Friday, January 29, 2010

Osama Bin Laden, The New Al Gore

Osama Bin Laden has now become an environmentalist. No, this is not a headline from Jon Stewart. In a statement released yesterday Bin Laden wants the whole world to abandon trade with the U.S. and stop the use of the dollar as a global currency because he accuses this country of causing global warming. Says Bin Laden, "Talk about climate change is not an ideological luxury but a reality. All of the industrialized countries, especially the big ones, bear responsibility for the global warming crisis."

Is he getting desperate because his jihadist messages are no longer resonating with his fellow Muslims? Does anybody think the Palestinians, the ones he claims to be fighting jihad for, care a rat's a** about global warming? I think Bin Laden is taking a page from Al Gore and trying to court the elite Hollywood crowd. He may even get an Oscar or a Nobel Peace Prize if he continues this new anti-Western message. Knowing the candidates the Nobel Peace Prize committee have rewarded, they may just give one to him.

Thursday, January 28, 2010

The Zen of Anesthesia

I was giving a MAC anesthesia to a patient in a sitting position for a brain biopsy. The head is completely draped and inaccessible. It is also pinned to a metal frame fixed to the OR table by a Mayfield device so an emergency laryngoscopy would have been virtually impossible. The case went very well. At the end of the case the surgeon looks at me and says, "It must be nice to get paid for just sitting there and doing hardly anything."

I was shocked he made this statement. I replied, "I only make it look easy." Internally I was indignant. I would never deign to presume that his work is simple and mechanical. Somehow he felt it was appropriate to make that remark to me. What he doesn't see is all the internal calculations that are a constant when a patient is under anesthesia. Is the patient's cerebral perfusion pressure adequate? What precautions have I made in case the patient gets an air embolus. Is the anesthesia deep enough to make sure the patient doesn't move while his head is pinned to the table? Is it light enough so that the patient can maintain a patent airway? If the anesthesia is too deep and he obstructs should I put in an oral airway? What if he starts coughing when an airway is put into his mouth? The patient has coronary artery disease and has had a cardiac bypass. Are his coronary arteries being perfused adequately? Are his blood pressure and heart rate optimal? He's rebreathing some CO2 under the drapes. How is that going to affect his pulmonary artery resistence pressure? How does his ETCO2 waveform look? Do the diminished waveforms mean the patient is obstructing or has the sample line moved? Are the patient's extremities adequately padded? Are his eyes protected from corneal abrasions?

All these questions and more go on inside my head throughout the procedure. But on the outside I exude the calm and confidence of a professional with years of experience in the OR. Thus the surgeon leaps to the conclusion that the anesthesia was "easy." I frequently tell surgeons that they want to see relaxed anesthesiologists. If they see their anesthesiologist running around at the head of the OR table, frequently ducking under the surgical drapes, and otherwise working frantically, then you know your patient is in trouble. So don't make the assumption that because your anesthesiologist is sitting there that the anesthesia is undemanding. It just means your anesthesiologist is in complete control of the patient's situation and you have nothing to worry about and can conduct your procedure with confidence. While you surgeons perform your single-minded task at hand, know that the other physician in the OR is watching out for the patient to make sure the operation is a success.

Wednesday, January 27, 2010

iPad=Feminine Hygiene?

Seems like the great Evil Empire that is Apple has stumbled badly when it came time to name their new tablet. I'm already sick of all their products that start with the letter "i". With all the billions of dollars they make can't they think of more creative names besides putting an "i" in front of a noun? (Same with McDonald's whose creativity ends at putting "Mc" in the front of their food names like McNuggets, McMuffin, and McGriddle).

When the iPad was announced, the association with feminine products quickly became obvious. Snarky remarks like this, "Heavy flow? There’s an app for that!" quickly made the rounds. The New York Times interviewed several people who noticed this awkward title. Says one public relations expert, "I’m waiting for the second version that comes with wings."

So I can see this happening somewhere sometime in the near future. A man goes to Best Buy to buy the new tablet. He asks the sales clerk where is the iPad. The clerk replies Walgreen is down the street. Ha ha.

Doctor Jokes Heard In The O.R.

An anesthesiologist calls a plumber to fix a clogged drain. The plumber comes, spends 30 minutes fixing the drain, and hands the anesthesiologist the bill. The anesthesiologist looks at the bill and is shocked by the cost. "I don't make this much as an anesthesiologist," he grumbles. The plumber replies, "I didn't make this much as an anesthesiologist either."

Five physicians go duck hunting in the woods. There is a pathologist, a radiologist, an internist, an orthopedic surgeon, and a surgical oncologist. Suddenly a bird flies out of the deep grass and into the air.
The radiologist says, "Let me study its shadow to see what kind of bird it is."
The internist says, "We need to form a committee and take time to study the bird's colors and texture of its feathers to determine the bird's species."
The orthopedic surgeon attempts to throw a rock at the bird.
The surgical oncologist grabs his gun and shoots down the bird. He hands the carcass to the pathologist and says, "Tell me what kind of bird this is that I just shot."

Tuesday, January 26, 2010

Labor Anesthesia With A Full Stomach

The New York Times highlighted a provocative research paper that advocates more leniency of NPO status in women undergoing labor. The paper is published in The Cochrane Review and is a meta-analysis of 11 studies looking at the rate of birth complications and likelihood of Caesarean sections as related to NPO status. The analysis shows no difference in APGAR scores, need for C-sections, or pain scores between women who were allowed to eat and those who were kept NPO. Thus the authors recommend that women should no longer be kept NPO during child delivery.

I say that's a bunch of hogwash. The official opinion from the American Society of Anesthesiology is not mentioned until at the very end of the article. Dr. Craig Palmer, Chairman of the Committee on Obstetrical Anesthesia said of the study, "From an anesthesiologist’s perspective, they missed the boat on this one. They looked at the impact on the progression of labor, but to be honest, that’s not an issue for anesthesiologists. Our primary concern is patient safety."

From my own personal experience most women who undergo C-sections have extreme nausea and vomiting during the procedure, especially when the uterus is brought out of the abdomen and hard pressure is placed on the dome to push out the baby. It is ugly enough when bilious emesis spews forth. I couldn't imagine the complications if the patient had a full stomach. The authors also fail to take into account well documented changes in gastric physiology of women with term pregnancies, including delayed gastric emptying, higher acidic content, and decreased lower esophageal sphincter pressure.

The news article mentions one OB/GYN who compares labor and delivery to driving a car. She says people can have accidents anytime, requiring emergency surgery. But we don't keep people NPO before getting into their cars. I'd counter that the argument is naive. Up to 25% of pregnancies now end with C-sections. If 25% of all vehicular trips end in accidents requiring surgery, then yes people should be NPO before getting into their cars. The authors also say that with improved techniques, the risk of aspiration with general anesthesia during labor is extremely low. Well that is a totally circular argument. The reason labor anesthesia is so safe nowadays is precisely because of rules advocated by anesthesiologists, including keeping patients NPO, that lowers the complication rates for the patients and their OB docs.

So this article is misinformative at best, dangerous at worst. The article leads with a mention of the low likelihood of gastric aspiration during labor anesthesia but that is not what the study is about. Now patients will be clamoring for their doctors to change their diet orders in Labor and Delivery when in fact the study does not compare the risk of aspiration in full stomach vs. NPO laboring patients. And frankly, a real randomized double blinded study like that will never be performed. If any women would like to volunteer to be in the full stomach branch of that study, be my guest. As long as they sign wavers absolving all legal responsibility of their doctors when they wretch up that oatmeal and bacon they had for breakfast and aspirate into their lungs.

Monday, January 25, 2010

Should You Eat It?

Hilarious algorithm for when to eat food after dropping it on the floor. Courtesy of SFoodie.

Sunday, January 24, 2010

I Hate Costco

Just finished the weekend with another brutal trip to Costco. Can there possibly be a worse shopping experience in America than going to Costco on a weekend? I think not. Sure the warehouse company is doing mega business and I wish I had bought its stock five years ago. But as far as shopping there one shouldn't go there if he is trying to control his blood pressure or anxiety. At least double your medications before heading out to the store.

There is something about having a massive number of people all crammed into one store that brings out the worst in humanity. It all starts in the parking lot. You circle the parking lot for an eternity, warming up the Earth's atmosphere another two degrees Celsius in the process, eventually stalking a shopper heading for her car. You feel like an idiot driving along at one mph following a total stranger, hoping she doesn't cross over into the next lane. When she finally gets to her car, she spends fifteen minutes unloading enormous quantities of frozen pizzas, toilet paper, wine bottles, and potato chips. Then as she leaves and you are ready to make your move, some moron coming from the opposite direction cuts into the space. You scream obscenities that will land you in the third circle of Hell and continue the Search for a Parking Space at Costco.

When the parking Gods finally grant you a spot, you are now faced with the daunting task of actually shopping inside the store. Giant grocery carts are whizzing by, with nobody giving anybody an inch of extra space or courtesy. Even NASCAR has rules about driving and passing. It is so bad I'm afraid to let my five year old walk next to me. I put her in the cart lest she gets into a hit and run with another shopper. Again huge numbers of shoppers are congregated around, well, everything. Good luck trying to get a free sample of food; somebody will steal it right out from under your fingertips. And whose stupid idea was it to put all the produce inside an open freezer? Sure it keeps it fresher but on a warm day when you're wearing T-shirts and shorts you don't want to walk into a room that's only forty degrees.

Finally the greatest challenge arrives, the checkout. An immense number of check out lines are open but each line stretches back halfway into the store. Which line might move the fastest? Let's see. One line has only five carts but each cart is packed to the rim. Another line has seven carts but fewer items in each. I'll try the seven cart line. Then you wait and wait and wait. Why does that person have to pay with a check? Doesn't she know it's the 21st century? Who doesn't own a debit card in this day and age? The next person says his wife is bringing more stuff and will be here in a minute. Ugh. I think my aneurysm is going to explode and leave a convulsing mass of human tissue here inside Costco, as if anybody would care.

Suddenly the aisle next to me opens up. I make a dash for it. The person on the other side also makes a run for the open line. Ha I made it first. Oh boy he doesn't look too happy. Hey what the hell. He has put the separator bar ahead of my stuff and is putting his items ahead of mine on the conveyor belt. What the f***? Of course the Costco employees are just standing there doing nothing, just talking about how much longer until closing time. I want to give this a**hole a karate chop right into his cricoid but alas, he is six inches taller and fifty pounds heavier. I think better of it and try to control my rage, and humiliation. Besides self preservation, it wouldn't look good if the newspaper reported that a local anesthesiologist was arrested for assault and disturbing the peace. Our group might not appreciate that kind of publicity. I tell myself, I'm letting this gentleman ahead of me, out of courtesy and respect for my fellow human being. Uh huh.

Finally, made it out of the store. Walk slowly back to the car, dodging all the traffic. Predictably there is a car tailing us as we walk all the way back. Okay, now it's my turn to slowly put my things in the car and strap the kids in the car seat while a stranger is lurking right behind me. Getting into the driver's seat, I let out a huge sigh of relief. Made it through another weekend at Costco. Until next week.

Friday, January 22, 2010

Medical Marijuana, Unlimited

In a victory for stoners in California, the California Supreme Court struck down laws passed by the state legislature that limited the amount of medical marijuana one can legally possess in the state. In 1996 California voters passed a ballot initiative allowing the use of medical marijuana. The state legislature later placed limits on how much drug one can hold. The maximum a person can possess was decreed as 8 oz. of dried mj and grow no more than 6 mature or 12 immature plants.

The Supreme Court ruled that the medical marijuana initiative that became part of the state Constitution never placed a limit on how much drug one can have. So now if somebody has a doctor's excuse, he can have as much marijuana in California as is "reasonably necessary."

Of course it is ridiculously easy to obtain a doctor's prescription for medical marijuana in California. I've written before how a doctor can moonlight as a medical marijuana prescription dispenser and make mucho bucks, all in cash. You don't even need to be certified in marijuana expertise because, well, there is no such thing. I know of no medical school in this country that even teaches a course on medical marijuana. So next time you visit California, don't be surprised if you see a bunch of bleary-eyed people driving around searching for White Castle.

Thursday, January 21, 2010

A Fool And His Car Are Soon Parted

If any of you are avid viewers of the Weather Channel, you know that we've been having epic rainfall here in Southern Cal. Floods, mudslides, tornadoes, mountain blizzards, we've had all that. The worst thing about all this bad weather is that Angelenos just don't know how to drive in wet weather. Take this picture from the LA Times for instance. Dude, you are about to drive a $130,000 white Mercedes sports car into God knows how deep that flood is. What the hell are you thinking? I can only dream of owning a car like that someday and you are getting ready to submerge this exquisite piece of machinery into that swirling tempest of water and mud. Better to return to the DMV to get a refresher courses on driving in rainy weather.

Tuesday, January 19, 2010

Lego Avatar

Some people are just so creative, and have a lot of free time. Check out these Pandora recreations using Legos. I don't have so much free time and admit that I haven't yet seen Avatar. I presume these are pretty good copies of what you see in the movie.

New Rules To See Doctors In California

California is about to institute rules on how quickly patients have to be seen by doctors. Family practitioners, and presumably all primary care doctors, have to see a patient within ten business days. Specialists have fifteen days to clear an appointment for patients. All phone calls to doctors' offices have to be returned within 30 minutes.

Hmm. Do you think these new rules will increase patient access to physicians or decrease it? Off the top of my head, I'd say the rules SCREW THE PATIENTS' ability to find a doctor. If a doctor already has his appointments booked two months in advance, who will want to take on more patients and possibly get penalized by the state for delayed office visits? So let's see, between Medicare reimbursement cuts and onerous rules about patient visits, good luck trying to find a doctor in California.

Why don't they apply these expediency rules to government agencies? They're the most notorious for delaying timely decision making. The rules only apply to HMO private insurance doctors. They don't apply to county hospital or VA doctors, which of course are controlled by the government.

Saturday, January 16, 2010

Anesthesia Rage

Despite all my rage I am still just a rat in a cage.
Smashing Pumpkins

Pardon me if I sound surly today. I'm currently doing the third night in a string of every other night calls and just the tiniest annoyances can push my buttons. Being on call is probably the worst part of being an anesthesiologist. Sure patients have to be treated at any time of day but that doesn't make that 3:00 AM phone call to come in for that stab wound to the chest any easier to take.

Being on call is the one thing in my professional life I feel like I have no control over. You can't do anything normal during that 24 hour period. You can't go out to dinner without worrying about getting called in during the middle of appetizers. You can't attend your children's school events without having to take two cars, in case you get paged and have to drive back, leaving your family behind. All I can do is sit around the house, just waiting. I can barely sleep at night on call. The thought of that damn pager buzzing me awake keeps my brain from completely letting go of consciousness and at best I toss and turn until dawn. The on call insomnia is actually getting worse the older I get. I thought I would get used to it but I never do.

Not only is the thought of the call beeper going off stressful, it's the "what the hell will I be facing when I answer this page?" thought that keeps me awake. On call, you don't get to have a nice little schedule printed out ahead of time so you can look up the patient's history and plan the anesthetic. Will the next page be a quick ten minute D+C? Or a full blown multiple GSW victim requiring placement of multiple lines, running two Level 1 blood transfusers while wading through a lake of blood on the OR floor? Psychologically the anticipation of these things just don't get any easier despite having more experience.

The grumbling about call schedules is worse among the younger members of our group. But you will get no sympathy when this issue is brought up at group meetings. The older members go into their condescending mode and start saying "When I was working here at your age, we had calls q 3 nights while trudging into the hospital through ten foot high snow drifts and dodging gangbanger crossfire on our bicycles."

Yes I love my job as an anesthesiologist. But taking calls will be the thing that finally induces me to retire. The stress burden makes me inappropriately cross with other hospital staff, patients, and sometimes my own family. God I hate taking calls.

Friday, January 15, 2010

World's Fastest Texters

In a texting competition held in New York City, a team of South Korean texters won the grand prize of $100,000. Second place finishers went to the U.S. National texting champion team of Kate Moore and Morgan Dynda. They share a $20,000 prize.

The mind blowing statistic is the quantity of texting these girls do every day. Ms. Moore says she averages 12,000 texts per month! Let's see, 30 days per month, 16 hours per day (they need some sleep at least), 60 minutes per hour. That works out to one text every 2.4 minutes. That's not even counting time for eating, school activities (I doubt her school let's her text during class hours), personal hygiene, homework, sports, etc... Though the prize money is nice, I'm not sure this prize is something she will want to list on her college application, let alone job resume.

Patient, M.D.

ZMD: Good morning. I'm Dr. Z. I'll be your anesthesiologist today.

Patient: They told you I was crazy, right?

ZMD: Uh, no. Why do you say that?

Patient: I said I don't want general anesthesia under any circumstance.

ZMD: Well most of the time this procedure is done with only IV sedation. I was not planning on giving you a general.

Patient: What do you mean "most of the time"?

ZMD: Well some patients require a general anesthesia if it is too risky to have only sedation, such as patients with morbid obesity or severe lung disease.

Patient: I have neither of that. Can you guarantee that I won't get a general anesthetic?

ZMD: I can't guarantee that. Some patients may require that an IV sedation be converted to a general anesthetic if there are unforeseen problems with ventilation during the procedure. But that would only be done if there is no other way to save the patient's life.

Patient: I don't care. I want a written guarantee that I won't get general anesthesia during the procedure.

ZMD: I'm sorry. I can't do that. Is there a reason you have such fear of anesthesia? Did you have a bad experience in the past?

Patient: No but I've done a lot of research and anesthesia just scares me. I just don't want to have it.

ZMD: Do you have any particular questions and concerns about anesthesia that we can discuss?

Patient: I know what you're trying to do. You want me to talk about anesthesia to try to change my mind. I told you I've already done a lot of research and I don't need to talk about anesthesia with you.

ZMD: So there is nothing I can do to try to relieve your anxiety and fears of anesthesia?

Patient: No.

ZMD: Okay. Let's wait for the surgeon so we can all talk about this together.

An uneasy quiet settles over the room as ZMD writes an extensive note chronicling the encounter with the patient in his H+P

Patient: I have a bad feeling about this. I don't want to do this today.

ZMD: Do you want to wait for the surgeon first to talk this over?

Patient: No. I don't feel good about this. I want to leave.

ZMD: Okay. Have a nice life.

ZMD thinking: Thank God. That was just a malpractice suit waiting to happen. Don't let the door hit you in the ass on the way out you paranoid freak.

Thursday, January 14, 2010

Labor and Government in Health Care Collusion

"The White House and labor leaders agreed Thursday on a formula to tax high-cost insurance plans." Los Angeles Times

"The White House, Congressional leaders and labor unions said Thursday that they had reached agreement on a proposal to tax high-cost health insurance policies." New York Times

"Unions and Democratic negotiators agreed Thursday to scale back a proposed tax on high-end health-insurance plans in the health bill." Wall Street Journal

Does anybody see any problems with these statements? What if these articles substituted the term union leaders for the U.S. Chamber of Commerce? If there are private closed door meetings between Congressional Republicans and the American Medical Association that will determine the course of 15% of the U.S. economy do you think there might be an uproar? Seems like there is a very public collusion going on between the government and a small minority of people that is affecting the health care for the rest of the country and the media doesn't care. Why isn't anybody pointing out that these back room deals for a small influential group of union workers (12.4% of working Americans) is forcing the rest of us to pay higher taxes so they can keep their Cadillac health insurance plans ie/we're subsidizing their health care premiums so they can have zero deductible zero copay free prescription insurance plans.

Just as galling is who isn't at the table negotiating the terms of these reform. I'll give you three guesses. We've heard from the unions, the elderly, and the tea partyers. But who has the most at stake in this debate? Who will be affected worst by the planned $500 billion cut in Medicare reimbursements in the next ten years. If you are reading this post you are probably one of them. That's right. Doctors will be directly punished by this legislation and yet we are not even outside the White House window looking in as decisions affecting our livelihoods are being debated. Where is the AMA in all this? Once again they show absolutely no political clout to advance the political priorities of physicians.

As usual the big spending special interest groups are making out like bandits: unions, insurance companies, government bureaucracy. The losers are the ones most directly involved in health care: patients, doctors, hospitals. Certainly no "change" in American politics since the presidential election.

Tuesday, January 12, 2010

Sex and Technology

A couple of interesting articles in CNET describes the association of technology and human relationships. The first article mentions a neat little project using Google to identify human social needs. The author of the book "Predictably Irrational" entered the phrase "How can I get my boyfriend/girlfriend to" into Google. Google's predictions for the completion of the search phrase yield insightful results. The top three things a girl wants to know how to make her boyfriend do is "propose, spend more time with me, and love me again." Pretty standard Dr. Laura stuff. The top three things guys are trying to find out how to make their girlfriends do is "give me head, make her sleep with me, and lose weight." Are men really this narcissistic?

If Google is unable to give satisfactory advice to save your relationship, there is now the sex robot. The anatomically correct figure is 5 foot 7 inches tall, 120 pounds, and comes in a variety of shapes and hair colors. She can sweet talk you and never turns you down. She also will cost between $7000 and $9000. But that can be cheaper than a night with a high end call girl, especially amortized over the life (?) of the robot. Sure beats the iphone any day.

Monday, January 11, 2010

Adventures in Waxing

The Happy Hospitalist posted the most hilarious anecdote on hair removal. He says the source is anonymous. It is fall out of your chair, I Love Lucy stomping on grapes, Ben Stiller catching his beans above his frank funny. The trauma ladies go through to please their mates.

Sunday, January 10, 2010

Two Americas

We'd like to think that we are in a postracial, nonpartisan, socio-economically indifferent society. But no matter how hard the politicians may try to convince us this, we are still a country with very different economic outlooks and social status.

The New York Times published a heat map put out by Netflix on the rental pattern of movies across different zip codes. The two pictures here are for the Los Angeles region. The one on the top is for the frequency of rentals of "The Reader," that high-brow Holocaust movie about a German woman who has an affair with a teenage boy (it was legal back then). The picture on the bottom is the rental pattern for "Transformers: Revenge of the Fallen." The title pretty much says it all. You tell me if we have two Americas or not.

Saturday, January 9, 2010

Anesthesiology Is Such A Thankless Job

Not only is anesthesiology one of the hardest jobs in America, it can also be one of the most thankless. I suppose that's another similarity we have with nuclear plant operators. I saw a patient in preop that was a total nightmare. His H+P ran nearly ten pages single-spaced small type. Needless to say he was an ASA Class 4.

While giving the informed consent, which by necessity involved explaining the risk for an MI or death with the procedure, he became extremely agitated and outraged. He accused me of being unprofessional. He said he was well aware of his medical conditions and for me to emphasize his morbid conditions was totally out of line. I was taken aback by his animosity. I apologized for making him feel so angry but he would not be placated. Any attempt at a conversation came to a complete stop. He would only give one word answers and most of the time just stared at me with the evil eye. In the meantime he was cheerful as he could be with the rest of the OR staff.

Of course thanks to expert anesthesia care the patient did well during the procedure. The patient suffered no cardiovascular calamities. He had survived the surgical procedure without any evident sequela. But did I get any credit for his life? Hell no. He continued to give me the evil eye in postop. He wanted my card so he could write a letter of complaint to the hospital administrator about my conduct.

At first I felt badly about how this situation had turned out. You never want the patient-doctor relationship to turn into a battle. But then I thought, "Screw it, and him." I did my job in a professional manner and the proof is that he is not lying in the morgue in the basement of the hospital right now. If he is so shortsighted and selfish that he cannot see what a miracle it is that he is still alive then f*** him. Let him write his letter. I don't care if he says I have poor bedside manners. I have had thousands of other patients who will say otherwise. That's always the problem--only the complainers are ever heard from. The people who are thankful for your care rarely write letters to compliment you. I am not going to let this one petulant irritating man make me feel I've given bad anesthesia care. They can review my record all they want. Everything is pristine and by the book. In other words, F.U.

P.S. I talked with a family member afterwards. He was very nice and understanding. I explained that the patient was extremely angry with my care when I was explaining the informed consent and the need to be very specific because of his multiple medical problems. He said not to worry. He can be overbearing at home too. The family member then thanked me for my anesthesia care and gave me a fist pump. I felt just a bit of my self respect return with that one kind act.

Friday, January 8, 2010

How Is Anesthesiology Similar To Running A Nuclear Power Plant?

A study printed in the Anesthesia Patient Safety Foundation equates practicing anesthesiology with the complexity of running a nuclear power plant. They describe human activities as a combination of interaction complexity vs coupling. An interaction is more complex when at each decision-making point multiple choices can be made. Linear interactions is self-explanatory; there are few decisions to make for each interaction. A tight coupling implies one consequence after each decision whereas a loose coupling denotes less rigid consequences of an action, thus the system is more forgiving of an error.

The authors rightly state that humans are extremely complex. However when the patient becomes anesthetized suddenly the compexity and coupling tightness leaps into the nuclear plant territory. Why? Because the anesthesiologist is now in control of every vital function of the patient. The complexity is still there but the consequences become catastrophic if not handled correctly, just like running a nuclear power plant. Remember your oral boards exam? What would you do if the patient goes into an arrhythmia, BP plummets, and he desats, sometimes all at the same time. Complex yes. And each action you take will lead to a certain consequence, thus tight coupling. Very little forgiveness if an error in decision-making occurs. With all the new technology currently available to anesthesiologists, the complexity becomes even worse. More information requires more processing leading to a higher pressure to make the right choice.

So you can see how being an anesthesiologist can be as nightmarish as running a nuclear plant. Of course the surgeons will probably agree that anesthesiologists are in fact very similar to a different nuclear plant operator:

Thursday, January 7, 2010

Cool Video

Do you ever feel like other people have cooler jobs than you? This video for the Honda Insight is pretty awesome. The actual commercial comes at the end of "The Making of..." segment.

Illegal Aliens Continue To Get Free Care From Grady

If you haven't been following, the New York Times has been chronicling the plight of illegal immigrant dialysis patients at Grady Memorial Hospital in Atlanta. Due to severe budget deficits the hospital had told its patients in the dialysis unit, nearly all of whom are illegal, that the unit will close this month. Out of humanitarian concerns they agreed to give the patients money to go home to their native countries and even offered to pay for three months of dialysis there.

Now it appears the unit will not close as scheduled. The closure date has been extended to February and may in fact stay open until September and beyond. However most of the patients had not even bothered to look for other dialysis centers. Says one patient, "I thanked God because he is really the only one that can allow us to continue our treatments."

Hmm, I think I now somebody besides God she should be thanking. How about you and me, the American taxpayers? While we are running up trillion dollar budget deficits and facing higher tax burdens, including mandatory health insurance purchasing in the new health care legislation, these patients are getting free health care thanks to our tax dollars. Illegal immigrants won't be forced to buy health insurance and are not eligible for Medicare so they wind up at charity hospitals getting free care from the public. Sounds like a pretty good deal.

And what about the illegal immigrants who did the right thing and went back home to get their dialysis? They are now struggling with substandard medical care. Once their free care courtesy of Grady and American taxpayers is used up, they are SOL. Good luck trying to sneak across the border with renal failure. They would need to get travel advice from Osama bin Laden.

No Good Deed Goes Unpunished

As the old cliche goes, no good deed goes unpunished. Last month a jury in Massachusetts awarded $15 million to the parents of a three year old boy, Jason Fox, who suffered postprocedure seizures and subsequently died while under the care of Boston Children's Hospital. The defendants were Dr. James Lock, a pediatric cardiologist and formerly physician in chief, and Dr. James DiNardo, the anesthesiologist.

Dr. Lock had unfortunately attempted heroic measures to repair the child's Tetralogy of Fallot after multiple operations at Children's Hospital of Philadelphia had failed. Dr. DiNardo, as far as I can tell, just happened to be at the wrong place at the wrong time. It is unclear from the news his role in the complications after the failed procedures.

Even the lawyers were surprised by the size of the jury award. Normally damage awards of that size are given to plaintiffs who have lifetime medical expenses. The plaintiffs supposedly reached a settlement with the doctors that will lessen the amount of the damages they will collect. Though the hospital denies it, because of the trauma of this trial Dr. Lock has decided to retire. A fine physician forced to quit because of another example of the capricious jury system in this country.

Wednesday, January 6, 2010

The More Things Change...

Is the Obama administration as incompetent with national security as the previous administration? In a word, yes. Let's count the ineptitude.

1. The U.S. has now revoked the traveling visa for the underwear bomber Umar Farouk Abdulmutallab. Of course the U.K. had refused to grant him a visa to travel there because of security risks but we thought he'd be alright to come here.

2. The president said he will stop sending Guatanamo Bay prisoners to Yemen. Gee, what were we thinking transferring dangerous jihadists to an unsettled Middle Eastern country.

3. All the missed warning signs before the bomber got on the plane, such as a heads up from the bomber's own FATHER, one way plane ticket bought with cash, and NO passport. Now the president said we failed to connect the dots in intelligence. Hmm, you think? This is the exact same excuse used by the Bush administration, "It's not our fault we went into Iraq, intelligence failed us on locating WMD's."

4. The president now wants all of us to be vigilant for suspicious activity. If we are all supposed to be watching out for our own safety then maybe we can stop spending billions of dollars on dubious screening protocols such as patting down four year olds and octogenarians at the airport. Though politically incorrect, a little profiling might be in order to reduce the inefficiency of screening every person that travels through the airport, no matter how unlikely they are to be suspects. That's what the public will do if we are supposed to be looking out for ourselves.

Yes running a country is hard, especially when you have crazy nutballs trying to blow themselves up in your territory every chance they get. But you would have thought this administration had learned some lessons from the previous one. Despite all the rhetoric during the election about how he would run the intelligence community differently if he became president, there doesn't appear to be any difference in security threats to the U.S. The public is still aggravated by all the same nuisances when traveling, the increasingly bloody and quixotic foreign wars, and the billions of dollars spent on security with no discernible difference in our safety. This is some change.

Tuesday, January 5, 2010

Return Of The Empire

Remember your civics class in school where you learned how a bill becomes a law? It seemed so simple back then. Congress sees a need for a new law. A bill is written up. The Congress then votes for it. They hold hands, sing Kumbaya, and send the bill to the president to be signed into law. Simple right?

Now it is so complicated. With all the filibusters, nuclear options, ping ponging, it's no wonder few things get done in Washington. The House of Representatives is likely to bring up this week the health care bill that was passed by the Senate. They'll make their changes and ping it to the Senate. The Senate will make further revisions and pong it back to the House. Back and forth until the grand Obamacare plan is finalized. Forget about debate or objections. Changes to fifteen percent of the U.S. economy is being executed in the name of efficiency to allow the president to present his singular (truly singular) achievement in office during his State of the Union speech. This is almost like the old Soviet Union empire, with entire industries being dictated by a privileged few at the top of the government. Yes we won the Cold War but we took the enemies' ideology and transplanted it here. Sigh.

For a reminder of simpler times, for your pleasure, you can watch a video of how a bill is supposed to become law.

What Is This?

We take a lot of surveys and inspections in our hospital. I found this binder at the nurses' station. Interesting title. Can you guess what this audit is all about?

Sunday, January 3, 2010

Wack A Qaeda

The U.S. and U.K. are now preparing more antiterrorism activity in the country of Yemen. That is supposedly where the underwear bomber got his training. Does anybody else get the feeling we are just following the terrorists from one country to another? First it was Kenya. Then after 9/11 Afghanistan was the center of terrorism activity. We went in there and pushed the bad guys out to Pakistan, where bin Laden supposedly still props up his feet. Now we are chasing them down in Yemen. This reminds me of the old carnival game Wack a Mole. We push them down in one area and they pop out somewhere else. And like that game, victory is elusive.

There is also more grumbling about the TSA's new too little too late rules for flying. It was bad enough after 9/11 that you could no longer park next to the curb at the airport to pick up grandma for the holidays without some security guy harrassing you to move on. Or that you had to lug your heavy bags from the check in counter to the TSA screening machine when you check your luggage. Or that after the shoe bomber you had to take your shoes off at security and walk on those disgusting seldom cleaned airport floors. Or that you couldn't accompany a relative to the terminal for takeoff or wait for them there when they arrive. (The airport scene in Sleepless in Seattle seems quite quaint now.)

Now read about all the ridiculous new rules the TSA has imposed on travelers flying into the U.S. Are we really safer when we can't use our electronic devices one hour from landing? Or use the bathroom? Or being frisked by some total stranger who probably got his TSA job because his parole officer knew somebody at airport security? When the underwear bomber was able to get on an airplane in Amsterdam without a passport, paid for a one way ticket to the U.S. with cash, and checked in no luggage for an international flight and still wasn't stopped by security, how are these new rules supposed to make us safer? If President Obama could somehow make flying more civilized again, he would see an immediate 10-20 point boost in his popularity, guaranteed.


There's a new weight loss surgery currently in clinical trials that promises to turn bariatric surgery into an outpatient procedure. While the current technology in laparoscopic gastric bypass allows a patient to go home after a couple of days in the hospital, the new transoral gastroplasty is performed as an outpatient procedure. And unlike laparoscopic gastric banding, TOGAs require no skin incision; everything is performed endoscopically.

The question for anesthesiologists is the acceptability of having morbidly obese patients as outpatients. When a procedure is considered so inconsequential that it can be performed in a surgery center setting will the patient have the proper medical workup? Will there be proper lab work prepared? Will there be an ECG and stress test? What about the facility? Will there be equipment for difficult airways? How will DVT prophylaxis be administered? Will there be pressure on the anesthesiologist to perform a MAC instead of GA since the TOGA is essentially just an EGD procedure? I've worked in surgery center settings where the preop workup was essentially nil. The workday becomes a factory line, get the patient on the table and off to recovery as fast as possible, regardless of any comorbidities.

There is also talk that the procedure could eventually be performed not out of medical necessity but for vanity. Seems like everybody I know has an extra 20 to 30 pounds they would like to lose. You could take a day off from work, any excuse will do, and head to the surgery center to have the surgery. Since there is no incision nobody would ever know. It would be similar to having a screening colonoscopy or a LASIK operation. I'm sure the plastic surgeons are salivating at the chance to perform another all cash operation, since the use of bariatric surgery in non morbidly obese patients would not be covered by insurance.

Saturday, January 2, 2010

Life Lessons from Dr. Seuss

I've read hundreds of books to my kids. Some books I feel like I've read hundreds of times. One of my favorite books is "Oh, the Places You'll Go!" by Dr. Seuss. I would rank this book in his top three, right up there with "The Cat in the Hat" and "Green Eggs and Ham". It was the last book he wrote before he died, being published in 1990. And it is unlike many of his previous books.

"Oh, the Places You'll Go!" is a book about life and the choices we make. Here he returns to basic story storytelling. It forsakes almost all the gibberish that marred his later publications, which depended heavily on make believe words strictly for the purpose of forming a nonsensical rhyme, like "Gox" or "Yink" or "Gack" (All from "one fish two fish red fish blue fish" one of my least favorite Dr. Seuss books) From the very beginning it doesn't read like a children's book. Mature messages include passages like

"You have brains in your head.
You have feet in your shoes.

You can steer yourself

any direction you choose.
You're on your own. And you know what you know.

And YOU are the guy who'll decide where to go

The book appears to foretell the travails of celebrity and warns of hubris and conceit.

"Oh, the places you'll go! There is fun to be done!
There are points to be scored. There are games to be won.
And the magical things you can do with that ball
will make you the winning-est winner of all.
Fame! You'll be famous as famous can be,
with the whole wide world watching you win on TV."

I used to think that page was about Michael Jordan, especially since 1990 was about the time when Jordan was at his peak. The illustration that goes with that page also shows a boy kicking a ball toward a distant basket. But now, I think the page is more appropriately about Tiger Woods. Because the very next page has this:

"Except when they don't.
Because, sometimes, they won't.
I'm afraid that some times
you'll play lonely games too.
Games you can't win
'cause you'll play against you."

Deep huh? Definitely not your typical elementary school book. This book has lessons that everyone can learn from. So as we start out a new year and new decade, pick up a copy of this book from the bookstore or library. Read what Dr. Seuss says about life, it's triumphs and challenges. And I'll close with a hopeful message from the end of the book:

"And will you succeed?
Yes! You will, indeed!
(98 and 3/4 percent guaranteed.)

Have a happy and prosperous new year (with or without health care reform).

Friday, January 1, 2010

New Year, New Diets

Just in time for New Year's. We all know about the Subway sandwich diet, featuring the ubiquitous Jerrod Fogle. Then I recently blogged about the cookie diet. With the cookie diet, you eat 4-6 specially prepared cookies a day and magically lose the weight you want. Too bad the cookies aren't Mrs. Field's white chocolate with macadamia nuts.

Now comes two more diets making the rounds. Both diets seem extremely far fetched and each is gross in its own way. First there is the Taco Bell Drive-Thru diet. Here a woman named Christine claims in the Taco Bell commercials that she lost 54 pounds in two years eating food from the fast food joint (I hesitate to call it a restaurant). The monotony of it alone would bore my tongue to death and cause me to lose weight.

Then there is the even more extreme tapeworm diet. Featured in an episode of the Tyra Banks Show, this is a very pathologic way of losing weight. Tapeworms have troubled mankind for all of history. Millions have probably died from malnutrition, bowel obstruction, and other ailments because of the tapeworm. And now people are willingly ingesting the worm's eggs in order to take off the pounds. Yew!