Sunday, February 28, 2010

Tsunami! Not.

We had a tsunami warning here in Southern Cal yesterday due to that awful 8.8 magnitude earthquake in Chile. Of course like morons who run towards a fire to watch its destructive powers, the hordes were amassed at the beaches to watch the tsunami. They were disappointed. The tide was less than three feet high. Most people didn't even know it had come and gone. The above picture is a cool graphic of the height of the expected tsunami across the Pacific Ocean.

Wednesday, February 24, 2010

A Life Saved By D-Cups

An LA area woman's life was saved when she was shot in the chest and the bullet's energy was dispersed by her large breast implants. Lydia Carranza was at her dental appointment last year when a gunman barged in and killed his wife, an employee at the office, after she filed for divorce. He then proceeded to fire his semiautomatic rifle around the room. He aimed his gun point blank at Ms. Carranza's chest. Luckily for her, the bullet went through one of her implants and stopped short of her heart. Point blank from a semiautomatic rifle and the bullet still stopped short of the heart? Sounds better than Kevlar.

Ms. Carranza's tissue wound has now healed but she needs to replace her breast implant. Her Beverly Hills plastic surgeon is asking her to publicize her story in the hopes she can get donations to help pay for the implants.

Tuesday, February 23, 2010

Pigs In The O.R.

Recently a group of surgeons from a surgery center hired away one of our bright young female anesthesiologists, Dr. A. It was a real loss to our group. She was smart, energetic, and a darn good physician. She could handle anything in the operating room. But when she started having children she wanted more predictable work hours, which they could offer in an outpatient setting.

I asked one of the surgeons the other day how Dr. A was doing. How does she like her new work? She loves it, he said. She is fitting in great. I then inquired why they didn't hire one of our more experienced anesthesiologists, like Dr. V. The surgeon looked at me in total disbelief. Are you kidding me, he asked. Look at her. She is so dour and stubborn. Dr. A is so pretty and has such a great personality. All the patients and staff love her.

So let me get this straight. You hire an anesthesiologist not because she is competent or has great intellect. You recruit her to be eye candy for the patients and surgeons. Oink oink.

Monday, February 22, 2010

Health Insurance vs. Cell Phone

Recently an uninsured patient was about to be discharged home. He was admitted for observation from the Emergency Room for abdominal pains. Before leaving he requested to have his medical marijuana prescription refilled. I wondered how he could afford marijuana but didn't have the funds to buy health insurance.

If you look at the typical indigent population, they may not have health insurance but they surely have cell phones or ipods. Some have brought their kids who are playing intently on their Nintendo DS. Before electronics people who did not have enough money for health insurance were out purchasing expensive cigarette and alcohol habits.

All this comes to mind because the health care debate still focuses on people being required to buy health insurance. If they can't afford it the government will give them money to buy it. Where do you think the money will come from? People don't buy insurance not because they can't afford to; they don't because it is a low priority in their lives. They would rather give up health insurance than their nights out to dinner and a rave party, or their cable tv, or their cell phones, or on and on. So the government will in essence subsidize these people's leisure and drug habits while the rest of us face ever higher health premiums. Welcome to Socialist America.

Tuesday, February 16, 2010

Going Through House Shopping Hell With A Realtor Devil

My mind hasn't been concentrating too much lately on this blog. You see, my wife and I have been in deep negotiations to purchase a house in the past month. We thought it was the perfect house (notice the past tense). Great school district, great floor plan, and killer views from every room. It was also a short sale. It was not cheap for a short sale as the owner took out a huge chunk of money a couple of years ago during the real estate fantasy bubble. Now he is divorced and the economy has done a number on his business. He can't afford to pay back the bank (one of the bailed out financial institutions). So we gave what we thought was a fair, though not cheap, offer and the seller accepted.

If anybody has ever gone through a short sale you know the buying process is not routine. Just because the seller accepts the price doesn't mean the bank, who owns the deed, will. Despite a program the bank instituted to expedite short sales, it still took a couple of weeks to get full approval. Then there were legal complications because of his divorce (the wife was still living in the house rent free and didn't want to move out). In the meantime the seller's realtor assured us we had the highest offer and he wasn't entertaining any other offers because the seller wanted to sell ASAP and stop making payments on his overdue mortgage.

Whenever the realtor or the bank needed us, we dropped everything to get it done. Need a signature? We're there. Need proof of financing? When can we fax it to you? We jumped through so many hoops to get this done. Here in Southern California it is virtually impossible to buy a nice house using conforming loans so jumbo loans are a must. And these days, banks are not willing to do jumbo loans without full documentation plus the blood of your first born, and possibly second born child. Down payment? Check. Credit rating adequate? Check. Proof of every last cent you own in this world? Got it.

Then last night we thought we finally got everything covered. We signed the last contract the bank sent to us that agreed to the short sale. At around 5:00 our realtor faxed the papers to their realtor. We thought we had finally started our escrow process. We started planning for the children's room, the housewarming party, where the big screen TV with Blu Ray and surround sound I was planning on getting this Christmas would look the best.

Suddenly at 7:00 we got a call from our realtor with devastating news. The seller had received two more offers, both higher than ours, and both ALL CASH. My head was spinning from this sudden turn of events. There was no way we could win a bidding war when the other party can offer all cash up front. My first reaction was disappointment, naturally. But my second reaction was pure white hot anger at the seller's agent. Despite his previous statement to us that he and the seller were not interested in soliciting other bidders, he obviously had been shopping our offer around this past weekend. There is no other explanation for the magical appearance of other buyers right at the last second.

I tried to console myself and my wife that this is just business. It's all about money. It's not personal. The seller has every right to seek higher offers for his house. According to the National Association of Realtors Code of Ethics, "When acting as listing brokers, Realtors shall continue to submit to the seller/landlord all offers and counter-offers until closing or execution of a lease unless the seller/landlord has waived this obligation in writing." It happens all the time on eBay, where you think you have the highest offer and with 30 seconds to go before the auction ends an anonymous buyer swoops in and grabs your prized Colecovision game cartridge from you. It sucks then and it really sucks now. But I can't help but feel misled by the whole process, the seller, his realtor, and the bank. We think this prolonged ordeal was done just to give the bank and seller more time to search for other buyers. We were too innocent to realize that wolves were circling around the house we thought was ours and they were abetted by the realtor.

We are so disgusted by this entire process that we have temporarily stopped searching for a house. And I'm not sure that if we do find another house we like as much we would feel comfortable with the entire process until the keys are actually in our hands. Who said there is a real estate slump in this country?

This also puts into crystal clear perspective the status of physicians in this country. We are at best upper middle class in stature. On the coasts, we're just barely considered middle class. There are millions of other people in this country who make more money than us and whose incomes are not dictated by some anonymous government agency working in the bowels of Washington far removed from the actual work of patient care.

Friday, February 12, 2010

Star Wars Is Here

The Defense Department has successfully tested an airborne laser system. Shot from a Boeing 747, the basketball sized (!) laser was able to shoot down a missile in midair (cool picture above). X-wing fighters here we come.

Thursday, February 11, 2010

Show Me The Money

Senator Harry Reid has eliminated the provision for delaying a 21% cut in Medicare reimbursements to doctors that is to take effect March 1. The cuts were supposed to be put off until September in order for Congress to figure out how they are going to pay all the rich doctors and hospitals. But the Majority Leader wanted to streamline the jobs bill in which the Medicare provision had been inserted in an attempt to facilitate its passage.

Again this just goes to show how little clout doctors and the AMA have in Congress. When special interests for lawyers donate millions of dollars more than doctors, hospitals, pharmaceuticals, and device makers combined, there is little hope physicians' voices will be heard. Is permanent reprieve from the SGR formula in Medicare important to you? Is medical malpractice reform a priority? Then you better have contributed to your medical society's PAC. I know I have. Because in Washington the only thing they pay attention to is who gives the biggest s***load of money to their reelection committees. Just joining a medical society is not enough. Writing letters may count in a quaint Mr. Smith Goes To Washington way. But ultimately it's all about the Benjamins. Sad but true.

Wednesday, February 10, 2010

Grey's Anatomy School of Medicine

I normally don't watch medical dreck on TV. But recently there was an episode of Grey's Anatomy that featured a patient with surgical recall. What brought this to my attention was a patient over the weekend who was extremely anxious about his surgery. After I introduced myself in preop the first thing he asked me was what I am going to do to prevent him from remembering his surgery. I asked him why he was so apprehensive about recall. He said he was watching Grey's Anatomy which showed a patient who remembered his whole surgery but was unable to call for help. Then our preop nurse helpfully chimed in and said she saw it on TV too. Sigh.

I tried to explain to the patient that the reason TV shows like to use surgical recall as a plot line is because it is such a rare occurrence. That's why it is so sensational (in a yellow journalism way) if it does happen. The patient then said he had Googled surgical recall and cited multiple reports. I asked him if he believed everything he read on the internet. He said yes. Uh huh. He also saw an episode on the Discovery Channel that highlighted recall. Again the preop nurse said she saw that too. Grrr. Again I tried to reassure the patient that surgical recall is extremely rare and we use BIS monitors to help decrease the incidence of recall. This finally relaxed the patient. He had read about BIS on the internet and wanted to make sure we use it in our operating rooms.

This goes to show the power of popular entertainment. People actually think they are getting a medical education from watching shows like Grey's Anatomy, House, ER, CSI, etc... The ASA was aware that this episode of G.A. was going to air and wrote a letter to the producers of the show. They were soundly ignored and the show aired anyway. I don't have time to watch shows like this. After going through medical school I can't watch medical shows anymore. I used to like M*A*S*H or St. Elsewhere but now all I see are flaws in their medical presentation and it ruins the whole experience. As an example there was an episode of M*A*S*H where they were in the OR. The surgeon goes over to the wall to look at an X-ray hanging on the light box. If you didn't know better it looked like a normal chest film. But it was very clear the film had the prominent breast shadows of a female patient; I don't think they allowed women in combat during the Korean War.

I'll admit I have not seen this episode of Grey's Anatomy, or any episodes for that matter. I normally try not to criticize something I haven't personally seen or heard. I'll try to catch it on Hulu if I have a chance, after catching up on my American Idol.

Tuesday, February 9, 2010

Humor In The Court Room

At the arraignment of Dr. Conrad Murray, the final coroner's report was released. An anesthesiologist consultant emphasized on the report that "There are NO reports of [propofol's] use for insomnia relief, to my knowledge," wrote Selma Calmes. Substances found in Michael Jackson's system included propofol, diazepam, lorazepam, and midazolam. The amount of propofol in his blood stream was declared enough to conduct major intra-abdominal surgery using only propofol IV anesthesia.

Besides administering propofol outside a hospital setting, the medical equipment in Michael's bedroom was practically nonexistent. An O2 cylinder was empty. There were no monitors or propofol infusion pumps available. Wrote Dr. (?) Calmes, "The only reports of its use in homes are cases of fatal abuse (first reported in 1992), suicide, murder and accident. Because of the risks associated with the drug, it should be administered only by anesthesiologists or other supervised anesthesia providers, trained to recognize respiratory or cardiac problems that can arise." Sounds like something straight out of the ASA practice guidelines.

When Dr. Murray was released on bail, the judge specifically forbade him from prescribing propofol or other sedatives. Says Los Angeles County Superior Court Judge Keith L. Schwartz, "I don't want you sedating people." Ha ha. Who says judges don't have a sense of humor.

Irony in Health Care Debate

The Obama Administration is investigating the large premium hikes instituted by Blue Cross here in California. The insurance company is raising premiums on its individual policy holders an average of 39%. Now everybody is now up in arms.

Of course the irony of this situation is that the health care reform bill being pushed by Congressional Democrats and the President requires that everybody in the country buy health insurance from one of these private insurance companies. When insurance companies are not allowed to raise premiums on the sick or deny coverage for those with preexisting conditions, you better believe everybody's premiums will rise. And there is no insurance regulation in the bill that would limit the amount of price inflation the companies can institute. No one envisions regulating insurance companies like electric utilities.

Ultimately the government will wind up paying so much money to subsidize the American public to help them buy insurance that the whole enterprise will collapse. Then people will realize that the single payer system is the only alternative to a for-profit insurance industry. The insurance companies will then be reduced to selling supplemental insurance policies, like they already do for Medicare recipients, which they do quite profitably.

Monday, February 8, 2010

He's Back

Conrad Murray, Michael Jackson's personal physician and alleged murderer, was charged with manslaughter today. Manslaughter, the unlawful killing of a fellow human being without malice or intent, carries at most a four year prison sentence. The doctor pleaded not guilty. It is widely reported that the Jackson family is outraged at this light charge.

The LA Times has a nice background on Dr. Murray. He was born in Grenada and his Caribbean accident enchanted MJ. He was in financial difficulties when he was hired by Mr. Jackson. Dr. Murray is supposedly supporting six children, two of which are with his wife. The youngest of his illegitimate children was born just last March in Santa Monica. He owed $1.7 million on his country club house that is now assessed at $1.08 million. He also was in debt of $435,000 to his creditors and student loans.

He is praised by his patients for excellent bedside manners. He blames his financial predicament on treating poor patients in Houston two days a month. He reportedly asked Michael for $5 million to be his personal physician during the "This Is It" concert tour. Michael insisted on having Dr. Murray accompany him to London despite urging by the tour company to use local doctors. The agreed salary was $150,000 a month. Michael had the last laugh though. He never signed Dr. Murray's employment contract. Now he is s*** up the creek and he didn't get a single dime out of this whole fiasco.

That's what happens when you use a doctor who is not invested in your health but in his own wallet.

News From The ASA

I noticed a couple of interesting items in the current issue of the ASA Newsletter. One, the tenth anniversary of MOCA is upon us. The year 2000 was the first year the ASA started granting time limited board certification. All the anesthesiologists who finished their residencies before then can coast to their retirement without taking another freaking exam. But the rest of us have board certificates that expire every ten years. This being the tenth year, all those anesthesiologists are required to pass their recertification before January 2011. The ASA lets you take the recert exam starting in year 7, assuming you've accumulated enough CME credits. This gives the anesthesiologist at least three chances to pass the test.

According to the ASA statistic, only 60% of the class of 2000 have passed the exam so far. The other 40% have only one opportunity left this year to take it. Hmm, I think we have a huge class of procrastinators out there. Luckily the pass rate so far has been greater than 90%.

The other article that caught my eye was a letter from a group of anesthesiologists in Boston. They advocate using a transparent ether screen (blood-brain barrier) in the operating room. They say the ability of for the surgeon to see the anesthesiologist working diligently in the OR promotes safety and cooperation with the OR staff.

I don't know about this suggestion. It's bad enough when surgeons peer over the screen to tell me how to conduct my anesthetic. I couldn't imagine how intrusive the surgeons will be if they can see into my workspace. Plus, when will I have a chance to eat my bologne sandwich in the middle of an eight hour case if they are always watching my every move?

Thursday, February 4, 2010

Beware Naked Man With Marijuana

A U.S.Airways flight from Philadelphia to Los Angeles was diverted to Pittsburgh when a passenger became unruly after taking too much medical marijuana. Kinman Chan went into the plane's restroom after takeoff and started screaming. If that wasn't concerning enough, he emerged with his pants down and shirt untucked. When told to sit down he became combative and had to be subdued with a choke hold.

Mr. Chan's excuse was that he took double his usual dose of medical marijuana cookies he had with him. The U.S. attorney's office in Pittsburgh examined his medical marijuana prescription and agreed he had a "legitimate" health issue for taking the drug.

This raises some interesting questions. If Mr. Chan took double the normal dose, does that imply there is a standard dose of marijuana? Is a medical marijuana prescription written in a state that allows the stuff (California) legally recognized in other states that don't (most of the U.S.)? Even though the the DEA has never recognized the legitimacy of medical marijuana, which it still considers an illegal substance, can the U.S. attorney claim a person has a legitimate health reason for taking it? If marijuana is legalized in more states, will we have an epidemic of naked men, or women, running amok in society? Where's President Obama's wisdom when we need it the most?

Wednesday, February 3, 2010

When Less Is More and More Is More

Will people really take better care of themselves if they were forced to pay more out of pocket health expenses? That has been the knock against insurance policies that shield people from the actual cost of their health care. In an article published in the New England Journal of Medicine, researchers have refuted that notion.

In the research that looked at Medicare recipients, they studied the effects of increasing copays on patients and their well being. They discovered that patients who had higher copays wound up using fewer outpatient services, had more hospital admissions, and longer hospital stays. They conclude that patients refuse to pay more for their care therefore they bypass routine health maintenance and wind up being hospitalized more frequently.

So this raises a perplexing problem. Trying to lower the cost of health insurance by making everybody pay higher out of pocket expenses winds up costing more money in the long run with increased hospitalizations. But if you lower the cost of health insurance to, let's say free, you also make the system more expensive as more people will abuse the system.

I'm just a poor anesthesiologist. I have no idea how we are going to get ourselves out of this conundrum. If you have any brilliant insights, I hear they need a few in Washington.

Why We Need Anesthesiologists

I'm scheduled to give anesthesia for a PEG. The patient has been having recurrent aspiration. In preop the patient was breathing about 40 times per minute. Room air O2 sat was 89%. "This doesn't look optimal for a MAC anesthesia," I thought. I start looking through her chart.

In the H+P in the very first paragraph the physician had dictated that the patient had a complete esophagectomy last year. Huh? WTF. She's scheduled for a PEG? Her GI doctor walks in. "Are we ready to get the patient into the room?" he inquires. "Uh, Dr. GI, did you know she had a total esophagectomy last year? Does she have a colon interposition or gastric pull up?" I asked. "Really, she had an esophagectomy? I didn't even know that," he replies stunned.

There is no mention of the type of esophagectomy in the H+P so we look at her CT scan. "Esophagectomy with gastric pull up" is what the radiologist dictated. "So Dr. GI, do you plan on putting the PEG through the patient's left ventricle?" Clearly embarrassed Dr. GI replies, "God I feel like such a bonehead. I'm going to schedule her with interventional radiology to get her feeding tube in. Thank you for looking out for my patient."

"Just doing my job Dr. GI." And that's why we need anesthesiologists.