The Truth And Nothing But

I met the nervous young patient in preop.  She was fidgeting in bed, having a difficult time laying still.  Her anxiety was extreme.  Her friend next to her attempted to calm her down, "Don't worry.  Everything will be fine."  But the patient was not easily soothed.  She pulled her blanket up to her face, almost covering her eyes.

I introduced myself.  She had a million questions about her anesthesia.  "Will I be awake or asleep?"  "Will I remember anything?"  "How will you know if I'm not completely out?"  On and on.  I was starting to get irritated.  It's nice when patients have questions about their medical care but sometimes my patience can run a bit short if they come at me like an interrogation session at Guantanamo Bay.

Finally she asked the money question, "What happens if I don't wake up?"  To which I replied with a wink and a smile, "Well, then you'll never know, will you."  They both gasped in shock.  Then her friend cracked up hysterically.  The patient was not as amused.  I explained that my job was to be in the operating room to make sure everything will be okay.  The operating room is filled with equipment to ensure the safety of the patient; we are not giving anesthesia in somebody's private bedroom.  She smiled just a little bit. "Are you ready to get started?" "Yeah"  "Okay, then let's go."

Say Hello To My Little Friend

Can you believe this?  This is an adaptation of "Scarface" for an elementary school play.  In some ways it's kind of awesome.  But watching those kids shoot each other with toy machine guns and shouting "motherfudgers" at each other is pretty disturbing.  I'm not sure I would hoot and holler for the kids like the parents do at the end of the scene.  Who needs counseling more, the teacher/director, the parents, or the kids?

Georgia Malpractice Cap Struck Down

The Georgia Supreme Court overturned a medical malpractice reform law that capped non-economic damages at $350,000. The case involved a plastic surgery procedure gone awry. A jury founded for the plaintiffs and awarded them over $1 million. Because of the law they were able to collect "only" $350k plus medical expenses. The plaintiffs argued that they did not get a trial by jury because the law overturned the jury's decision in handing out compensation. Unfortunately the Georgia Supreme Court agreed.

It seems to me that the plaintiffs did in fact get a jury trial and they won the lawsuit. Just because the runaway jury awarded them a lottery jackpot doesn't mean that justice wasn't served. The law was passed to prevent vindictive juries like this from handing out unreasonably large malpractice awards. Maybe the plaintiffs would receive more of the award if their lawyers didn't take 30-40% of the money off the top. All you poor Georgian physicians. Get ready to watch a flood of malpractice suits washing over your practices while your insurance premiums skyrocket. I hear Texas is nice this time of the year.

Springtime At The Huntington Library

One of my favorite places in Los Angeles is the Huntington Library in the suburb of San Marino. And one of the best times of the year to go is spring. So unfortunately we picked this weekend to go see the gardens of the Huntington which happened to be the hottest weekend of the year so far. The library grounds sit in a large topographic depression. Thus there is little breeze to cool the air. It is also extremely large, covering over 120 acres. You can walk around for hours in stifling temperatures to see all the different gardens spread out around the place. But as you can see by the pictures it was well worth the effort. The blossoming flowers are breathtaking this time of the year.

Huntington Library also has a large art gallery. Some of their most famous paintings include The Blue Boy by Thomas Gainsborough and Pinkie by Sir Thomas Lawrence. However in my opinion the best part of their collection is their rare books department. I always get a kick out of taking visitors there, especially book lovers, as they come face to face with an original Gutenberg Bible or first editions of William Shakespeare's plays. Books that you've only read about are right there, close enough to touch. But of course you can't.

Perhaps the reason I love Huntington Library so much is because of something purely personal; I proposed to my wife there. If any of you have ever seen the move "The Wedding Planner" with Jennifer Lopez and Matthew McCaughnehey, the scene where they are desecrating a stone statue was filmed at the Huntington. The stone bench by the statue where the two actors are sitting was where we sat when I proposed. Of course I didn't know it at the time but I recognized it when I saw the movie on cable later on. So from then on, if our friends ask us where we got engaged, we tell them to rent "The Wedding Planner" and fast forward to the scene where J. Lo is pulling off a piece of a statue's anatomy. That always gets a good laugh.

Tho$e Were The Day$

Can Medicare and insurance reimbursements possibly get much worse in this country? Of course it can. Listening to some older colleagues who have lived through previous government intervention into medicine, they think in five to ten years physician income will drop another 25%. They remember back before the early 1990's anesthesiologists were easily making $800k to $1 million working 40-50 hours per week. That was when gasoline was $1.25 per gallon and a nice house in Beverly Hills cost less than a million. Now most anesthesiologists work like dogs to make half that amount if they are lucky.

Even if there is no actual cut in reimbursement, the likelihood of our incomes keeping up with inflation is remote. While government service workers get annual cost of living adjustments to their paychecks, we consider ourselves lucky if Medicare just pays us the same amount every year. The AMA would declare victory if they can prevent the 21% slashing of Medicare reimbursements that is now due in October. But that is not exactly the same thing as receiving a cost of living inflation raise is it? If our income just holds steady for the next ten years, our inflation adjusted income will have dropped at least 25%, depending on the inflation rate in the next decade.

ObamaCare makes American medicine more and more like a losing proposition for our best and brightest students. Massive Medicare cuts to doctors and hospitals, millions more patients paying Medicaid rates, no medical malpractice reform in sight, and truly soul-breaking student loan debt at the end of residency will only drive our smartest kids away. Becoming a physician used to be an aspirational endeavor, and part of that is the high steady income doctors make. Let's face it, people hold high income earners in greater esteem than low income earners. Why do we idolize Bill Gates or Warren Buffett? They make a lot of money. Ask yourself, what has Warren Buffett done for you lately? Yet people consider him some sort of guru while the doctor who takes care of their sick children are derided on Angie's List.

I've wondered if there is a corollary between declining physician incomes and the increasing lack of respect shown by patients to their doctors. Eventually will patients see us as just another service worker paid to take care of their needs, like their local auto mechanic or cabinet installer? The day is coming when all these factors will stop innovative American medicine in its tracks and we'll all be just government drones clocking in at 8:00 and skedaddling to the parking lot by 4:00, regardless of how long the line is in the reception room. There will be no more incentive to work harder to make medicine one of the few success stories America has against the world.

D-Day For American Medicine

March 21, 2010

If ObamaCare passes Congress today, this will be the beginning of the decline and fall of American medicine as we know it. As Stanley Tucci warns in The Devil Wears Prada, "Gird your loins!" and your wallets too.

Cholecystectomies By The Fireplace, Herniorrhaphies In The Dining Room

Dr. Roberto Bonilla of Inglewood, CA was charged with involuntary manslaughter in the death of a patient when he attempted to perform a cholecystectomy in a medical office converted from a residential home. The doctor, with a degree from Autonomous University of Guadalajara Faculty of Medicine, took $3000 from the patient to perform the surgery.

When paramedics arrived after the patient died and the family called 911, they found the patient had a 4 inch incision in his abdomen and bleeding from the nose. The doctor's attorney claimed the patient died from an allergic reaction to the anesthesia. The DA's office says three expert opinions determined the patient died from an overdose of local anesthetic, thus the inability to resuscitate the man after he went into cardiac arrest.

Again, why do people think it's easy to perform anesthesia? Just because anesthesiologists make it look effortless doesn't mean anybody, even with an MD degree, can do it. Judging from the article, this "surgeon" attempted to perform an open cholecystectomy under local/MAC. Unless he was extremely skilled at placing a regional block for a cholecystectomy, it's unlikely he could have successfully completed the operation, even if he did have all the proper monitoring and resuscitation equipment in that operating room/house. If surgeons want to perform anesthesia, they should go through an anesthesiology residency training and learn the proper way to administer it, not tell an assistant to push more propofol or give him more local. When will they ever learn?

Giant Robots

Cool pictures of giant robots from around the world. They're no longer confined to your favorite Transformers cartoons. Now you can reach out and touch one. Awesome.

Anesthesia Eponyms

I am not one of the lucky anesthesiologists with a perpetual unlimited anesthesia board certificate. I recently had to take my board recertification exam. While reviewing my old textbooks (thank goodness I kept a few of them from residency) and sample questions, I made a list of some anesthesia related eponyms I came across that would have been fun morning rounds pimp questions. I didn't recall the definitions for some of them but they were good to relearn and promptly reforget hours after the exam was over. So if you're bored out of your mind right now in the middle of a ten hour breast reconstruction case you might look these up and learn something.

1. Schimmelbusch mask
2. Thorpe tube
3. Quincy tonsil
4. Biot's ventilation
5. Scultetus position
6. Pores of Kohn
7. Molteno valve
8. Melzack-Wall gate control theory
9. Hering-Breuer reflex
10. Barlow's syndrome

Have fun! Or not. BTW I passed my board recert. No more recertification exam for another ten years. Hooray! Congratulatory ecards accepted.

Thalidomide

Check out a fascinating article in the New York Times on current research into the infamous drug thalidomide. Yes we were all fed the information in medical school that thalidomide should not be given in pregnancy due to horrible birth defects fifty years ago. But like so many questions that were left unanswered while we were students, nobody ever told us why it happened. As it turns out nobody else knew the reasons either. Now there has been really interesting research on the effects of thalidomide and limb formation in embryos.

When you think about it there is very little we know in medicine. Any five year old will ask ad nauseum "why" until you are unable to come up with a reasonable answer. But in medical school we are force fed information with very little time for introspection. We are just supposed to accept information as they are given, whether they are factual or theoretical. Therefore fundamental presumptions about subjects such as why we age, what causes cancer, how anesthesia works, are regurgitated as facts when in fact we have no clue, yet. It's good to see hard working people still searching for the truth in medicine.

Aspiration, How Real Is It?

After years of anesthesia practice and thousands of cases of anesthetics, I've found that the risk of aspiration is much less than what was preached in residency. Let me explain. Most of my cases involve outpatient procedures, mostly GI endoscopies. There have been many cases where after an upper endoscope was inserted, the stomach was found to be filled with hundreds of cc's of fluid and/or food, despite the patient being NPO overnight. Usually the reason is the patient is diabetic with gastroparesis, or the patient is on high dose narcotics for some chronic pain condition (being scoped for abdominal pain of unclear etiology).

Even with a full stomach, the patient rarely if ever vomits despite the scope instilling hundreds of cc's of air. The endoscopist just suctions out the fluid, sometimes requiring two cannisters to contain all the contents, then proceeds with the procedure. If there is food matter that can't be suctioned, it is left in place in the stomach, It usually adheres to the stomach wall and doesn't regurgitate up the esophagus.

I've only had one case of significant aspiration of stomach content during an endoscopy. That was in a patient who was being scoped by a GI fellow. His technique was less than slick. After much fumbling around in the mouth and esophagus, gastric contents started pouring out. We quickly placed cricoid pressure and proceeded with a rapid sequence intubation. I was able to suction much of the gastric fluids out of the bronchial tree with the aid of a fiberoptic scope and the patient did fine afterwards.

I wonder what has been the experience of other anesthesiologists in regards to the risk of aspiration in upper endoscopies. Have others made similar observations in their practices?

Eight Track Is Back, Maybe

On a subject that has nothing to do with anesthesia or medicine but brings back fond personal memories, there is a cool article in the Wall Street Journal today about a guy who has amassed a 2000+ collection of 8 track tapes. Mr. James "Bucks" Burnett first started collecting 8 tracks after finding a Beatles White Album in that format at a flea market. He eventually was able gather all the Beatles on 8 track tapes after twenty years, collecting other artists along the way. That to me is AWESOME. I am a huge Beatles fan and I didn't even consider that their music was published in 8 track format. Everybody talks about collecting vinyl but I've never seen them on 8 track.

My brother had an 8 track player in his alarm clock when we were growing up. It was the only such player in the house. I remember how annoying it was when you wanted to hear a certain song but the only way to fast forward was to advance up to one of the four predetermined stops in the tape. If the song was in the middle of that segment you had to wait for it. I think that was one reason the cassette tape was so much superior. As a kid I wanted one of those hi-fi quadrophonic systems that incorporated a record player, AM/FM radio, cassette player, and 8 track tape player, usually made by Zenith or Marantz or Fisher. We wanted our dad to buy an Oldsmobile that had an 8 track player along with CB radio. We envied the kids who could talk to truckers on the road who were fluent in CB chat (Breaker 1-9, Breaker 1-9. That's a 10-4 good buddy). He bought a VW Bus instead.

Ah, good times.

Stop The Madness

I think there are departments in our hospital whose only jobs are to come up with new rules and regulations to drive the rest of us working stiffs to insanity. Take for instance these two sharps boxes. Well one of them isn't really a sharps box. Can you tell which is which? According to the new rules, any syringes with unused drugs are supposed to go into the white box. But only the syringes. The needle on the syringe is supposed to go into the red box. Any drugs inside the syringe are supposed to be squirted out before being dropped into the white box. This is to prevent anybody from reaching into the sharps box and stealing leftover narcotics. Now the simple act of disposing of a dirty syringe that should take about half a second involves multiple steps and the handling of dirty needles. There are even people who come into the operating room to make sure the boxes have the proper contents in them. Can anybody say FUBAR?

Anesthesiologists and Pelvic Exams

Thanks to the Anesthesioboist, the talk amongst anesthesia blogs is about--pelvic exams. I kid you not. Anesthesiologists are reminiscing about the first time they had to perform a pelvic exam as a medical student. (Notice I didn't use "romanticizing".) Over at I Used To Be Disgusted, Bleeding Heart describes how students and residents are invited into the operating room to practice pelvic exams while the patient is asleep under anesthesia, WITHOUT THE PATIENT'S CONSENT. Wow, they do things differently in Canada.

I figure I'll put in my two cents worth on this topic. That plus I've kind of dried up on printable subjects to discuss lately (personal issues that have preoccupied most of my awake, nonworking time keep me from thinking through on ideas lately). At my medical school in the Midwest, one of the GYN faculty was paid bonus money for allowing medical students to practice pelvics on her. You talk about A-W-K-W-A-R-D. I remember very clearly how she'd hitch herself up onto the exam table and plant her feet into the stirrups. Then she'd guide your trembling hands on the proper placement of a speculum. The worst part was how she'd verbally instruct you on a proper bimanual exam.

"Put your fingers right THERE. Feel that? That's my cervix. Feel how firm that is? Like the tip of your nose. Now move your hands over to the right. Squeeze your hands together. Ooh yeah. Not too hard. That is my right ovary you're squeezing."

None of us could really look her in the face after that. I heard she made enough extra money every year to jet off to Europe.

Haute Dog

Read this review of a new hot dog restaurant in Pasadena. It's called Slaw Dogs. Never heard of a hot dog restaurant? These just aren't any old hot dogs. How about a chicken Caesar salad hot dog? Or pictured here, the TNT super dog. It looks like a giant burrito stuffed with chili, bacon, pastrami, french fries, grilled onions, fried egg, and off course a ten inch sausage. Yum. Check it out if you're ever in Pasadena. I know I will, after I've downed a bottle of Lipitor.

Porsche 918 Spyder Hybrid

Now this is my kind of environmentally friendly green car. Unveiled at the Geneva Auto Show, Porsche displayed this stunning 918 Spyder plug in hybrid concept car. Check out the stats. 500 HP V8 engine. 214 HP electric motors. And the most impressive statistic: 78 MPG! With four different driving modes, it can go all electric for up to 25 km up to Sport Hybrid mode that uses the electric motors to supplement the V8 (I bet it won't get 78 mpg then). Zero to sixty is 3.2 seconds with a top speed of 198 mph. The capabilities of hybrid power trains just keeps getting more fantastic by the year. This is one car even Ed Begley, Jr. and Al Gore would love. If they could just price this thing at about the Boxster S level, the dream would be complete. No word yet on pricing or whether it will even be built.

Computer Security Madness

I was just notified by our IT department that my computer password is about to expire. That means it's time to come up with another inscrutable yet easy to remember password so I can log into my hospital's email system. The rules are pretty onerous.

1. The password must be at least 8 characters long.
2. The password must contain at least one capital letter.
3. The password must contain at least one number.
4. The password must have at least one symbol ie/#&$.

The password also cannot cannot contain any part of your name and it has to be different from your previous five passwords. Got that? Actually it's not that bad. Only three of the four criteria need to be met, not all four. Ha ha. These rules are so difficult to follow that I actually had to call our IT guy to help me come up with a password that would pass muster. He was very friendly and obviously had helped lots of people with this problem. After about three attempts I finally came up with one that the security system would accept. Hopefully I'll still remember it by the end of the day. After all, you're not supposed to write it down anywhere lest somebody found it and hacked into your account. Some computer browsers helpfully remember passwords for you and automatically log you in. But that kind of defeats the purpose of these security measures, doesn't it.

The New York Times recently had an article about the kinds of computer passwords that are commonly used. Believe it or not the top three passwords people use are 123456, 12345, and 123456789. Obviously none of these, or even the top 32 on their list, would pass the scrutiny of our computer security. There must be a way for the IT guys to come up with a security system that doesn't drive its users to madness, or feel like they are having early Alzheimer's. Perhaps some sort of biomechanical security measure like fingerprint identification or retinal imaging? But of course that is a little sci fi for our hospital. Our network still runs Windows XP! (IT promises that we are upgrading to Windows 7 by the end of the year.) So in the meantime I better start working on my next password since this new one will expire in only six months.

If He's Done The Crime...

It is now official ABA policy. The American Board of Anesthesiology has decided that any board certified anesthesiologist must not assist in carrying out capital punishment. Based on the ancient dictum of do no harm, the ABA states that an anesthesiologist risks losing his board certification if found to be helping the execution of a death row inmate.

I wrote of my feelings about this situation last year. If a person (?) can rape and murder an innocent child with his bare hands, why should he get the expertise of an anesthesiologist in getting an IV started? Is it really cruel and unusual punishment to get poked with a needle multiple times trying to get an intravenous line when he has committed a heinous act? Let him get poked until he resembles an acupuncture model. Why should he expect a nice little subcutaneous lidocaine injection to ease the discomfort of an IV? Many of our normal patients don't need it so why should death row inmates expect it? I say if he's done the crime, he should serve his time, for all of eternity. Just don't expect to get there on a pillow cloud of empathy from the rest of civilized society.

Medicare And Anesthesiologists

There is a lot of handwringing in the medical blogosphere today about the 21% cut in Medicare reimbursements. Some are advocating dropping Medicare patients completely as a sign of rebellion. With Medicare payments so low, many doctors feel they can do better by not accepting Medicare. After all, what's the point of keeping these patients when the payments are below the cost of rendering services. It's like the clueless retailer who sells goods below cost but tries to make it up in volume. The numbers just don't add up. Some people say that because doctors are obligated by the Hippocratic Oath to treat the sick that we should just suck it up because it is the ethical thing to do. What I never understood is why it is the physicians' responsibility to go into bankruptcy to take care of patients when the public and the government refuses to pay for such services? If people feel that strongly about taking care of the elderly and the disabled then maybe they should do some sacrificing of their own, such as paying higher taxes, to treat them.

Anesthesiologists are in a different boat. True we will still get 21% less for treating Medicare patients. But unlike primary care doctors we don't have the option of dropping these patients from our practice. When anesthesiologists sign up to provide services for a hospital, one of the requirements usually is acceptance of Medicare. Otherwise the surgical services would be completely chaotic. If a surgeon brings an elderly patient in for a hip replacement, it would be detrimental for all involved if the anesthesiologist cancels the case because he doesn't accept Medicare. So you see anesthesiologists pretty much have to grin and bare it when it comes to accepting below cost Medicare payments.

The Senate is set to introduce legislation that will put a temporary patch on these Medicare cuts. This will give them time to find a more permanent fix but I'm not holding my breath on that one. They'll just put in another one year fix because they can't come up with the money for a real repair of Medicare's SGR formula. In the meantime Congress is still debating passage of healthcare reform that will permanently decrease the pay of physicians regardless of what Medicare does.