an angry letter to the hospital administrator complaining about the staff's lack of courtesy calling her a cow. Now we never mention the word cow in the O.R.

Monday, November 9, 2009

Best thing about my iphone

I've had my iphone for almost a month now. It is a fascinating piece of technology; all that power that I can carry in the pocket of my scrub shirt. I find I can type on the virtual keyboard fairly easily, if slowly. That's okay because I'm not trying to compose a novel on the thing. The browser works as expected but without Flash support. It was neat to watch U2's concert stream on YouTube on that little thing, like having a portable TV in my pocket. The iphone's ability to pinpoint my exact location and give me real time traffic report for the streets around me is both fascinating and creepy in a 1984 sort of way. The apps, like I've said before, are overrated. I suppose some people download dozens of games and whatnots on their iphone. But I've only downloaded about 20, most of them news apps. I paid $0.99 for a couple of games (80's arcade style games is my thing) and used them hardly at all. There are no worthwhile anesthesia apps to download.

The best thing about my iphone actually is the screen. Not the touchscreen functionality, but the fact that it accumulates no grease. It is quite amazing. When I first got the phone I thought this touchscreen would be a bitch to clean. But after a month, there is no fingerprints on it. For comparison, my wife got a touchscreen phone from another manufacturer and her screen is totally smudged with fingerprints and face grease. She wouldn't believe that my iphone screen would dissipate skin oils automatically so she rubbed my phone all over her face, leaving a giant smudge on the screen. I put the phone away. When I brought it out again 30 minutes later, the face grease was almost gone. The screen stays shiny and clean, almost like new. Magical.

Apple has put on what they call an oleophobic coating on the screen to solve this problem of oily skin. Bill Nye has a nice short explanation of this. It really works well. It is smart thinking like this that makes them a $200 a share company. Wish I had been an Apple stock believer earlier. Sigh.

Sunday, November 8, 2009

Best anesthesia song ever

I'm talking of songs about legally prescribed sedation, not illicit drugs. So that eliminates most rock songs like "Lucy In The Sky With Diamonds" and "White Rabbit" (though that is now street slang for propofol). Every time I hear this song I feel like the song was written by an anesthesiologist. Not only is it a great song about anesthesia, according to Wikipedia this song contains one of the greatest guitar solos of all time and was voted the best song ever by this band. Of course I'm referring to Pink Floyd's "Comfortably Numb" from their album "The Wall." Most people probably could relate more with "Another Brick In The Wall" with its rebellious anthem "We don't need no education. We don't need no thought control." But as an anesthesiologist "Comfortably Numb" makes me feel like I had written the song myself if I was ever that brilliant. Sometimes I'll say a couple of these lines almost verbatim to a patient when I'm taking a history. Unfortunately nobody has ever accused me of being the next Roger Waters.

Come on now. I hear you're feeling down.
I can ease your pain, get you on your feet again.

Relax I'll need some information first.
Just the basic facts. Can you show me where it hurts?

There is no pain you are receding.
A distant ship's smoke on the horizon.
You are only coming through in waves.
Your lips move but I can't hear what you're saying.

O.K. just a little pin prick.
There'll be no more aaaaaah!
But you may feel a little sick.

Can you stand up?
I do believe it's working good.
That'll keep you going through the show.
Come on it's time to go.

According to Rolling Stone magazine, the song was conceived during Pink Floyd's concert tour promoting their Animals album in 1977. Waters was having severe stomach cramps in Philadelphia when the house doctor came and gave him a tranquilizer so he could continue the show. Ah the sacrifices great artists make for their art. I thought about including a YouTube clip of "Comfortably Numb" from their movie "The Wall" on this blog but I didn't like the movie much and the visuals distract from the poetic lyrics so I'll let you readers surf over there yourself if you're interested. A must have song on any anesthesiologist's playlist.

A close second for best song about sedation might be The Rolling Stones "Mother's Little Helper." However that song's subject might be more appropriate for a psychiatrist's playlist than an anesthesiologist's.

Friday, November 6, 2009

What do anesthesiologists do?

What do anesthesiologists do for three hours when the patient is asleep on the operating room table? Here is a funny video parodying anesthesiologists. Video probably came from the U.K. based on the singer's accent and the spelling "anaesthetists." It's funny because it's (half) true.

Death of a surgeon

There is a shrine in one of the operating rooms at my surgery center. It is dedicated to a young surgeon who died a few years ago. The shrine consists of his framed picture and a mix music CD he liked to play while operating. He always liked to finish his cases playing Quiet Riot's "We're not gonna take it."

Working in that room the other day, I'm reminded of one of the most surreal moments in my life. I was on call on a Saturday night. That surgeon books a laparoscopic appendectomy to start around midnight. He is very nice and well liked by all the staff. He comes in cheerful as usual. The case goes well without any drama. He leaves the operating room around 2:00 AM, saying thanks and goodnight to everybody. He looked the picture of health and good cheer.

Come Monday morning he doesn't show up to the operating room, which is extremely unusual for him. The OR pages him and calls his cell phone without success. They call the police to his place. He is found dead in his bed. No signs of foul play. He was single with no dependents. Everybody is completely shocked. Word spreads quickly throughtout the hospital. Some nurses are brought to tears. I realized I may have been the last person he saw and spoke to before he died. The hospital held a memorial for him and he was eulegized by many surgeons and anesthesiologists. He was only forty years old.

Thursday, November 5, 2009

Annoying surgeon's request

Okay so I've detailed a couple of outrageous, maybe even dangerous, surgeon's requests. Now here is one that is simply annoying. We were in the middle of a breast biopsy. The surgeon was operating by himself with just the scrub nurse helping him. Suddenly he looks at me and asked me to hold a retractor for him through the drapes. I was taken aback. I thought, was he serious? When I refused, he appeared surprised and irritated. He then asked the circulating nurse to hold the retractor for him.

So now this became a hassle. Everytime the surgeon needed a new suture or the phone in the OR rang, the nurse had to drop the retractor. Plus she was standing at the head of the bed, partially obstructing my access to the patient. The broader implication of this request was that the surgeon had no respect for my job. He thought I had nothing better to do than to stand there holding a retractor for him, as if I was behind the drapes only playing video games or something. He obviously did not appreciate my work keeping the patient stable so he could have a successful operation. If I was holding a retractor, that would make it impossible for me to adjust the anesthetic if the patient got too light, or give her a pressor if her BP got too low, or a hundred other things I do during a case that the surgeon doesn't see and apparently doesn't care.

When I querried other anesthesiologists later about this, some of them surprisingly said that they have been asked and have assisted the surgeon by holding the retractor during a case. But it gnawed on their dignity while they were doing it. It was just easier to help out the surgeon than to look him in the eye and say no. But by doing so, the surgeon gets the idea that he can get away with operating without an assistant by asking the anesthesiologist to do the work, trivializing our job. So this is a good lesson for me. Sometimes you have to do what's right for the patient, even defying the surgeon if necessary. By saying no, the surgeon may be upset but at least he'll know I take my job seriously; I'm not some gasman sleeping behind the drapes.

Doctors, no money for you

The proof that physicians have no friends in Congress is at hand. The Senate passed a bill that will extend unemployed benefits to 99 weeks and continue the home buyers tax credit. The tax credit now will be open to anybody, not just first time home buyers. The income limit for eligibility has also been raised so more people can use it, maybe even allowing some doctors to take advantage of it.

It didn't seem to matter that the original tax credit has already cost the government $10 billion in tax revenue during a time of trillion dollar deficits. This new tax credit is calculated to cost $11 billion. It also didn't make any difference that there is rampant abuse of the original home buyers tax credit. Many people who are ineligible have applied, and received, the money. Some people have used their children's name, some as young as four, to claim a first home. Others have used it to buy investment property. One tax preparer in Jacksonville, Florida has been sentenced to prison for helping his ineligible clients get the credit then pocketing $1000 for himself each time. The IRS is investigating over 100,000 cases of possible violations of the tax credit rules. Into all this the Senate has deemed an urgent need to throw in another $11 billion. Maybe it's because Sen. Harry Reid of Nevada, the Majority Leader of the Senate, comes from the state with the most use of the credit on a per capita basis.

With all this money being thrown at a "systemic risk" Congress couldn't find in their multitrillion dollar budget the money to prevent a 21% cut in Medicare reimbursement next year. Again doctors are playing by other people's rules. While lawyers, insurance companies, homebuilders, car dealers, etc are throwing millions of dollars into lobbying Congress, doctors just sit back and pray that Congress will see their plight, or the plight of the elderly, and dribble some money our way.

Wednesday, November 4, 2009

Outrageous surgeon's requests

As an anesthesiologist, I try to make sure everything in the OR runs as smoothly as possible. To do that, it helps not to step on anybody's toes and try to get along with everybody as much as possible. But sometimes a surgeon will make a request that can be simply outrageous, even downright dangerous to the patient.

There was this one surgery center I used to work at that performed a lot of arthroscopies. A surgeon who worked there, and may have been a partial owner, was known to be a real tyrant. He went through dozens of anesthesiologists who all eventually refused to work with him. His main request, or more accurately demand, was that during his arthroscopies, the patient's systolic blood pressure be less than 100, in the 80's if possible. It didn't matter that the patients he brought had all sorts of morbidities: morbid obesity, hypertension, diabetes, coronary artery disease. The preop workup was usually minimal, practically nonexistent. He would have his patients up in the sitting position for the shoulder arthroscopies, constantly looking over the drapes to check the blood pressure. If the BP went over 100, like 101 or 102, you got a good yelling. It got to the point where right before the BP cuff inflated, I would give a small dose of nitroglycerin to make sure the BP appeared low. Cerebral perfusion pressure be damned. After a few months of this, I left that surgery center and got my self esteem and sanity back.

At another site that I used to work in, they did a lot of pain procedures such as epidurals, facet joint injections, etc. The way to make money in a pain center is to drive through huge volumes of patients. The pain doc, really an overpaid egotistical anesthesiologist, didn't want his patients to feel any pain upon injection and didn't want to wait for a routine anesthetic to kick in. So he demanded all his patients receive Versed 10 mg and Fentanyl 100 mcg IV boluses right before he injected. Of course that cocktail put the patient's out like a light switch. Since pain procedures usually take about ten minutes to perform, the patient was usually still sound asleep when he was finished. Now you can't clutter up a small recovery room at a pain center with a bunch of sleeping patients. So the routine there was to give a bolus of Flumazenil and Narcan when the procedure was completed. That usually woke up the patient right away though many still felt groggy. They were discharged pretty quick, before the reversal agents wore off and the patients fell asleep again. It's surprising not more people had complications from this.

There are so many other difficult surgeons I could write about. These are the reasons why I don't understand the desire of many anesthesiologists to work in surgery centers. They are usually owned by the surgeons and your bread and butter really depends on satisfying their every whim, no matter that fulfilling their requests would probably get your anesthesia board certificate revoked. I don't work in these places anymore but it's scary to think that many are still out there.