The Maimed Hand of Adam Smith

I am struck by the perversity of medical economics in America.  The passage of ObamaCare has focused the attention of the media on the lack of primary care physicians.  Who is going to take care of millions of new patients?  If the business of medicine followed classic economic principles, this should be a panacea for internists and family docs.  The law of supply and demand should kick in and all these scarce doctors should see their incomes rise exorbitantly as patients seek out their medical skills. 

But because medicine does not follow Adam Smith's economic theories, the exact opposite has happened.  Medicare reimbursements are still under relentless downward pressure.  Everybody wants to be seen by a highly competent doctor but nobody wants to pay for it.  In the meantime the medical fields that work in a competitive economic system are raking it in.  For instance, people are willing to pay cash out of pocket for cosmetic surgery or vision correction surgery.  Is it any wonder plastic surgery and ophthalmology are so highly sought after by medical students?  Maybe more PCP's will realize the futility of chasing after that elusive government dollar and join the concierge medicine movement.  Only when enough doctors drop out of the current self destructive business model will the government wake up and actually pay doctors what they are worth.

The DMVing of Medicine

Ms. Ghigliotty is one of several patients involved in a civil rights complaint filed with the New York State attorney general’s office charging that several New York City hospitals discriminate against Medicaid patients; the complaint says that Medicaid patients are referred to clinics while privately insured patients are referred to faculty practice offices, and that they do not receive the same quality of care.

New York Times April 27, 2010

After all the cheerleading for the passage of ObamaCare, the liberal press has finally discovered the major flaw in the law; millions of people will be enrolled in Medicaid but no doctors will be available to take care of them.  Ms. Ghigliotty is a 36 year old mother from the Bronx who believes it is because she is a Medicaid patient that she did not receive an accurate diagnosis for her abdominal pains until a year later when she was found to have colon cancer.  Says Ms. Ghigliotty, "The minute they hear you have Medicaid they say, ‘Sorry, we don’t accept that.’"

I would suggest to Ms. Ghigliotty that she had a bad doctor that missed the diagnosis, not because she is a Medicaid patient.  However, as for the whining that private insurance patients get to go to nice offices while Medicaid patients have to sit in crowded clinics, that's called capitalism.  Would you expect the same service if you went to Golden Corral as you would get if you went to Ruth's Chris?  Would the level of attention be the same if you took your Kia to the dealer for an oil change vs. your Lexus dealer?  So why should people who have free or nearly free health care insist on the same level of service as someone who pays for private insurance? If medicine is as egalitarian as the liberals want, then all doctors' offices will resemble the Department of Motor Vehicles: long lines, impersonal service, indifferent staff.  There will be access for all but everybody will complain about how awful it is.  Then we'll see how many missed diagnoses will occur.

Limited Means, Unlimited Wants

Mr. Robert Collison, the patient who underwent a 43 hour operation to remove a large abdominal tumor, has passed away.  As I said in an earlier blog, the surgery was estimated to cost $300,000.  The New York Times today has a more exact figure, $295,264, not counting anesthesiologists' and surgeons' fees.  The insurance company so far has come up with $156,477.  While it is hard to put a price tag on life, especially in this country of unlimited wants and expectations, the patient saddled his family with $150,000 of debt for an extra four months of life.  Even those extra four months were not truly vital.  He didn't leave the hospital in New York until February of this year and spent the last few weeks in a hospital in Wisconsin.  So at most he only had about one extra month of productive life at home.

Yes this line of reasoning can be considered brutal and inhumane.  But the money the insurance company spent for his treatment will have to come from someone, probably in the form of increased premiums on everybody else.  Insurance companies don't usually like to absorb the costs of their medical expenditures--bad for shareholder morale.  In essence we will all be paying more for this man's extra one month of life.  When we are running trillions of dollars in debt and everybody will soon be forced to buy health insurance, this expenditure needs to be reconsidered for its soundness, the way Britain's National Institute for Health and Clinical Excellence (NICE) rations money for proven efficacy, not experimental "but my father wants everything done and the surgeons promised us a 10% chance of survival" procedure.

As for the anesthesiologists fees that were not detailed in the article, is it any different than the lack of recognition in the original NYT article that only pictured a single arm representing the anesthesiologist in the surgical team?  At least we can say the anesthesia was well worth the money.

Propofol Doesn't Kill People...

I read about an anesthesiologist who was facing a dilemma.  Patients, when told they will receive propofol for their anesthetic, will express trepidation and fear.  They always point to the unfortunate death of Michael Jackson as the source of their anxiety.  The doctor tried to explain to the patient all the scientific studies and minimal risks associated with propofol.  This scientific babble usually didn't help much.  I have a better idea; use the analogy that has worked for the National Rifle Association for decades.

A patient asked me about the safety of propofol.  Will what happened to Michael Jackson happen to her?  I told her there is nothing wrong with propofol, just the doctor who gave it to Michael.  Propofol in the proper hands is very safe.  It's like a gun.  A gun in the right hands is very useful in society.  When a crime is committed with a gun, it's not the gun's fault.  Guns don't kill people; people kill people.  Right away patients get the analogy and are much more relaxed and at ease.  The tension is released and everybody's happy. 

How The AMA Is Like Kmart

I received the following spam from the American Medical Association.  It is beyond embarrassing. If the AMA truly felt they were performing such good service on behalf of doctors, they shouldn't have to peddle themselves at half price like some cheap linen sale at Kmart.  While most doctors opposed ObamaCare, the AMA endorsed it to give the administration cover.  In the meantime Medicare reimbursement is still scheduled to be cut 21% in, which month is it now?  April? May? October?  Whatever happened to tort reform?  Is that even on any legislative agenda between now and when hell freezes over?  Is it any wonder less than 25% of all physicians in the country belong to the AMA?  Until this once proud organization really starts paying attention to the needs of practicing physicians it will continue to dwindle and doctors as whole in this country will suffer.

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• Privacy protection for individual Medicare reimbursement data - The AMA protects its members' privacy related to Medicare reimbursement because that privacy helps prevent erroneous conclusions from being drawn about individual physician competency as the raw Medicare reimbursement data does not, and was never intended, to measure the quality of care provided by a physician.
  
  
• Live support (free) on the issues of fair contracting, accurate payment practice efficiency, clinical integrity, fee schedules and other practice management issues.
  
  
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A Better Pain Chart

Check out this more accurate, and graphic, pain chart made by Allie who blogs at Hyperbole and a Half.  It's for those times when those pain charts with frowny to smiley faces just don't cut it.  Each number category has a description too.  Number 10, for instance, is "I am actively being mauled by a bear."  Hilarious. Her blog is full of her zany and off the wall doodles like this.  She even sells samples of her works from her blog site.  So if you want to support an original slightly unhinged entrepreneurial artist, this is it.  I hope she has great e-commerce success with her blog.

Want To Get Away

I had an embarrassing encounter with a patient, similar to those "Want To Get Away?" commercials for an airline.  I approached my next patient in preop.  She seemed like a nice lady.  Pretty blond hair, makeup, eyebrows plucked just so.  "Hello Ms. Jones, I'm Dr. Z.  I'll be your anesthesiologist today."  "Nice to meet you," she replied in a sweet voice.

I looked through her chart.  Her H+P from her surgeon's office was an incomprehensible chicken scratch.  Luckily most of the form was a checklist for the review of symptoms, which were all marked negative.  After asking some rote questions, I told her I was going to start the IV.  "My you have nice big veins.  The IV nurse would love you."  "Yes," she replied, "I have never had any problems with IV's before, though they're not very lady-like."  I swear I could stick a central line catheter into her peripheral veins.

Then we were ready to go.  I gave her some Versed and wheeled her into the operating room.  I hooked her up to the usual anesthesia monitors.  Then I started my induction.  Just as she began falling asleep, she whispered, "I'm a man."  "What was that?" I wasn't sure what I had just heard.  At the last second, right before she lost consciousness, she said in a loud voice, "I'M A MAN!" Then he was asleep.

The circulating nurse and I looked at each other in amazement.  My face felt all flushed.  We lifted up his gown, and sure enough--he was a man.  The patient never corrected me in preop when I kept calling him "Ms."  The surgeon walked in and laughed.  "I see you've had your 'Crying Game' moment with the patient."  He explained that the patient was in the process of having a sex change.  He changed himself as much as he could but did not have enough money to undergo the final "transformation." 

Lesson learned.  Just like one should never assume the person standing next to the patient is a relative, one should never assume the sex of the patient by the face alone.  Next time I'll be sure to ask, besides the usual questions about age and weight, "Are you a man or a woman?"

Ten Simple Rules For Disposing Of Used Needles And Drug Wastes

You thought you learned this your first clinical month in medicine.  When you draw up a drug, you dispose the syringe and needle intact into a sharps container to prevent a needle stick injury.  Simple, right?  Now it's a lot more complicated.  I previously mentioned the new rules for disposing of needles and how asinine and convoluted this is.  I felt that following these prescribed procedures would lead to GREATER risk for needle stick injury.  I thought these rules were dreamed up by some bureaucrat in our hospital but I have since been corrected and notified that these rules in fact come straight from JCAHO and are in affect nationwide.

Now word comes from the head of our department that more rules are in place for throwing away used needles and drugs.  They have been nicely summarized in this ten part dictum:

1- Syringes are to be dated, timed, initialed, and labeled with drug and concentration.

2- All medications in syringes will be considered expired 24 hours after the time on the label except for propofol which will be 6 hours after the time on the label.

3- When done, syringes are to have their contents emptied into the blue/white container and the syringe thrown into that container. Needles are to be discarded into the red sharps container.

4- The correct order for drawing meds into syringes is draw the med first, then apply the label and then initial it etc.

5- Open multi-dose bottles are to be dated and initialed.

6- Open multi-dose bottles are considered expired 28 days after the date on the vial.

7- Open multi-dose bottles with non trace amounts of drug are discarded into the blue/white containers. The contents of the bottle do not have to be removed from the bottle prior to discarding it. The exception is any controlled substance (narcotics, versed etc.) in any container, the contents of which must be removed, fully discarded, witnessed and documented.

8- Open multi-dose bottles with trace amounts of drug may be discarded in the trash.

9- Open bottles of volatile anesthetics will be discarded in the blue/white containers.

10- IV infusion bags containing pharmaceuticals (not straight LR or NS) will be discarded into the blue/white bins and will not have to be emptied prior.

What's really aggravating about JCAHO's rules is how they treat physicians like children.  For instance, Rule #4 tells us exactly what order to draw up drugs and label them, as if we haven't been doing that thousands of times a year already.  Or how used bottles of some drugs may go in the trash while used bottles of other drugs have to go into the blue containers.  But we are warned that if we don't follow these commandments to the letter, the next time our hospital gets inspected we could lose our accreditation.

I don't know when JCAHO suddenly attained a monopoly on regulating hospitals and surgery centers.  They are not a government organization.  Yet whenever they come around the entire hospital is thrown into convulsions trying to anticipate every potential infraction the surveyors may find.  But the problem is that there is no published book to follow.  When the surveyors are here they seem to make up procedures as they go along and we get written up for not following "the rules".

For instance, a few years ago we were cited for not saving the empty bottles of drugs after drawing out the meds inside them.  That was something new that none of us had ever heard of before.  So before they left for the week word came down that we had to save all these empty bottles of propofol, succinylcholine, fentanyl, etc. on top of our carts until the case was finished.  Believe me the cart table became a mess with drippy bottles of drugs everywhere, including the opened glass ampules of medications.  Then about two weeks after the surveyors left, we got a mea culpa letter from JCAHO saying we no longer needed to save those bottles.  So did they make up that method on a whim in the first place?

If there was a published book of proper conduct wouldn't you think every hospital in the country would follow it and then there would no longer be a need for JCAHO?  I would love to see hospitals, particularly the large academic hospitals, rise up and say no to JCAHO's tyranny.  Call their bluff.  If JCAHO does take away a hospital's accreditation and shuts down, would the sudden lack of medical access drive a popular revolt?  If everybody refuses to allow JCAHO inspectors through the doors would the insurance companies and Medicare dare to refuse reimbursement for patient care?  Somewhere along the line these unelected officials who meet behind closed doors dreaming up new inane rules to drive terror into the hearts of hospital administrators everywhere need to be held accountable.  Otherwise we will get more and more codes of conduct like above.  Next thing you know they will be telling you how to wipe yourself since obviously you can't do that properly without somebody telling you how.

Sued For Caring

A jury in Florida has awarded $10 million to a woman who gave birth in an ambulance and now the child has severe cerebral palsy.  The plaintiff went into premature labor at six months and went to Bert Fish Medical Center for treatment.  An ambulance was called which was supposed to transport her to one hospital but instead was diverted to the Arnold Palmer Hospital for Children in Orlando over fifty miles away.  The three month preemie was born fifteen minutes into the ambulance ride.  The EMT's had difficulty intubating the tiny infant and the child subsequently suffered hypoxic brain injury.

Here is my two cents worth.  It is always sad when a birth does not result in a smiling pink active baby with an APGAR of 10.  I couldn't imagine the horror the EMT's faced when this tiny baby popped out in a moving ambulance.  Experienced anesthesiologists have trouble intubating such small patients in the operating room, let alone a moving target like the inside of a speeding vehicle.  And forget about starting IV's.  How many people can say they can start a neonatal IV under the best of circumstances? 

Should the ambulance driver have turned around?  It sounds like Bert Fish Medical was not equipped to take care of extremely premature infants.  Would the ambulance company and the hospital have been sued for attempting to treat a preemie they were not capable of doing properly?  Probably.  Would the ambulance company have faced a lower judgement if the baby had died? Yes, because there is not the lifetime compensation the jury gave to the plaintiffs.  This is another case of caregivers being sued for caring.  Again, no good (medical) deed goes unpunished in this country.

Dodgertown Grub

Who says L.A, is all about tofu burgers and alfalfa sprouts?  Check out the latest offering from Dodger Stadium.  This new stadium "food" is called the Victory Knot.  The pretzel is about the size of a pizza.  It's made with TWO pounds of dough and sea salt.  It comes with three dipping sauces:  chipotle honey mustard, sweet cinnamon creme, and beer cheese.  No calorie counts have been provided but it is supposed to serve four people.  I guess Frank McCourt needs to do something to draw fans to the game to pay for his divorce proceedings. 

If that's not enough food for the hungry sports fans in your family, you can always go to Pasadena after the game and stuff yourself with the TNT super dog.  Cardiac catheterization recommended if you wind up eating both items the same day.

One Million Hydrocodone A Year

Dr. Daniel J. Healy of Duarte, CA pleaded guilty to prescribing narcotics without medical purpose.  He was known around town as the "Candyman," willing to dispense narcotics to anybody who asked.  He prescribed over one million tablets of hydrocodone in 2008, ten times the amount of an average pharmacy.  One patient who was stopped by the police after leaving his office was found to have over 7,500 tablets of Vicodin and Xanax with him.

He made $700,000 in sales of hydrocodone in 2008.  His patients needed so much cash to buy their drugs that he installed an ATM in his office.  He made so much money as a prescription drug dealer that he contemplated writing books with titles like "The Million Dollar Practice" and "A Doctor Should Be Wealthy".

His lawyer claims he was bullied into giving that many drugs by the addicts who visited his office. Prosecutors are expected to ask the judge to sentence Dr. Healy to 17 years in federal prison.

The Propofol Burn

One of the least desirable effects of propofol is the burning sensation a patient feels when it is injected into the vein.  I've had many patients complain about the irritation from a previous anesthetic experience.  Being in GI anesthesia, I've had much experience with this as a consequence of the high turnover of patients and the near universal use of propofol.  After years of trying different methods to reduce the pain, I've had great success with a protocol of lidocaine followed by a propofol chaser.

It's very simple.  When the patient is ready for induction, I give 30 mg of lidocaine and immediately follow that with 30 mg propofol.  I then wait 30-60 seconds and then give another bolus of propofol of 30-40 mg.  Continue this cycling of propofol boluses until the desired level of sedation is achieved.  I've found that this eliminates the propofol burn greater than 90% of the time.  The key I think is the small amount of propofol injected each time.  The first bolus given as a 1:1 ratio with lidocaine seems to give good relief from vein irritation.  Waiting 30 seconds before giving the next bolus allows the patient to achieve some level of sedation so that they have less awareness of the burning with the subsequent boluses.  Another advantage of giving small intermittent boluses is decreased risk of having the patient go apneic, which can happen if they are given a large initial amount of the drug.

Why not give a benzo like Versed as a sedative?  In GI the cases are very quick.  Even though Versed is short acting it is not short enough.  You wind up with a recovery room full of patients sleeping off their Versed.  Patients achieve alertness much faster after using only propofol.  Versed induced amnesia is also inconsistent; some patients still remember the pain while others are amnestic five seconds after Versed is given.  Patients are also happier when they wake up faster from anesthesia.  Many patients complain of being drowsy for hours when they go home after being given Versed.  They report feeling alert and normal when only given propofol.

Fentanyl has also been advocated as a preop sedative to alleviate the burn.  My experience has been that narcotics have an unpredictable effect on respiration, especially when given with propofol.  Some patients do fine while others go into prolonged apnea when propofol is given.  And again the patient takes longer to wake up in recovery.  There is also an increased risk of post operative nausea and vomiting when adding a narcotic to your anesthesia. PONV is something patients find extremely unpleasant and want to avoid at all cost.

Of course there are some instances where this intermittent bolusing of propofol doesn't work.  If you are trying to achieve a rapid sequence intubation, screw the burning pain.  Just inject and go.  The pain is the last thing you should be worried about.  Also patients who have tiny veins will almost always have pain with injection no matter what protocol you use to prevent it.  They just have to live with it for a few seconds until they fall asleep.

Obviously there is no scientific basis for this method of induction.  It was arrived through years of propofol injections.  But give it a try.  I would like to hear how other anesthesiologists minimize the amount of burning when they give the milk of amnesia.

POS Cardiology Consult

Cardiology consults can be such a waste of time it's a wonder we bother getting them at all.  Around here it has almost become a joke.  I was seeing my next patient for a PEG placement, an elective procedure.  She was an inpatient with a positive review of systems:  obesity, hypertension, diabetes, CVA, CHF, renal failure on hemodialysis, A-fib...  We hooked her up to the monitors in preop and lo and behold, her vitals signs were: HR 120-140 in A-fib, BP 170/110.  Occasionally her heart rate surged to 150 when she coughed.  Not a pretty picture for an elective case.

I flipped through her voluminous chart to see why how long she had been in this condition.  Vital signs from two days before showed normal heart rate and normotension.  Cardiology was consulted yesterday when she was found to have converted into rapid A-fib.  They gave her some metoprolol and said she was cleared for the procedure.  Their advice was to continue beta blockers and maintain her blood pressure.  From their point of view the patient needed the PEG so she could get her medications.  Hello?  Have they never heard of IV meds?  Were they even trying to rule her out for an MI?  I thanked them for allowing me to bill for an anesthesia consultation and sent her back to her room.  Call me when she is "medically optimized".

Anesthesiology Personalities

What kind of people are anesthesiologists?  They're not all the quiet subservient personalities shown on TV and movies, if they are noticed at all.  (The rare exception being Nip/Tuck).  Bleeding Heart has a hilarious guide to different anesthesiology personality traits.  It is funny because it is so true.  I can picture exactly who in my department fits into each category, some into multiple categories (multiple personality disorder perhaps?). What am I, you might ask.  Of course I'd like to think of myself as Dr. Perfect but if you've been a reader of this post you probably recognize me more as Dr. Whiny ;-).

The Public Option--It's Heeere!

Remember all the angst and handwringing from liberal Democrats when ObamaCare did not include a public option to compete against the insurance companies?  Well fear no more.  The Obama Administration has announced a new program that is a public option in all but name.  The Dept. of Health and Human Services will start a program to allow people with preexisting medical conditions who have not been able to buy health insurance for at least six months to purchase from a high risk insurance pool being set up by the federal government.  The program is intended to be "temporary" until January 1, 2014 when insurance companies are supposed to accept everybody, regardless of their medical conditions.

The program will start with $5 billion to pay medical claims for people in this high risk pool.  The premiums are supposed to be based on "standard rate" which are supposed to be no higher than somebody without preexisting conditions.  Plus the total out of pocket expenses is to be no more than $5,950 per individual. 

If this is not a public option, I don't know what is.  It sounds like an act of compassion to allow people to buy into a high risk pool now until the insurance companies have to accept them in three years.  But my hunch is that by 2014 this program will be so popular that it will be impossible for the federal government to withdraw the program.  This in essence will be Medicare for people with preexisting conditions.  Even though ObamaCare states that insurance companies have to accept everybody who applies for insurance, which in fact is everybody thanks to the individual mandate to buy insurance, the very crafty people who work there will figure out a way to dump patients into this new program.  The nationalization of the medical industry has already begun.