Sunday, May 30, 2010

There's An AAP For That

Gastroenterologists have been pining for the right to use propofol for their endoscopic cases for years.  At the recent DDW conference in New Orleans, there were multiple talks on gastroenterologist administered propofol (GAP) or nurse administered propofol (NAP) vs. anesthesiologist administered propofol (AAP).  Everyone agrees that propofol (while it's still available) is superior to other forms of sedation for endoscopy.  The friction between the professional societies is over who is the most qualified to give it. 

I found this little gem from the American Gastroenterological Association.  It is a guide from the AGA Institute on how to give propofol sedation.  One of its tables describes how best to monitor a sedated patient.

Notice that the AGA Institude recommends that ECG monitoring is optional while capnography (the measurement of expired carbon dioxide) is not necessary.  Really?

By comparison. guidelines from the American Society of Anesthesiology on respiratory monitoring during endoscopic procedures state, "Monitoring for exhaled carbon dioxide should be considered during endoscopic procedures in which sedation is provided with propofol alone or in combination with opioids and/or benzodiazepines, and especially during these procedures on the upper gastrointestinal tract."

If your are a patient, who would you prefer to watch over you while you are sedated and helpless? Dr. GI, please stick with what you know best and leave the patient and airway monitoring to the doctors who do this every day, your helpful and friendly anesthesiologists.  Case closed.

Saturday, May 29, 2010

Man Dies From Uterine Cancer

That is not a typo.  A man in New York, Vincent Liew, received a kidney transplant from a donor who was not known at the time to have uterine cancer.  Once the donor's status was discovered, Mr. Liew's surgeon told him that the chances of him contracting uterine cancer was slim.  He kept the kidney until he too became ill.  By the time the donor kidney was removed, the cancer had already spread.

His wife sued NYU Langone Medical Center for not having the kidney removed sooner.  A judge ruled in favor of the defendants. 

Friday, May 28, 2010

Death Of Propofol

If a company cannot make money from a product, it will stop making it.  As I feared, Teva Pharmaceuticals has announced that it will stop the manufacture of propofol in the wake of a $356 million judgement against it by a jury in Las Vegas.  The greedy plaintiffs and their lawyer along with an ignorant vigilante jury ruled against the drug company despite no evidence of any wrong doing on its part.  The real culprit of the outbreak of hepatitis C infections in Vegas were the doctors and nurses at an endoscopy center who drew syringes of propofol for multiple patients from bottles that were clearly marked for single use only.  The doctors settled for less than $3 million and the owner of the center declared bankruptcy. That wasn't good enough for the plaintiff, Henry Chanin, and his lawyer, Robert Eglet.  Naturally they went after much deeper pockets, despite the dubiousness of their case.  Lucky for them, they rolled the dice and wound up with a jury that could not or would not see the fallacy in their theory on who was really responsible for spreading hepatitis to the patients.

This leaves only two manufactures of generic propofol: Baxter, which was also found "guilty" by the same jury and punished with a nine figure judgement, and APP, a European company that makes propoven, which is thought to be bioequivalent to propofol.  Generic drug makers live on single digit profit margins, as cost is the main differentiator of generic medications.  Total annual sales of propofol in the U.S. is about $500 million.  The Vegas jury's punitive damages against Teva and Baxter was $500 million.  You do the math and figure out why Teva is pulling out of the propofol market. Even if a judge later reverses this outrageous verdict, the threat of gargantuan liability awards against propofol makers will forever hang over their heads.  No sane company and its stockholders want that kind of unpredictability and no insurance company will want to cover this potential financial disaster.

Thanks to this bunch of yahoos in Vegas, the choice of anesthetic drugs just became significantly smaller and costlier.  Propofol is difficult to manufacture to begin with because it is easily contaminated.  There was an extreme shortage of the anesthetic last year that was only recently remedied.  If the other companies continue to make propofol or its equivalent, they will have to raise prices, maybe even significantly, to cover the cost of their liability insurance, if they continue to make it at all.  Anesthesiologists may then resort to fospropofol. Fospropofol is classified by the DEA as a controlled substance, is much more expensive than propofol, and not widely available yet. 

So if you need a colonoscopy or any kind of surgery in the near future, you better call your doctor and make an appointment ASAP.  For the first time, a drug that has been approved by the DEA will be pulled from the market not because of any risks to a patient's health, but because of the greed of lawyers and plaintiffs.

Sunday, May 23, 2010

You Gay, You Have A Dog

How would one describe an inhabitant of gentrified downtown Los Angeles?  According to Sylvain Copon, a business owner downtown, "You go downtown, you gay, you have tattoo, you have dog."  Hilarious.

Friday, May 21, 2010

Nail Salon, No. Dropped Babies, Yes.

After some investigation, the allegation that health workers at Olive View Medical Center, a county hospital in Los Angeles, received manicures and eyebrow waxing in the neonatal ICU is largely unsubstantiated.  Instead, those services were offered in a room adjacent to the NICU, during the work day.  About sixteen employees admitted to partaking of this service.  However the accusations that a baby was dropped off a scale and some babies were burned in the NICU were confirmed.  Now don't you feel better?  More examples of government workers earning their pension dollars.

Celebrate Pac-Man with Google

Check out Google today.  They are celebrating the 30th anniversary of Pac-Man.  Push the Insert Coin button under the search bar and start playing.  Push the button twice to play Ms. Pac-Man though I think there's is a bug in that game since the Ms. Pac-Man character wouldn't move when I started the game; just a regular Pac-Man started moving.  Is it any wonder people love Google?  What have you done for us lately Bing?

Best Lou Gehrig's Disease Joke I've Ever Heard

Carla Zilbersmith, a comedienne in the Bay Area, has died from amyotrophic lateral sclerosis, or Lou Gehrig's Disease.  She was only 47 years old.  She didn't let ALS get in the way of her sense of humor though.  According to an article in the San Francisco Chronicle, she even made a joke about her illness when she was first diagnosed.  Said Ms. Zilbersmith, "For those of you who don't know, I was diagnosed with Lou Gehrig's disease a couple of weeks ago.... I hate baseball.  I'd really much rather have been diagnosed with a basketball disease. Maybe Wilt Chamberlain disease. That's the one where you have sex 20,000 times and then you die."
RIP Carla Zilbersmith.

Health Care For Poor SubordinateTo Government Employee Pensions

I read two articles in the Los Angeles Times that demonstrates an interesting juxtaposition of where the real power lies in this country.  LA County's Department of Health Services is facing an over $200 million deficit this year and almost $600 million next year.  An ER nurse said the wait time before being seen at LA County-USC Medical Center is up to 35 hours

By contrast, the California Public Employees' Retirement System is facing a $700 million deficit in pension funding because of the bear market of the last two years.  CalPERS' portfolio value dropped by 24% last year, or $55 billion.  This year the state has already put in $3.3 billion into the pension portfolio.  That is more money than what they spend for the University of California system.  But unlike the sick and poor, CalPERS can force the state to give it the money to cover their deficit.  Thus the retired government worker will not lose his life long retirement pension. 

You tell me where our priorities are.  Our taxes keep going up but the money is being used for government pension obligations?  This is madness.  Is it any wonder the Tea Party is gaining such momentum?

Wednesday, May 19, 2010

Weird or Wow

The Cleveland Clinic Lou Ruvo Center for Brain Health in Las Vegas.

WooHoo! We're Number Two!

According to Forbes magazine, anesthesiologists have the second highest paying job in America.  We have an average salary of $211,750.  We rank second only to surgeons (boo!) who make $219,770.  They apparently didn't survey neurosurgeons or interventional cardiologists.  The magazine said our salaries went up 7.1% in the past year.  Really?  Our profession seems to have slipped a notch when compared to Money magazine's survey which said anesthesiologists have the best job in America, with a median salary of $292,000.

Despite all the talk about how poorly primary care doctors are paid in this country, internists are ranked at number six on this survey, with an average income of $183,990.  General practitioners are ranked at number eight with an income of $168,550.  Is it any wonder doctors get no sympathy from the general public when we complain about how little we get paid?

"Weapons of Mass Infection"

That's how plaintiff attorney Robert Eglet describes the 50 cc bottles of propofol used at an endoscopy center in Las Vegas the led to the hepatitis C infection of Henry Chanin.  This led a Vegas jury to award $500 million to the Chanins.  The lawyer successfully convinced the jury that Teva and Baxter, the manufacturers of the propofol, were at fault for selling these large vials of propofol to an endoscopy center that only required a few cc's for each procedure.  Thus the poor doctors and nurses who worked there had no choice but to use each bottle on multiple patients, despite the clear warning on the label that each bottle is for single use only.

The Chanins are playing the victimized heroes.  Says Henry Chanin at a news conference, "If we didn’t come forward and we didn’t pursue some kind of action, we weren’t doing all we could to make sure that what happened to me doesn’t happen to anybody else."  The jury was itself far from impartial.  According to jury forewoman Celeste Williams, she wanted to award more than $500 million.  In fact some jurors wanted to give $1 billion. 

The doctors and nurses of the center settled before the trial.  The owner of the endoscopy center Dipak Desai has filed for bankruptcy. Smart thing.  Their liability coverage was only $3 million.  Obviously not enough for these plaintiffs.  The drug companies refused a settlement of $1.7 million from the plaintiffs, rightfully thinking that any jury in their right minds would know that there was nothing wrong with the drugs, just how it was implemented by the end user.  They forgot that this is America.  A smart lawyer will assemble an ill informed jury, one which is preferably from the lower socioeconomic scale, to play on their sympathies.  When these two drug companies decide that the liability of producing propofol no longer justifies its manufacture, then we will no longer have propofol in this country.  It is simple as that.

Tuesday, May 18, 2010

Gastroenterologists and Anesthesiologists--Can't We Just Get Along

A couple of days ago, I mentioned the antagonism shown to Dr. Alexander Hannenberg, president of the ASA, during his presentation at the DDW.  He was trying to lay out his reasoning for why anesthesiologists alone should provide propofol sedation during GI endoscopy.  This naturally didn't sit well in a room filled with hundreds of gastroenterologists. I feel that this animosity is more motivated by money than any legitimate medical reason.  So let me present some logical reasons why anesthesiologists and the use of propofol should be used in every endoscopic procedure.

Improved patient compliance.  Patients' worst fears and the reason many avoid needed endoscopic screening are the perceived pain felt during the procedure.  They hear horror stories about how uncomfortable the procedure is from friends or recall bad memories of previous endoscopies.  But once they've experienced a screening with propofol sedation, many are effusive with praise.  When they wake up, they can't even believe the procedure is already finished.  They have no further hesitation for future endoscopies and highly recommend to their friends and family the virtues of propofol sedation.  Thus more procedures and money for the gastroenterologists.

Improved examination.  When the patient is well sedated with propofol by an anesthesiologist, the patient has minimal movement compared to a versed/fentanyl moderate sedation.  The gastroenterologist is free to take his time to examine the GI tract thoroughly at his leisure instead of telling three people to hold the patient down before he falls out of bed.  A better examination leads to a better reputation which leads to more referrals, which again means more money for gastroenterologists.

The gastroenterologist can concentrate on his exam.  Two sets of eyes watching the patient during a procedure is better than one.  Sure a nurse can give the sedation and chart the vital signs and assist the doctor and monitor the patient's airway for impending obstruction.  But isn't it safer to have another physician who is a trained expert in all those activities in the room?  If the patients loses his airway and codes, guess who is going to get sued? The sedation nurse and the gastroenterologist.  And the nurse's lawyer will punt the responsibility to the MD in charge of the room.  If an anesthesiologist was present the GI doc's lawyers could legitimately say that the airway is not his concern and is the onus of the anesthesiologist and we would agree. Why does an endoscopist want to risk a malpractice lawsuit from a patient that becomes hypoxic and possibly get an MI, stroke, or even dies on the table when there are plenty of anesthesiologists willing to help out to prevent such a tragedy? Fewer lawsuits, more money.

As you can see, there are plenty of monetary incentives for GI docs to use anesthesiologists in the endoscopy suite.  There are now papers that document increased satisfaction from patients and endoscopists with propofol sedation.  In this era of evidence based medicine, the gastroenterologists should abandon their traditional ambivalence and embrace anesthesiologist-administered propofol for endoscopy.

Sunday, May 16, 2010

BP Oil Spill--A Little Perspective

 Full disclosure: I own shares in BP

Shrieking headlines are proclaiming the end of marine life as we know it in the Gulf of Mexico.  "Giant Plumes of Oil Forming Under the Gulf," screams a New York Times article.  Researchers have found a large collection of oil near the site of the oil rig explosion that measures 10 miles long, 3 miles wide, and 300 feet deep.  One researcher cautions that oxygen levels near the spill have dropped 30%.  GASP!

Let's get a little perspective on this whole fiasco.  The Gulf of Mexico measures 810 miles wide.  It holds an estimated 660 quadrillion gallons of water.  That is 660,000,000,000,000,000 gallons.  Even if this oil spill eventually leaks twice the amount of oil as the Exxon Valdez in 1989, say up to 22 million gallons of oil, it would represent only 0.00000000033% of the total volume of the Gulf. 

Scientists seem to be surprised by the lack of evidence of the oil spill on the surface water and beaches.  The large plume on the ocean floor appears to answer that question.  But isn't this a good thing?  You would expect that in the frigid high pressure environment at the bottom of the ocean the oil would clump up and sink to the bottom.  Isn't this better than having it float up and contaminating all the fish and birds near the surface?  How much marine diversity could there be at the bottom of five thousand feet of water?  Some assorted odd creatures that may be lurking near this plume will get snuffed out.  But I doubt these are the kinds of fish people consume in the restaurants of New Orleans.  Other more nimble animals should be able to swim away from this area and find the other 615,000 square miles of the Gulf that are still unpolluted as hospitable as before.

If I've learned anything from all this, it is that the United States still has an enormous amount of oil just waiting to be accessed.  Imagine with all the talk of peak oil we can still dig a hole in this country, albeit a very deep hole, and oil will literally gush out of the ground unless properly controlled.  We are spending billions of defense dollars protecting our access to Mideast oil when we could use some of that money to drill for oil here.  No blood for oil?  Then maybe instead of sending our young men and women overseas we should train some of them in offshore drilling here and not worry about defending some Arabic governments who allows ten year girls to get married and raped and call that their culture heritage.

Finally I found this picture on the bottom quite amusing.  It is from the Los Angeles Times.  I guess nobody told the tourists in the background they needed to wear protective clothing before heading into the water.  Nice going clean up crew guys in the front.  Way to protect the public from this "disaster".

Friday, May 14, 2010

Gastroenterologists and Propofol Envy

There is mounting evidence that propofol is the ideal anesthetic for endoscopic procedures.   At the recent Digestive Disease Week conference in New Orleans, which bills itself as the "world's largest gathering of physicians and researchers in the fields of gastroenterology, hepatology, endoscopy, and gastrointestinal surgery," there were many presentations and posters extolling the use of propofol for GI sedation.  If you go to the DDW web site and search under "propofol sedation" you will see many talks of the advantages of propofol over traditional sedatives like Versed and Fentanyl.  See here and here and here for examples.

However when Dr. Alexander Hannenberg, president of the American Society of Anesthesiologists, made his case at the conference for having anesthesiologists administer the propofol, he was widely criticized in the GI dominated room.  One prominent gastroenterologist, Dr. Douglas Rex, had reviewed 600,000 cases of endoscopist administered anesthesia and found no adverse safety issues.  (How did he have the time?)  He accused the ASA of enriching its own members by keeping the FDA from approving a computer administered propofol infusion device that would not require an anesthesiologist to be present. 

This got me thinking, why do GI docs care so much about using propofol without anesthesiologists present in the room?  The following are three excuses I've heard from gastroenterologists about why they want to administer their own propofol sedation.

Anesthesiologists are not readily available when you are ready to start a case.  In other words, our lack of presence is slowing them down. Well there is a ready answer for that--hire more anesthesiologists.  If there were not enough nurses or not enough scopes available, you would expect them to spend money to get more, therefore decreasing downtime and increase revenue.  The same logic should apply to hiring more anesthesiologists.

Anesthesiologists slow down the procedure schedule.  I've heard this one many times.  We spend an eternity in GI Time carefully looking over the patients' H+P and talking to patients.  We delay cases when there are missing lab work or ECG's.  We have to take the patient to recovery after a procedure and won't allow the next patient to be whisked in without first interviewing them.  I have two words for that:  PATIENT SAFETY.  In the name of patient safety anesthesiologists make sure the patient can undergo a sedation safely with as few complications as possible.  The hurried life of gastroenterologists often keep them from noticing the finer details in life, like a patient having had an esophagectomy with gastric pull up but is scheduled for a PEG.

Anesthesiologists cost the patient more money.  I've always felt this was a deceitful way of keeping anesthesiologists out of the GI suite.  The patient makes the same copay whether an anesthesiologist is present or not.  In fact if the insurance company denies reimbursement for the anesthetic, it is the anesthesiologist that bares the loss.  Let's face it, the only money the GI doc is trying to save is the insurance companies' and his own.

What is the underlying commonality of all this?  Willie Sutton would know; it's all about the money.  When the anesthesiologist notices a missing ECG and "delays" a case by ordering one in a 65 year old patient with history of atrial fibrillation, that is costing the gastroenterologist time, which of course equals money.  While it's true that 95% of the time the endoscopist can administer the sedation safely without complications, is it really worth the heartache and headache if something bad happens?  And over hundreds of cases of sedation invariably something will.  Does the endoscopist really want to have the responsibility of  ensuring a patient's safety when an anesthesiologist is able and willing to help out?  Having an anesthesiologist present for sedation is a small price to pay for this peace of mind.  I'm sure a vast majority of patients would agree.

Thursday, May 13, 2010

Anesthesiologists Are Lone Wolves

The Journal of the American Medical Association has printed a very personal and touching essay from a cardiologist in Pennsylvania.  It is also highlighted in the Well Blog of the New York Times.  The physician, Dr. Ram Gordon, describes in a series of letters his evolving relationship with a patient that ultimately led to much more than a clinical doctor/patient interaction. 

This got me to thinking how anesthesiologist will rarely, if ever, have this kind of relationship with our patients. Do I miss it?  I must admit that I got misty-eyed reading that beautiful essay by Dr. Gordon, but in reality, not really.  First of all, having a deeply personal relationship with patients is extremely rare as Dr. Gordon himself alludes to.  I bet he has at most one or two other patients in his whole office that he has shared his personal information.  Most patients come in complaining about this or that symptom and could care less that you have three children in school and one of them just got a blue ribbon in 4H for pig raising.  And let's face the truth; we anesthesiologists see a patient for ten minutes before a case and maybe another ten minutes in recovery.  That time constraint is not conducive to developing a meaningful rapport with the patient and his family. 

The subspecialty fields in anesthesiology where you might have more face time with patients also aren't likely to blossom into a beautiful relationship.  Critical Care patients are usually too sick or sedated to share their family stories with you.  Pain Medicine patients just want drugs.  They'll tell you any story you want as long as you renew their prescriptions.

So I guess I'm destined to go through life without ever having an extraordinary bond with a patient that is worth writing about in the NY Times.  But I suspect that this kind of interaction with patients will become increasingly rare as doctors hustle to see more patients due to cuts in reimbursements.  And if physicians become employees of large hospital organizations, as some cost cutters advocate, you can forget about having any bonding that does not benefit the employer.  After all, when was the last time you had a deeply personal conversation with your post office clerk?

Who Raised A Stink

One of our surgeons has a new fellow working with him.  The fellow is a nice enough chap.  Friendly demeanor, knowledgeable, a competent doctor.  But boy does he have bad body odor.  I'll be charting during a case and suddenly smell a horrendous stink. Bad as in I-haven't-smelled-anything-like-this-since-high-school-locker-room-after-football-practice bad.  Malodorous as a European in August inside a crowded subway.  Disgusting as a four day deep sea fishing trip without a shower.   I look up and it would be him. Ugh.

When he first started working, I couldn't quite place the origin of the smell.  Initially I attributed it to a stinky patient.  Don't we doctors always associate bad characterizations to patients (poor attitudes, poor compliance, poor reimbursements)?  But then I noticed that I would only get a whiff of that stink when the fellow was around. 

He appeared to be well groomed.  He did enjoy sporting a 3 day old beard, which is common with young people these days (though I'm not sure what patients think about that).  I can't tell if his hair is deliberately greased down or whether he just has greasy hair.  His clothes are always clean and spotless.  But every time he walks into my room I have to start mouth breathing to keep from gagging.  It's worse than a poorly prepped colonoscopy.  Maybe not that bad but close.

I tried to bring this up with his attending.  I casually remarked that his fellow should probably take a bath every now and then.  He just laughed and didn't say anything.  Knowing the surgeon I think he would be too embarrassed to bring it up to the fellow.  Since I don't have the support of the attending the best I can do is hold my breath until this particularly fellow moves on to his next rotation.

I sure feel sorry for his patients though.  I couldn't imagine waking up every day to his odor hovering over my hospital bed. For the sake of his professional career I hope he gets some treatment for this.  And I hope he doesn't just try to cover it up with some strong cologne because that rarely works.  The mixture of cologne and B.O. is even more disgusting.

Wednesday, May 12, 2010

Five Hundred Million More Reasons For Tort Reform

A jury in Las Vegas has awarded a couple $500,000,000 in punitive damages after the husband contracted hepatitis C following a routine colonoscopy.  The companies named in the suit , Teva Parenteral Medicines and Baxter Healthcare Corp. are the manufacturers of propofol, the anesthetic used during the procedure.  The anesthesiologist at Desert Shadow Endoscopy Center had been using the same bottle of propofol for multiple patients.  The victim, Henry Chanin, a headmaster at a private school, had already received $3.25 million from the same jury while his wife was awarded $1.85 million from the pharmaceutical companies for "breach of implied warranty and failure to warn".  Said their lawyer, Robert Eglet, "We're hoping that it sends a message to these drug companies that they need to come here to Las Vegas with the right people and sit down and get these cases resolved."

How much more evidence do we need that this country needs tort reform immediately?  First of all, the punitive damages will certainly be shot down.  According to U.S. Supreme Court guidance, the punitive award should be no greater than nine times actual damages, so the Chanins will probably get no more than $45 million.  Of course Mr Eglet will walk away with about $15 million for his troubles out of that reduced amount. 

The drug companies had previously offered to settle with the Chanins for $1.7 million.  That was already a generous amount of money considering there was nothing wrong with the propofol or the manufacturing of the drug.  The culprit was the doctor who was in essence sharing the same needle with multiple patients.  Any CA1 anesthesiology resident will tell you that you shouldn't share the same syringe of propofol between multiple patients and that any propofol withdrawn from the bottle should be discarded after six hours.  But the doctor's malpractice insurance probably wasn't going to pay much more than $1 million.  Therefore legal logic says to go after the deep pockets of international drug manufacturers regardless of their culpability.

Teva and Baxter were not allowed to present evidence that the same syringe of propofol was used for multiple patients.  They also were prevented from showing the warning labels already in place against using propofol over multiple patients. The bottles clearly say single patient use only.  The Chanins' lawyer maintains that the propofol was manufactured in a size too large for single use, encouraging their use over multiple patients.  Say what?!  It is up to the physician using the drug to decide how much to use and for whom.  The only responsibility of the drug companies is to make the propofol in a sterile condition at the proper concentration.  How it is used after it leaves the factory is up to the caregiver, for good or bad.  If this verdict holds up, theoretically, Michael Jackson's estate could sue Teva and Baxter for making a "defective" product despite the fact that it was not used as instructed. 

Lucky for Mr. Eglet, this is just the first of 40 patients who contracted hepatitis C that he is representing.  If this lawyer wins many more suits against the propofol makers, they could theoretically go bankrupt and deprive all of us of this wonderful breakthrough anesthetic.  Then we'll see how patients like it when we go back to Versed and Demerol for sedation, or god forbid, pentathol. 

The 2010's are going to be very good years for this lawyer.  And very bad years for legal sanity.

Now I Remember Why I Didn't Go Into Internal Medicine

We had an anesthesiology grand rounds the other day that reminded me why I did not choose internal medicine after medical school.  The lecturer was very knowledgeable.  She came from our local university hospital and had multitudes of slides to supplement her talk.  The subject was congestive heart failure.  I thought, great, I could use some updating on management of CHF in the surgical patient.  But alas, she came from the medicine side.  As she went over slide after slide of different drugs for managing CHF, my eyes started to atrophy.  To keep myself alert, I started writing down the names of the different studies on CHF she was highlighting.  These studies with their overly cute names were mentioned in the span of less than 45 minutes.

SOLVD--Studies of Left Ventricular Dysfunction

CHARM--Candesartan in Heart Failure: Assessment of Reduction in Mortality and Morbidity

RALES--Randomized Aldactone Evaluation Study

EPHESUS--Eplerenone Post Acute Myocardial Infarction Heart Failure Efficacy and Survival Study

DIG--Digitalis Investigation Group

COPERNICUS--Carvedilol Prospective Randomized Cumulative Survival Trial

MERIT-HF--Metoprolol CR/XL Randomized Intervention Trial in Heart Failure

COMET--Carvedilol or Metoprolol European Trial

MOCHA--sorry, can't find what MOCHA stands for.  I'm not going to spend fifteen minutes on the net searching for it.

A-HeFT--African American Heart Failure Trial

Some of these trial names are quite clever, like RALES and CHARM.  But you can tell that the researchers were trying desperately to find a memorable name for the others, like COPERNICUS and EPHESUS.  Though all the pretty bar and pie graphs were nice, it was not relevant to my anesthesia practice.  It was not until the question and answer session did I get some useful information.  I'm glad one of my colleagues articulated what we were all thinking, "I get a patient in preop whose blood pressure is 85/50 and the cardiologist says he's optimized for surgery.  What am I supposed to do about that?" The lecturer's answer? "Though nearly all anesthetics can lower blood pressure, you guys have lots of drugs that can raise the blood pressure also."  Gee. Thanks.

Most Expensive Salon In Los Angeles.

Where was the most expensive and exclusive nail salon in Los Angeles?  Apparently it was the neonatal ICU at Olive View/UCLA Medical Center, one of four county hospitals in LA.  How selective was it?  Well, you have to have a reason to be in the NICU, such as having some sort of medically related degree or tech training.  It seems the entire staff at Olive View was in on this little side business.  One doctor "had a French manicure right on the high frequency ventilator."  What the heck is a French manicure, for those of us not metrosexual enough to know the difference between a French and regular manicure.  Some of the services offered, besides saving neonatal lives, included eyebrow waxing and nail filing.  An anonymous complaint said, "The smell of acetone permeates the back area of the NICU."

The NICU nurse manager has been fired.  The county Dept. of Health Services has had several hospital staff removed.  County Supervisor Mike Antonovich is calling for an investigation.  And for now, this elitest of salons in SoCal is closed.

Tuesday, May 11, 2010

No Experience? No Problem

How screwed up is our government and legal systems?  All together now, "How screwed up is it?"  It is so screwed up that Elena Kagan, President Obama's Supreme Court nominee, is being hailed as an ideal candidate precisely because she has little judicial experience.  She will be holding a lifetime position that affects the lives of every person in the U.S. for the next 30-40 years yet we know very little about her reasoning abilities or legal propensities. 

By comparison, would you want a physician who was dean of Harvard Medical School, has done research at the NIH, and done policy work for the government, and suddenly expect him to perform a liver transplant or take care of ICU patients?  You would wonder about his medical judgement and clinical abilities since he has been away from patient care for so long. 

Perhaps Obama is trying to surround himself with inexperienced people, as he himself is and demonstrates that fact every single day. 

A Movie About A Demented Surgeon, Or Is That Redundant.

This is "The Human Centipede", a sick horror film about a surgeon who fantasizes about creating a human arthropod.  Have trouble picturing it? Think back to your Microbiology classes when you heard about stool to mouth transmission.  You get the idea.  Wait until the very last scene in the trailer and you'll get a split second shot of the product of his "vision".  You'll never look at a two person horse costume the same way again.

Sorry I can't get the whole width of the clip into my column. This is the smallest size video that I could embed.  Of course you can always surf over to YouTube for the entire trailer.

One Trillion Dollars

With a simple stroke of a pen, world "leaders" have magically conjured up $1,000,000,000,000 to rescue the weaker countries in the European Union.  Can it really be that simple?  Can the world's greatest problems be solved with an edict from finance ministers that every problem will be financed with absolutely no consequences?

Have all this handwringing over how we're going to pay for Social Security, Medicare, Medicaid, public pension liabilities, Wars on Terror, interest payments on public debts, public education, infrastructure improvements all been for naught? Can we have the highest quality medical care for every single person in this country, if not the world, if we really wanted it by just issuing more money?  Were we just being juvenile and naive when the country got hysterical over Ronald Reagan's $200 billion dollar budget deficits? Or George W. Bush's $400 billion?  So what was the point of having a budget surplus during Clinton's presidency?  Maybe we were depriving ourselves of all we could have bought by saving so much money during the 90's. Are the Chinese and other tight fisted Asian countries just chumps for not spending more and living the good life?  Would the world be a better place if the Chinese stopped saving so much money and started spending like the Greeks, the Spaniards, the Portuguese, and yes the Americans?

President Obama's federal budget deficits of $1,420,000,000,000 in 2009 and projected deficit of $1,170,000,000,000 in 2010 almost inures us to these inconceivably large numbers.  But as we head deeper into the 21st century, these are scary times for those of us who don't print our own money but will suffer the consequences of the actions by those who do.  Good night, and good luck.

Thursday, May 6, 2010

Greek Doctors Are Destroying The World Economy. Now That's Power!

The Dow Jones Industrial Average dropped nearly 1000 points this afternoon as fears of debt default by Greece continues.  And what may be the cause of Greece's debt problems?  Apparently Greece is a country of tax evaders.  It has been calculated that tax cheaters cost the Greek government $30 billion a year in lost revenue.  Many blame the doctors of the country for not paying their taxes.  It is common practice there for patients to pay their doctors in cash, a term called fakelaki.  Of course none of this is reported.

In a tax audit of 150 physicians in an upscale neighborhood, more than half claimed an income of less than $40,000 and 34 returns claimed an income of less than $13,300.  That means they did not have to pay any taxes at all.  The doctor's union defends the physicians by claiming that the low incomes reported may be the result of new doctors just opening up their practices. 

I say more power to the Greek physicians and their union.  If American doctors' reimbursements continue to trend downwards to oblivion, we may have our own version of fakelaki here.  No access to health care?  No problem if you just slip a little envelope under the secretary's mousepad.  You can have your appointment in next week, tomorrow if the envelope is just a wee bit bigger.

What Cinco de Mayo Means To Me

Cinco de Mayo, the Mexican-American pseudo-holiday celebrated more here in El Norte than Mexico itself, has become a huge party holiday, especially here in Southern California.  It ranks right up there with the Superbowl and St. Patrick's Day.  But for me Cinco de Mayo this year meant something a little less celebratory--I had to endure getting caught up in a sobriety check point on the way home.

It was a very long day in the operating room.  Walking in the dark to the parking lot I couldn't wait to jump into my old beater Honda to go home.  On my usual getaway road a hazard sign appeared unexpectedly, "Water main break ahead.  One lane only."  Well that is new, I thought.  Darn it.  It's late already and now I have to drive my newly washed car through some flooded intersection.  I could see police patrol lights up ahead.

As the line of cars inched toward the flashing lights suddenly a new road sign emerged, "Sobriety checkpoint ahead".  They had strategically placed this last sign so that there was no way to turn around if you are under the influence.  A few cars at a time were waved into a shoulder lane for inspection.

A very tall and very young police officer loomed over me as he shined his flashlight into my car.  "Good evening," he said.  "Are you heading to work?"

"No, I'm getting off work," I replied.

"Where do you work," he inquired.

"At Big Name Hospital," I said.

"I figured that."  Luckily I was still wearing my scrubs.  "May I see your driver's license?"  I dug out my wallet and showed him my license. "Very good.  You can go now.  And have a good night."

"Thank you," I replied.  And off I went for a long delayed meeting with my pillow.  And that's how I spent my Cinco de Mayo.

Tuesday, May 4, 2010

Sometimes You Have To Get Yourself A Little Dirty

I got this email from the American Society of Anesthesiologists Political Action Committee (ASAPAC).  Full disclosure: I am a proud contributor to ASAPAC, donating every year for the last several years. Besides highlighting the PAC's accomplishments, the email gave step by step instructions on how to influence your congressman.  The following is quoted directly from the ASAPAC email that I received.

One of the easiest ways to get involved with the political process locally is to attend a political fundraiser, and ASAPAC is here to make it even easier for you!

ASAPAc LogoStep 1: Make sure you are on your lawmakers' campaign mailing lists so you know when and where these events will be taking place. They are a great opportunity to spend time with your representatives in Washington, advocating for anesthesiology and our patients.

Step 2: Please contact the Washington office to see if support is available for your Representative or Senator.

Step 3: If support is available, we'll have a check mailed directly to you to deliver at the event.

There you have it, how to buy congressional attention in three easy steps.  You don't even have to give any money out of your own pocket; the PAC will mail you a check to give to the congressman at his neighborhood meeting.  How much simpler can it get?  

Yes the whole process sounds sleazy, but that is the way the game is played.  Perhaps if the entire medical community had been as generous to their congressional delegates as the lawyers and insurance companies we wouldn't be in the current mess we are facing with ObamaCare.  For instance, of all the ASA members in California, less than 10% donated to ASAPAC, which is quite pitiful.  Let's not kid ourselves, money talks in Washington.  We can't strut around naively hoping that the government will take care of us because we are on some noble mission to help the poor and infirmed.  The government will help those that feed its immense bureaucracy and screw everybody else.  So if you haven't already, take a deep breath, hold your nose, and with your other hand write a check to ASAPAC or your medical society's PAC.  Then take a shower to wash that slimy feeling from your conscious. 

Monday, May 3, 2010


You can cross off-shore oil drilling as a future source of energy in this country.  After the devastating explosion in the Gulf of Mexico of an oil rig, there are loud outbursts of rage from environmentalists for a moratorium of off-shore drilling.  But let's count down the possible alternative sources of energy we have at our disposal.

Coal fired power plants--huge no-no.  Don't you know there is global warming going on?

Gas fired power plants--you still have to drill for it somewhere.

Shale--it's okay to overturn huge swaths of forests for this oil as long as it's in Canada, right?

Nuclear power--are you kidding? 

Hydroelectric power--we don't want to kill off the fish population that requires an intact stream to spawn, do we?

Wind power--would you want one of these giant turbines within the visible horizon of your house?  Just ask the residents of Cape Cod.

Solar power--can't disturb the delicate environment that would be covered up by acres and acres of solar panels to make this endeavor commercially worthwhile.

Geothermal--do we really want a power plant anywhere near Old Faithful?

Fusion--might as well ask for dilithium crystals from the Star Trek Enterprise.

So there you have it, the possible major sources of energy for our planet.  Somewhere along the line somebody has to decide what is an acceptable compromise in energy exploration or we'll all be sitting in the dark burning candles.  Oh wait.  Candles produce soot and worsens air pollution.  Scratch that idea too.

Why Can't A Doctor Be More Like A Lawyer?

Two recent articles in the New York Times show an interesting contrast in the livelihood of doctors and lawyers.  The first article talked about a study in the New England Journal of Medicine that detailed the "invisible" work of primary care doctors.

Family doctors are paid mainly for each visit by patients to their offices, typically about $70 a visit. In the practice in Philadelphia covered by the study, each full-time doctor had an average of 18 patient visits a day. 

But each doctor also made 24 telephone calls a day to patients, specialists and others. And every day, each doctor wrote 12 drug prescriptions, read 20 laboratory reports, examined 14 consultation reports from specialists, reviewed 11 X-ray and other imaging reports, and wrote and sent 17 e-mail messages interpreting test results, consulting with other doctors or advising patients.
The second article talks about the billing practices of attorneys involved with the recent bankruptcy cases of America's iconic corporations like Lehman Brothers and General Motors.

THINK the lawyers are expensive? Meet the consultants. Alvarez & Marsal, a turnaround firm that is essentially running what remains of Lehman, has billed more than $262.1 million.

No charges have been too big, or too small. The Huron Consulting Group, a management consultancy involved in Lehman, charged $2.54 for “gum in airport.” In the G.M. case, Brownfield Partners has billed $230,209.55, including an $18 fitness-club charge at a hotel.

 The doctor has gone through four years of medical school, three to four years of residency slaving away at subminimal wage, incurred hundreds of thousands of dollars in debts, only to work in an environment where requests for reimbursement is denied or downgraded and much of the work isn't even billable.  In the meantime lawyers can charge their clients for chewing gum and pretty much make up whatever hours they please as "research" into their clients' cases with little oversight.  This country's priorities are so screwed up that we willingly accept these lawyers fees for complicated paper shuffling that the same profession has set up while the task of saving lives is nickeled and dimed until less than ten percent of medical students want to go into primary care.