Back To School Madness 2

As I mentioned in my previous entry, my older child is starting first grade this week. Not having had any experience with elementary schools in nearly four decades, I'm surprised and not delighted by changes in school administration since I was carrying around a Scooby Doo pencil box. (Judging by my kid's school supplies needs, children nowadays won't even know what pencil boxes are.)

The school has helpfully assembled an eighty-five page handbook for parents.  That's right. Eighty-five long, frequently single-spaced legalese pages of rules we parents are supposed to conform to.  It is full of information about conditions leading to expulsion, mischief that requires an automatic five day suspension, the principal's right to transfer your problem child to another school within the same district or even kicked out to a different district. There are all sorts of scary words like "threatening", "weapons", "drugs", and "sexual harassment." Is this a school my child is entering or San Quentin state prison? We are to list emergency contacts in case something happens to our child. Fair enough. But they also want a long distance contact because, "Long distance service will be the first telephone service repaired...in the event of a catastrophic disaster." Talk about paranoia. The dire warnings make me want to lock my kid in a nuclear bunker.

Besides all this apocalyptic language there is the constant nagging. There are about ten pages requiring the written consent of one or both parents.  One page confirming we had read and agreed to the terms of the handbook insists on the signature of the parents AND the student. How can a six year old child agree to the terms of this handbook? The school practices cover-your-ass legal defense like an ER doc. Then there is all the money grubbing. With dire warnings about increased class size, decreased arts and music classes, lower school morale, they are respectfully requesting hundreds of dollars in donations per student.  This from a public school! They already want each student to "donate" $10 for teacher appreciation.  Whatever happened to an apple?

I'm sure my parents never had to confront "weapons" and "sexual harassment" when they started me in first grade all those years ago. Through rose colored glasses of my distant memory, elementary school was all about finger painting, practicing writing, and acquiring math skills. Sure there were a few instances of bullying even at that level, but certainly not to the point where a handbook was needed to spell out conditions for expulsion. It's sad that the world's wealthiest country has an educational system that is so inane and destitute. How soon will we lose our preeminence on the international stage if our children's education is so marginal? Who will replace our technologic wizardry, artistic excellence, or medical innovations? I hear Chinese classes in school are becoming very popular now.

Back To School Madness

My older child starts first grade this week. My how time flies. Sniff. The school has helpfully provided a list of school supplies they recommend our child should bring to class.  All the stores were madhouses today with back to school shoppers.  Target was a total disaster area.  There were stuff on the floor, piles in the wrong bins and racks, and generally they were out of the things on my list. Staples was crawling with parents and kids. I managed to snatch the last box of Crayola 24 ct. crayons off the shelf. Thank goodness for Office Depot.  Not so great for them because their business seemed quite light, but good for me since I was able to finish my shopping list there.

And what a list it is.  I wonder if our school system gets kickbacks from the Crayola company.  Very clearly, in no uncertain terms, they only want us to buy Crayola products. They specifically mention a competitor's name as one to avoid. Hmm. Heaven forbid my kid should be the only one to have a different brand crayon.  There were stacks and stacks of competitors' crayons at cheaper prices but because the school specified Crayola, these were nearly swept clean from the aisles.

Let's see what else is on this list.  They want fifteen glue sticks along with a bottle of glue. Fifteen? I thought it was usually one or the other.  Why have both glue sticks and regular glue? And why that many sticks? And why specifically Elmer's? Another kickback? They also need four dry erase markers, again brand specific. Do first graders really need all this? This feels very different from when I went to school eons ago. In fact all this stuff won't fit into the cute little backpack we got; we have to go buy a bigger one, just for first grade. Wasn't there a study about increased incidences of childhood back pain in association with these massive backpacks kids wear nowadays?

After looking through this list and checking it twice, I realized there is something missing.  Looking at the picture can you tell what's not there that is fundamental to education as I remembered it to be? Any guesses? That's right, there is no requirement to have No. 2 pencils for our child to bring to school.  There is a demand for a set of headphones to use with computers but not writing instruments to learn basics, like maybe penmanship and writing.  How times have changed.

VICTORY!

The Food and Drug Administration has sided with anesthesiologists and denied the American College of Gastroenterologists their petition to remove from propofol's label the requirement that administrators of the sedative have training in general anesthesia and not be involved in the surgical procedure itself.  Says the FDA, "After considering your [petitioners'] claims and the literature you provided for our review, we conclude that you have not shown that the warning is no longer warranted or appropriate.  In fact, we conclude that the warning is warranted and appropriate in light of the significant risks associated with propofol, and we further conclude that the warning should help ensure that propofol is used safely.  Accordingly, we will not seek to have the warning removed, reduced, or otherwise amended."

This should have been a no brainer for the FDA.  In light of the death of Michael Jackson, it should be self explanatory that propofol is a dangerous drug in the hands of people who have not had proper training in airway and cardiovascular resuscitation.  It continues to puzzle me the ACG's persistence in demanding the right to use propofol sedation.  Why is it not obvious to them that it is inheritantly dangerous for the operator to also be in charge of the sedation? Airway collapse can happen in seconds. Are they going to be vigilant enough to notice?  And if they are how good a job are they doing with the endoscopy? Will they see that flat polyp hiding in the hepatic flexure or the ulcer right behind the pylorus if the patient starts to desaturate or brady? What of all those studies published in GI journals expounding the safety of gastroenterologist administered propofol? Most of them use doses of propofol that are practically homeopathic.  If anesthesiologists gave that small an amount, we'd probably get kicked out of the procedure room for not know how to give MAC sedation. 

What about the ACG's contention that requiring an anesthesiologist present to give propofol increases the cost of the procedure? The FDA's answer in essence is, "How can you put a price on patient safety when it is so easy to make sure they survive the procedure by having an anesthesiologist in the room?" The extra cost is more than justified given the significant risks of poorly administered propofol sedation. How would the endoscopist explain to a patient's family that the victim suffered an acute MI or anoxic brain injury because they were too cheap to hire an anesthesiologist to monitor the sedation? They can't. And now thanks to the FDA, they won't have to. If a medical catastrophe happens, we anesthesiologists are man enough to take the blame.

Can Anesthesiologists Perform Inception?

For those who haven't seen the movie, Inception is the story of a mercenary played by Leonardo DiCaprio whose job is to extract information from his sleeping subjects.  On his last job, he is hired to insert an idea into his victim, or inception, for nefarious purposes. As an anesthesiologist I found the process of inducing the people in the movie to sleep just as fascinating as their treks through multiple dream levels.  I wanted to hire that chemist in Mombasa, Kenya who had developed a sedative that could keep people sleeping for hours then wake them up instantly with just a tap on the shoulder.  Take that propofol.

One question patients often bring up is will they dream under anesthesia.   The stock answer is, "maybe." There have been some studies involving dreams and anesthesia.  One showed that 22% of patients recalled dreaming upon waking from surgery.  I usually tell patients that they may dream under anesthesia, but like waking up from physiologic sleep, they may not remember their dreams when they emerge from the anesthetic. 

Patients ask if they should count backwards from 100 as they go under.  I think that is so cliched, and so boring.  I say, if you want to count numbers, why not make it more challenging and count backwards from 100 by sevens, or recite pi as far as you can before you go to sleep? Okay, that might induce more anxiety than relaxation. Instead, why not try to make it more pleasant and fun?  As they drift off to sleep on the operating table, I ask them to tell me about their last vacation, their favorite beach, or their grandchildren.  Does my amateur attempt at inception work? It's hard to say.  Again most patients emerge not recalling any dreams at all.  But those who remember dreaming usually recount them as being enjoyable, occasionally even amorous.  It is extremely rare for them to wake up and complain about having any unpleasantness or nightmares.

Do other anesthesiologists have similar experiences with their patients?  Do any of you attempt inception?

Mental Fortitude

David Brooks in yesterday's New York Times wrote a column about mental fortitude, or lack of it in today's society.  He used the excruciating radical mastectomy experience of Fanny Burney, a 19th century English author, to illustrate mental courage. This was the state of surgery before the invention of anesthesia.  Ms. Burney didn't even have the benefits of alcohol for sedation; the surgeon simply placed a piece of cloth over her face to shield her eyes from the horror her body was about to suffer.  She could feel every slice as the scalpel cut through living tissue.  Just when she thought the worst was over as the surgeon finished cutting through skin, she had to undergo more torture when the surgeon cut her tissue down to the bone, literally feeling the knife scrape against her ribs.  It is amazing Ms. Burney lived through this. 

Could anybody today tolerate such torture?  Of course not.  First of all it would be completely unethical to knowingly conduct surgery on a conscious patient, unless of course you were some mad scientist performing some sort of fiendish human experiment.  Can this happen undetected by the surgeon or the anesthesiologist? Unfortunately, the answer is yes.  While extremely rare it's not out of the question that patients have undergone surgery while paralyzed but awake.  It is probably the number one fear among patients about to have an operation.  That's why there is much research into preventing surgical recall and the American Society of Anesthesiologists has established a registry to document any cases of recall in order to understand its etiology.

What's acceptable in advanced Western society today is radically different from the attitude of two centuries ago.  This was before the advent of anesthesia, narcotic pain relievers, or post traumatic stress disorders.  People acquiesced to the fates dealt to them by the gods.  Doctors had little to offer other than cutting and bleeding. No amount of whining would have changed their outlook.  Life was accepted as harsh and unforgiving.  You can still see this kind of compliance when treating patients in less medically advanced societies.  Even their children are less apt to complain about the pain they feel postoperatively. To these people they are just gratified that anything was done at all.  Sometimes it seems to me the more we offer our patients, the less satisfied they are with our care. I think if people understood how far we've come in treating medical diseases they might be more thankful for what they have instead of complaining about how miserable they feel.

ASA President Defends Anesthesiologists, Feebly

The American Society of Anesthesiologists is losing a public relations war with the nurse anesthetists.  There was that recent AANA sponsored study splashed across the pages of WSJ.com that claimed the care received by MDAs and CRNAs are equivalent.  Then there is this study in the Journal of Nursing Economics that claims the care provided by CRNAs is 25% cheaper than anesthesiologists without affecting the quality. Oy vey! Alexander Hannenberg, MD, president of the ASA, has been a pretty busy guy lately, putting out all these PR fires smoldering around the Society.  He was quickly trotted out to dispute the findings of this latest paper.  But upon reading his defense of anesthesiologists, it is obvious he has little substance to work with.  It reads more like a he said/she said argument.  His line of reasoning wouldn't pass muster in a high school debate class.

In this interview he makes seven points about MDAs vs. CRNAs.  I won't reprint his arguments in their entirety here but you can read his interview in Becker's ASC Review.  I'll just go down the line and give my two cents about why his assertions are weak and almost indefensible.

1. Scope of services provided by MDAs and CRNAs are not equivalent.  Maybe not completely equivalent but in reality they are quite close.  Critical Care Medicine is one field where CRNAs don't practice.  But few anesthesiologists practice CCM either.  Out of around 40,000 anesthesiologists in this country, the American Society of Critical Care Anesthesiologists only counts 563 members.  And that includes resident and medical student memberships.  So for all intents and purposes, MDA and CRNA practice parameters are practically equivalent.  What about Pain Medicine?  Here the ASA is running around the country trying to legislate pain procedures out of CRNAs' hands.  If not for legal obstacles many CRNAs would be in procedure rooms right now doing blocks just like MDAs.

2. Comparison of outcomes invalid. It is true that studies show MDAs take care of sicker patients than CRNAs.  That was also found in the WSJ article.  But the reason for that is most rural hospitals only have CRNAs staffing the ORs.  These small hospitals typically handle more routine cases.  Any complicated cases are transferred to urban tertiary care facilities.  It will be impossible to fully equalize the case complexities between doctors and nurses. Good luck trying to attract anesthesiologists to 75 bed hospitals in the middle of Podunk City, Middle of Nowhere, U.S.A. 

3. CRNAs rarely go "solo" when administering anesthesia. This argument is not going to last much longer.  More and more states are deciding to opt out of Medicare's requirement to have physician supervision over nurse anesthetists.  Regardless, taking care of a surgical patient is a team approach, or at least that's the way it was always taught to me in anesthesiology residency.  Even anesthesiologists don't always decide on the anesthesia "solo". We consult with surgeons when there is a complicated or unusual presentation.in the patient. Together as a team we decide on the anesthesia that will provide the best outcome for the patient. No prima donnas in front of or behind the surgical drapes.

4. Use of CRNAs as solo providers could cost more for Medicare patients. Here Dr. Hannenberg's argument is particularly specious.  He claims that CRNAs would actually cost more because they will order more medical consults than MDAs to "assess co-existing medical conditions." Really Dr. Hannenberg? I've ordered plenty of consultations myself if I felt the patient needed it to get through an operation safely.  Besides, many surgeons prefer to work with CRNAs precisely because they are less likely to delay a case for further medical workup, for better or worse.

5. CRNA and physician compensation are not an apple-to-apple comparison. This is actually a sad indictment against anesthesiologists but alas also true.  A hospital will have to pay nurse anesthetists overtime to work nights and weekends regardless of the number of cases performed, potentially raising their costs.  We smart anesthesiologists are so smug in our superiority that we don't mind sitting around in an uncomfortable doctor's lounge, away from our families, uncompensated, wondering when our next meal ticket will arrive in the emergency room.  There goes another sleepless night on call in the hospital only billing for an appendectomy and a couple of epidurals.

6. Study is unsubstantiated, inaccurate and questionable. Dr. Hannenberg cites a CDC study in 1980 that said comparisons between CRNAs and MDAs are unachievable since the rates of mortality and morbidity from anesthesia are so low.  And they are lower now thirty years later.  Well, it can be argued that if the difference in M&M is so low between the two professions, the nurses must be doing something right.

7. Patients prefer physician anesthesiologists. This maybe true, if the costs were the same.  But how many patients have been surprised by a bill from an anesthesiologist who was not in their insurance network and subsequently disputed or refused the charges? Do you think these people would feel more satisfaction with their hospital and surgeon if they got no anesthesia bill at all because the CRNA administering the anesthesia was an employee of the hospital and thus wouldn't charge the patient separately? Where is the study that shows patients prefer paying extra for an anesthesiologist or anesthesiologist-supervised CRNA vs. a free solo or surgeon-supervised CRNA?  (Free meaning their insurance company pays for it.) Are we afraid to find that people would not want to pay more money to be anesthetized by an MDA or MDA-supervised CRNA? And how much more would patients be willing to pay to have an anesthesiologist instead of a CRNA give the anesthetic?  $1000? $100? $10? Of course it's easy for people to tell researchers they want anesthesiologists present or nearby when the anesthetic is given.  But when they have to reach deep into their own pockets for the privilege I'm willing to bet their stories will change pretty quickly. That type of study involving real money will need to be conducted to prove we are indeed preferred over CRNAs.

As a practicing anesthesiologist, and a proud member of the ASA who contributes to ASAPAC every year, it pains me to have to write these words.  And it really isn't Dr. Hannenberg's fault that his arguments are so anemic.  We anesthesiologists are so busy in our ivory towers trying to understand the molecular basis of lung ventilation in the name of patient safety that we have failed to see the soul of anesthesiology is being hijacked by the nurses.  While the AANA is cranking out multiple papers per year on why they are at least equivalent to MDAs for less cost, we haven't produced a study demonstrating the value of anesthesiologists in today's health care environment.  The nurses only need to prove they provide care as well as doctors to have an advantage, because if all else being equal, the deciding factor will be cost, their ultimate trump card.  If that situation should come to pass, the only way we anesthesiologists can stay gainfully employed is if we lower ourselves to an equivalent salary.  That will indeed be a sad day for anesthesiology.

Global Warming Refuted

I saw this display during my trip to the Museum of Natural History.  It is shown to point out that the earth has been experiencing severe global warming since the beginning of the Industrial Revolution.  That change in temperature is represented by the infamous "hockey stick" line all the way over on the right side of the graph.  But when I saw this at the museum all I noticed was the average global temperature over the previous seventy million years as drawn on the rest of the chart.  From the chart it is obvious the earth has previously been much warmer. Only in the last few million years have we experienced a more temperate climate.  The recent global warming phenomenon doesn't even take us back to the previous baseline of global temperatures. We are still below average compared to a few million years ago.  It is clear the earth went through an Ice Age in recent history. But now it seems obvious that was not the norm.  The earth is merely rebounding from an abnormally cold climate.  So should we be spending trillions of dollars globally trying to combat mother nature when she is just trying to get back to her previous warm state?

Museum of Taxidermy

No, not really.  But it would have been appropriate when I went to the Museum of Natural History with my kids.  It was hall after hall of stuffed dead animals that looked like they were state of the art in 1960, not 2010.  Even Disneyland uses animatronics mimicking live creatures to entertain the young'uns.  At the museum there were only rows of ancient dioramas with small placards explaining the scenery. "Oh look son, another window of a stuffed seal sitting on a very fake looking ice floe." The bird hall had a massive glass display filled with hundreds of dead birds.  It was actually rather creepy.  The kids were bored quickly and asked incessantly to play with my evil iPhone.  I wished Ben Stiller was there to turn the experience into a Night at the Museum. 

The few areas of the museum that held my children's interests involved live animals or hands on interaction.  They got a kick out of the Insect Zoo.  They had multiple small terrariums filled with all sorts of icky creepy creatures like tarantulas and giant beetles.  Kids love that.  I couldn't pull my son away from all those bugs.  Then in one of the mammalian halls they had several touch screen computers that were swarming with children.  One of the computers had an interactive display comparing different types of animal dung (bears don't digest berries well).  Very amusing, and very educational. 

In the age of Google and the internet museums need to keep pace with the expectations of their audience.  Still models of dead animals will not suffice when children can get dynamic videos on their home computer screens. I used to love going to museums.  But I was a child three decades ago.  Today's children need more to pull them away from their Wii's.  Unless museums understand how to modernize their displays, they could soon themselves be relics.

Surgical Prowess, Or Just Really Good Anesthesia

I read this headline in the LA Times the other day, "Surgery in dire conditions can be safe."  The article talks about a study that says there is only a 0.2% mortality rate in 20,000 surgical cases performed in "resource limited areas" from 2001 to 2008.  The study was published in Archives of Surgery. 

My immediate reaction upon reading this was "Where are the anesthesiologists who should be given at least equal if not greater recognition for allowing surgeons to perform their cases safely in these impoverished conditions? Why isn't there a comparable paper in Anesthesiology called, 'Anesthesia in dire conditions can be safe'? Why do the surgeons get the big write up in a national newspaper while the anesthesiologists who make the cases possible have to stand down away from the spotlight?" I've ranted before about the lack of anesthesia recognition in extremely complicated cases. It doesn't seem just the surgeons get all the glory when anybody with a knife and sutures can slice a body to pieces and put it back together.  It takes a skillful anesthesiologist to make sure the patient survives the ordeal and lives to see another day.  Who was the anesthesiologist when Christiaan Barnard accomplished the first heart transplant?  Who gave the anesthesia when Michael DeBakey performed the first carotid endarterectomy?  Without skilled anesthesiologists, these immortal surgeons would be just hacks with a dead patient on the operating room table.

Look at this study from Archives of Surgery, "Endovascular Repair of Blunt Traumatic Thoracic Aortic Injuries."  Their conclusion says, "Thoracic endovascular aortic repair, via a percutaneous groin approach and without systemic anticoagulation, for blunt thoracic aortic injury can be performed safely with low periprocedural mortality and morbidity." Yeah the surgeons can repair traumatic aortic tears using minimally invasive techniques.  Yippee. The question is who was keeping the patient alive while the surgeons were fiddling with their catheters.  Anybody who has ever treated a trauma patient with thoracic aorta injuries knows it takes a great deal of force to cause this damage.  While the surgeons got a nice paper out of this, the anesthesiologist at the head of the table who was managing all the other injuries in the patients got bupkus. Who was managing the fluid volume?  Who was maintaining blood pressure control?  Who made sure the subject patients did indeed have low mortality and morbidity so the surgeons could dream up their next paper to fill out their C.V.'s?

By contrast, what do anesthesiology journals talk about?  They don't trumpet any advances that generate eyeball grabbing headlines that astonishes the public with the technologic wonders of anesthesia.  We get study after study about the latest research into NMDA receptors or the latest comparative research between bupivacaine and ropivacaine.  Yawn. We anesthesiologists need to get better at promoting the work we do that allows these "miracle" surgeons to shine. We have to make sure people know that behind every great surgeon is a great anesthesiologist.

Somebody Fell Asleep During Anatomy Class

This is my encounter with a recovery room nurse after a procedure.

"Hi Nurse Betty (not real name obviously).  This is a 47 year old female who we just performed an ERCP for choledocholithiasis."
Nurse Betty asks the patient, "Do you have a lot of pain?" as she starts to lift the hospital gown.
"No, this was all done endoscopically.  Everything was performed through the mouth."
"So did you give propofol for sedation?" she inquires.
"The patient is obese so I intubated her and gave her a general anesthesia."
Nurse Betty looks at me quizzically.  "How did you do the procedure through the mouth if she was intubated?  Did you go through the rectum?"  She starts lifting up the patient's bottom.
Me with a look of horror and amusement. "Uh, no. The endotracheal tube went down the trachea.  The endoscope was passed through the esophagus."
"Ohhh. I was wondering how you did the procedure if there was already a tube down the patient's mouth."

That was my contribution for the benefit of mankind for the day.

Gratitude

"Doctor, I am hurting so bad.  I missed my Dilaudid this morning because the surgery instructions said not to eat or drink anything.  Can't you please give me something right now.  I feel like I'm going to faint the pain is so bad.  Also please don't take off the fentanyl patch during the surgery.  And remember to write me for Benadryl afterwards.  If I don't get my Benadryl around the clock with my Dilaudid my itching is unbearable."

"The Taliban on Sunday ordered their first public executions by stoning since their fall from power nine years ago, killing a young couple who had unsuccessfully tried to elope.  The punishment was carried out by hundreds of the victims’ neighbors and even their family members in a village in northern Kunduz Province."
The New York Times August 16, 2010

"What do you mean you can't get my IV?  Why is it you people never seem to be able to get an IV in when I'm here.  When I go get my blood drawn they never have this problem.  I'm going to give you one more chance to get this IV.  Then I want somebody with more experience than you to do it.  If not I'm leaving and never coming back.  This place is a real piece of s***."

"In northwestern Badghis Province on Aug. 8, a 41-year-old widow, who was made pregnant by a man she said promised to marry her, was convicted of fornication by a Taliban court. She was given 200 lashes with a whip and then shot to death."
The New York Times August 16, 2010

"What's wrong with this OR? My cases never start on time. The anesthesiologist is taking forever to see my patient.  The equipment I requested for this case isn't ready yet?  I'm never going to bring any patients here again.  I can get a lot more work done at my surgery center without all the crap I have to deal with here."

"A 12-member team with International Assistance Mission set off from Afghanistan's capital for remote Nuristan province to operate a mobile clinic with eye doctors, a dentist and a general practitioner for people who had little access to medical care. Ten of the team were killed in an ambush Aug. 5 in neighboring Badakhshan province as they made their return trip to Kabul."
The Los Angeles Times August 9, 2010

"Gratitude is not only the greatest of virtues, but but a parent of all the others." Cicero

CRNAs=Anesthesiologists? Blasphemy Says ASA

Here is the ASA's official response to the recent paper in Health Affairs that stated the quality of anesthesia care between CRNAs and anesthesiologists are equivalent. If you surf over to Health Blog in the WSJ where the story first originated, there is a very good, highly emotional debate going on in the comment section. By the way, when I first read the news article and wrote my blog, it failed to mention that the study was funded by the AANA.  Oops.  Kind of an important detail there.  That oversight has since been corrected by the paper. Do you think the WSJ was paid by the AANA to print this now obviously biased study?

ASA Statement Regarding AANA-Sponsored Paper Published in Health Affairs, August 2010 The American Association of Nurse Anesthetists (AANA) - sponsored paper published in the August 2010 issue of Health Affairs, titled “No Harm Found When Nurse Anesthetists Work Without Supervision By Physicians,”1 is an advocacy manifesto masquerading as science and does a disservice to the public.  It makes dangerous public policy recommendations on the basis of inadequate data, flawed analysis and distorted facts. The Institute of Medicine (IOM) reported that in the past 25 years, anesthesia mortality rates have been reduced from two deaths per 10,000 anesthetics administered to one death per 200,000-300,000 anesthetics administered. 2 This achievement did not occur spontaneously: it is the product of forward-thinking ASA leaders and physician scientists.  The development of new monitors, adoption of safety standards, creation of the Anesthesia Patient Safety Foundation, the ASA Closed Claims Project and, most recently, the Anesthesia Quality Institute are evidence of decades of our members’ commitment to improving patient safety through genuine science. The Health Affairs paper reflects the weaknesses of billing data when used to make an assessment of safety and quality.  These billing data were not created for this purpose and do not distinguish between complications resulting from surgery or anesthesia, nor do they discriminate between conditions existing prior to surgery and those resulting from surgical or anesthetic care.  Thus, meaningful analysis of anesthesia outcomes is impossible from billing codes alone. Using the anesthetic-related mortality frequency reported by the IOM,2  the 481,000 cases analyzed in the AANA-sponsored paper would have produced two deaths related to anesthesia, an obviously insufficient number to support any conclusions about mortality.  This exemplifies the gross inadequacy of the paper to draw conclusions about anesthesia outcomes.  Nonetheless, the authors ignore these critical limitations and advise altering Medicare policy, adhering to AANA’s advocacy agenda.  And they make no apology for the disturbing trend in their own data1 toward increasing frequency of mortality and complications in nurse-administered anesthesia during the opt-out “experiment” as compared to improved outcomes in physician and care-team cases. The paper acknowledges that anesthesiologists care for patients undergoing the most complex procedures, but does not recognize that this is also true for the sicker patients undergoing even routine surgery.  Even if one accepted the study’s assertion that outcomes were equivalent, this would point to mortality far higher than expected in the nurse anesthesia group caring for a decidedly lower-risk population.  In a scientific study funded by the Agency for Healthcare Research and Quality (AHRQ), investigators at the University of Pennsylvania found that the presence of an anesthesiologist prevented more than six excess deaths per 1,000 cases in which an anesthesia or surgical complication occurred. 3 This represents compelling evidence that anesthesiologists’ capacity to provide life-saving medical care should be reflected in standards of care. Dulisse and Cromwell assert that the training of nurse anesthetists and anesthesiologists is essentially equivalent.  Since nurse anesthetists receive approximately two and a half years of training following the bachelor’s degree and anesthesiologists spend eight years preparing for practice after the pre-medical undergraduate education (four in medical school and four in residency), this claim defies arithmetic.  The prolonged period of training is to acquire the knowledge base and skills to provide expert care of the patient and all their co-existing disease before, during and after surgery.  Years of experience managing complex disease in hundreds of patients, training 80 hours weekly, prepares the anesthesiologist to do more than administer anesthetic drugs and perform procedural tasks. It provides them the ability to rescue patients who have significant perioperative problems.  This broad responsibility is what makes anesthesiology the practice of medicine. ASA member anesthesiologist Ann C. Still, M.D., a former nurse anesthetist provides additional perspective on the difference between a nurse’s care and a physician anesthesiologist’s care.  “Having cared for patients as a CRNA and now as an anesthesiologist, I see daily how safe patient care requires a physician’s training.” Anesthesiologists serve as the leaders of anesthesia care teams because their level of skill and training is necessary for the safety of the patient. The authors also make the claim that unsupervised nurse anesthesia is more “cost effective.”  Considering that the payment for anesthesia services under Medicare’s system (adopted by most private insurers, too) is identical whether provided by an unsupervised nurse, solo physician or the physician/CRNA team, the fallacy of the “cost effective” claim is evident. The existing Medicare policy requiring physician supervision of nurse anesthesia is rooted in the overwhelming preference of patients, particularly Medicare beneficiaries, for a physician to be responsible for their anesthesia care. 4 Suggesting that this patient preference be pushed aside on the basis of flimsy analytics is irresponsible and is reminiscent of the “scientific studies” purchased by the tobacco industry to demonstrate the safety of tobacco.  Americans understand the value of physician care, just as we saw through the false reports that promoted cigarettes. 1. Dulisse B, Cromwell J. No Harm Found When Nurse Anesthetists Work Without Supervision by Physicians.  Health Affairs. 29(8) August 2010. 2. Committee on Quality of Healthcare in America, Institute of Medicine:  To Err is Human, Building a Safer Health Stystem.  Edited by Kohn L, Corrigan J, Donaldson M. Washington, National Academy Press, 1999, p 241. 3.   Silber JH, Kennedy SK et al. Anesthesiologist Direction and Patient Outcomes. Anesthesiology. 2000; 93:152-63. 4. Tarrance, 2001 at http://www.asahq.org/news/Tarrancestudy2001.pdf

Medical Video Wars

The video sensation that was Orthopedics vs. Anesthesia has unleashed a video war between medical specialties.  However, as Hollywood frequently demonstrates, the sequels and copycat videos are not nearly as good as the original.  While the original had an element of surprise and delight, the followups feel forced and cheap.

The first sequel was Orthopod's Revenge. Anybody who watches this video will instantly recognize the total piece of fiction that it is.  Like a Jerry Seinfeld standup routine, the reason O vs. A was funny was because it cut close to reality.  Revenge just feels like a bad Matrix sequel.


Then there are the videos that practically plagiarized O vs. A. Anesthesia vs. Neurosurgery even repeats the asystole gimmick that was put to such great effect in the original. 


Of course anesthesiologists can't have all the fun.  Several videos return the favor and throw a harsh light on a common perception that anesthesiologists are obstructionists (remember it's all about patient safety) and clock watchers (we're not CRNAs).







Anesthesiologists aren't the only ones to come under criticism from other specialties.  Physicians from fields as diverse as emergency medicine, colorectal surgery, and even radiology are lampooned harshly by videographers presumably with bad experiences dealing with other specialties. Where will these vendettas end?  We haven't yet heard from residents blasting their attendings, physicians satirizing hospital administrators, or doctors ridiculing lawyers. Stay tuned.

Why We Can't Trust Health Care To The Government

Why we can't trust health care to the government.

Fighting The Last Battle

Generals, and nations, are often accused of fighting their last battle during a current skirmish.  For instance, after the Cold War ended, the U.S. military was still ordering giant aircraft carriers and nuclear submarines even though our new enemies were hiding in caves or melting into the civilian population.  Obviously the generals at the Dept. of Defense were anticipating future Soviet era style warfare when that was not the enemy we are facing.

Doctors also become trapped in this fallacy of confronting a (medical) battle based on a previous experience that may not prove to be entirely appropriate for the situation at hand.  When I was a medical student during the surgery rotation, one of the surgical residents made a brilliant diagnosis.  A patient came into the ER with excruciating abdominal pain radiating to the back, hypotension, and pulsatile abdominal mass.  He accurately determined that the patient had a ruptured abdominal aortic aneurysm and called the OR to get a room set up emergently for a AAA repair.  The patient was rushed to surgery and the resident was hailed for his outstanding acumen. He was beaming, strutting around the ward for days afterwards, retelling the same story over and over again.

Wouldn't you know it but the following a week another patient came into the emergency room with sharp abdominal pain radiating to the back, hypotension, and what the same surgical resident felt was a pulsatile abdominal mass.  Again he called the operating room to set up for an emergent AAA repair.  As we rushed to the OR we all commented on how remarkable it was that two cases of ruptured AAA came in so close together.  Once we got into the OR and opened up the belly disaster revealed itself.  As you may have guessed, the patient did not have a ruptured AAA.  He didn't even have a surgical abdomen.  The patient was later diagnosed with acute pancreatitis.  The following week the crestfallen resident was grilled by the inquisitors at M&M conference for taking a nonsurgical patient to the operating room.  Same battle plan, wrong scenario.

I recently faced a similar situation.  A few weeks ago I took a patient to the OR for a routine D+C.  This is a fifteen minute procedure that is usually performed as an outpatient.  No big deal.  I've done dozens of them.  Except this time it was different.  As soon as the gynecologist inserted the suction catheter, the patient bled out a liter of blood.  The patient's blood pressure dropped precipitously.  It became a full trauma level situation.  A Level 1 blood transfuser was rushed into the room and multiple units of blood were transfused.  The surgeon was unable to stop the bleeding and had to resort to an abdominal hysterectomy to control the bleeding.  One of the scariest moments in my life.

You can imagine my trepidation next time I was on call and had to give anesthesia for another D+C.  I treated the patient like she was about to undergo a coronary bypass.  I made sure she had two large bore IV's in her arms.  I typed and crossed her for multiple units of blood.  The surgeon was aghast.  Why are you doing all this, he demanded.  Because as any textbook will tell you, you have to be prepared for massive hemorrhaging with any D+C, was my Oral Board certification level answer.  Naturally the operation proceeded uneventfully.  In and out of the room in fifteen minutes.  Is over preparation also a crime in the OR?  It may appear that I had overcompensated but at least I had peace of mind.  It will probably take me several more D+Cs before I feel like it is another routine case again.

Here Comes The Next Generation of Obese ADHD Inflicted Children

I couldn't believe my eyes when I first saw promos for an infant cable channel, BabyFirst TV.  First established in 2006, it's a channel aimed specifically at children who can barely crawl.  Their website claims the programming has been developed by "education experts" and as a bonus it is commercial free.  Yes the commercials would have been so much more detrimental to the development of the infant brain.

I wonder who the experts were that the network hired to program the channel?  They certainly weren't members of the American Academy of Pediatrics, who have specifically come out against any television viewing for children under the age of two.  The so called experts also didn't do any academic research on the subject of TV viewing in infants and toddlers or they would have seen that there are multiple papers linking TV and development of ADHD later in life.  The network obviously didn't consult with the Disney corporation, who had to recall all their Baby Einstein videos and send a refund for claiming the DVD's was educational for children.  I won't even go into the numerous studies linking TV viewing and obesity.

Have we as a society become so harried that we will pay (it is a premium channel, not basic cable) to have the TV babysit our children for hours at a time?  Even hiring a babysitter would be more stimulating to our children then plopping them in front of the LCD, assuming you didn't get one of those psycho babysitters.  Unfortunately corporate thinkers have come to the conclusion that there is big money to be made broadcasting programs to pre-toddlers, future of America be damned.  They'll just leave it to the insurance companies and government to clean up the mess later by spending billions of dollars on obesity and ADHD related illnesses. 

Leeches

The Happy Hospitalist has an interesting link to a recent survey of physician income.  As one might suspect, neurosurgeons come in at the top of the food chain.  Their average annual salary is $571,000.  However they also brought in the most money for the hospital, with an annual revenue of $2,815,650. Not bad, with a revenue to income ratio of 5:1.  The general surgeons also do pretty well, with incomes averaging $321,000 and revenues of $2,112,492.  The internists have a right to complain about their income.  They average a salary of $186,000 but brought in revenues of $1,678,341, an almost 10:1 ratio. Seems like they are not getting their fair cut of the money brought in compared to the surgeons.

See anybody missing from this list?  That's right, anesthesiologists are not counted in the survey.  Why is that, you ask?  Well, it's because we don't actually bring any revenue to a hospital.  Instead, we siphon off money that other doctors bring in.  That's the reason anesthesiologists, along with emergency physicians, radiologists, and pathologists are frequently considered the leeches of the hospital.  When you consider that an anesthesiologist's salary is about 2/3 that of a general surgeon, you can see that we don't actually bring much value to a hospital's finances. 

This lack of perceived value is why anesthesiology is a commodity product.  Unless the anesthesiologist can bring in paying patients, like procedures for chronic pain, the hospital will always look for the cheapest anesthetist it can get away with.  Radiology is in a similar boat.  With X-ray films now largely in digital format, it is very easy for hospitals to outsource their film reading to a cheaper location, like India.  This search for the cheapest labor is why anesthesiologists should fear the encroachment of CRNAs.  As more states opt out of requiring physician oversight of CRNAs, there will be enormous financial pressure on hospitals to utilize the cheapest person able to intubate and turn on the Sevo vaporizer.  No amount of lobbying by the ASA to keep CRNAs subservient to anesthesiologists will prevent hospitals from their search to maximize their profits.  With the advent of ObamaCare imminent, with its millions of patients with Medicaid level reimbursement, the cheapening of anesthesia services will only accelerate.

CRNAs = Anesthesiologists. We Only Have Ourselves To Blame

Sigh.  In another indictment on the worth of anesthesiologists in the operating room, a study in Health Affairs has declared that patients who receive anesthesia from CRNAs are no more likely to suffer a complication than those who are anesthetized by anesthesiologists.  The authors of the report looked at anesthetic complications in states who opted out of Medicare's rule requiring physician oversight of CRNAs vs. states who did not opt out.  They found no differences in the reported rates of deaths or complications from anesthesia.  They also looked at the complication rates before and after states opted out.  Again there were no differences. They only found that anesthesiologists tended to perform more complicated anesthetics, perhaps due to CRNAs doing more work in small rural hospital settings.

For any anesthesiologist who has worked with CRNAs, the results should come as no surprise.  Though we hate to admit it, most of them are every bit as competent as MDAs. I wonder though how much of this equivalency is the result of the evolving nature of anesthesia.  Are anesthesiologists and the ASA, in our relentless pursuit of patient safety, devaluing our own work?  It was not that long ago that the practice of anesthesia was a tedious, tiresome, hands-on drudgery.  Back before automated sphygmomanometers, the anesthesiologist had to crouch under the drapes to measure the blood pressure by listening for distant Korotkoff sounds in a noisy operating room.  Good luck if the patient was hypotensive or the arms were not accessible.  In the days before capnography, anesthesiologists were literally tethered to the patient by a precordial or esophageal stethoscope to ensure the airway was patent.  Nowadays with all the automated monitoring in the operating room, an anesthesiologist is free to walk around the OR to chat up the surgeons and the nurses or just to stretch his legs.

Anesthesia is so safe now that anesthesia attendings feel comfortable leaving a CA 1 resident in the OR by himself to do a case while he goes to another room nearby to teach a different resident.  The safety profile of anesthesia is so high that it takes thousands of cases to find any meaningful rates of complications.  Take for instance the recent quick demise of rapacuronium.  The FDA tested this new muscle relaxant on thousands of patients before approving its use. It was not until millions of doses had been given that the FDA realized there were serious side effects of the drug and had it quickly pulled from the market.  Succinylcholine would not stand a chance of approval today.

Is it any wonder that, despite the ASA's demagoguery of CRNAs, their work holds up just as well as anesthesiologists.  I fear it will get more difficult in the future for anesthesiologists to justify our reimbursement levels when we can't prove that our skills are any more valuable than CRNAs', not when technology has leveled the playing field for everybody.

California's Housing Bubble And The Primary Care Physician Shortage

I saw this new housing development while driving the other day.  I noticed it mainly because of its ghastly architecture and colors.  Who would live in places that looked like that?  I looked up the developer's website that was posted on the fence.  They describe this complex as "Modern and stylish with a contemporary color palette and exceptional craftsmanship."  How many people do you think will live on this crowded lot?  The developer says that this is a "fourteen-home community of fashionable luxury homes."  Fourteen?!  I bet you didn't think it was possible to take a picture of fourteen "luxury homes" in a single frame.  In most parts of the country you couldn't; that would usually require a couple of blocks to fit fourteen luxury homes.  I also want to mention that these homes happen to sit on one of the busiest streets in town.  How much would you pay to live here?  $100,000? $250,000?  The website currently doesn't have an offering price, but similar places around town made by the same builder go for the mid $500,000 and up. 

If you are a medical school graduate from say UCLA or USC, how likely would you go into primary care if homes in decent neighborhoods start around $500,000?  Can you justify dragging your family through years of debt working down a six figure student loan while paying a rising federal income tax, California income tax of 10%, an LA County sales tax of nearly 10%, taking care of hordes of MediCare, MediCal, and indigent illegal immigrant patients all the while making less than $200,000 a year?  It's no wonder that doctors are avoiding primary care or leaving the state entirely. Other than the greater New York City area, a doctor can get a pretty decent house elsewhere for less than $500,000, even in large cities like Chicago or Dallas.  In California, you either learn to become a specialist or you're just another schmuck who's been drinking up the Koolaid of primary care nobility the medical schools and government have been feeding you.  Yes people appreciate your sacrifices but nobody will pay you a living wage for your services. Oh, that's right.  You didn't go into medicine for the money, did you?