Thursday, September 30, 2010

The Seduction Of An Impressionable Med Student

In a previous article I wrote down the spiel I usually give to medical students when they ask why I went into anesthesiology.  I listed all the medical fields I considered and rejected. Now I will discuss the profession I did match into after med school.  That would be General Surgery.

Imagine me, an introverted, bookish nerd wanting to enter the exalted world of surgery.  On Match Day when our results were revealed, there was an audible gasp in the auditorium when classmates found out I had matched into surgery. It wasn't just any surgery residency either--it was a highly coveted categorical program, which meant that I had a clear path through the entirety of residency.  I wouldn't have to compete for an open position each year like the transitional residents stuck in the pyramidal side.

Why did I choose surgery? Let me count the ways. Surgery was the complete antithesis of everything I disliked about Internal Medicine. The consequence of treating a patient was immediate and understood. It's a great feeling knowing that you are taking a sick patient into the OR to make them better. No more waiting for the patients' symptoms to improve by mere watching and waiting. When in doubt cut it out. I loved that philosophy.

There's also a certain hero complex involved when entering the surgical realm. It seemed you got a certain level of respect when people knew you were a surgeon. Surgeons are frequently the physicians of last resort when a patient is on a downward spiral. When the Medicine docs can't understand why a patient's septic and all the labs and scans come up equivocal, the surgeon is the one who gets paged. After days of watching an ICU patient slowly deteriorate, the surgeon swoops in, rushes the patient to the OR, and makes everything better. "Those dumb ass internists. What the f*** were they thinking watching a patient for a week when it was so obvious what the problem was. If they had waited one more day, the guy would be dead." Mockery of other specialties was a frequent and bonding experience with surgeons. Fun times.

Finally I had several groups of great guys as mentors while doing my surgery rotations. Med students gravitate to fields where they are led by talented attendings and residents.  Who wouldn't want to grow up and be just like them? The surgeons I rotated with made their work seem so much fun and important. Their intellect and confidence was everything I wanted to be as a doctor. I was hooked.

So why am I an anesthesiologist now? That will require a long answer best reserved for the next article in this series.  It is not for nothing that I call my surgical career My Lost Years. Stay tuned.

Continue here.

Tuesday, September 28, 2010

Doctors May Whine But Nobody's Listening

Physicians are up in arms over the advent of ObamaCare and the imminent increase in taxes for people making over $250,000 per year (the rich).  We complain about the tightening of reimbursements from the government and insurance companies.  We decry the escalating costs of running a business.  We bemoan the unfairness of rich Wall Street bankers being bailed out by the government to the tune of billions of dollars for pretty much destroying the world economy and wrecking everybody's retirement savings while we can expect a $500 billion cut in Medicare reimbursements.  You know what, nobody cares.

The Happy Hospitalist recounts an enlightening exchange at a restaurant with an acquaintance.  When asked how they were doing, the friends were surprised that Happy and his wife were not driving a Lamborghini.  Why would he be driving a Lamborghini?  Because he is a doctor, and aren't all doctors rich and self important and drive expensive and exotic cars like a Lamborghini?  Try explaining the trials and tribulations of being a physician and nobody will believe you.  Happy did, and I'm sure it fell on deaf ears.

Todd Henderson, a University of Chicago law professor, recently blogged about how President Obama's planned tax increases on the wealthy (income greater than $250,000/yr) is going to severely affect his family's lifestyle.  He and his wife, a pediatric oncologist, claim to make just over the arbitrary definition of rich.  With both of their student loans totally over $250,000, taxes, childcare, private education for their children, and various domestic help, they claim to save only a few hundred dollars a month.  This blog was ridiculed by hundreds of readers for its self-pitying tone and unrealistic expectations.  You're not going to get any sympathies for having to cut back on professional lawn care services.

According to the U.S. Census, the median household income in 2008 was $52,029.  I bet greater than 90% of physicians make more than $100,000 a year.  When doctors grouse about the enormous debt burdens they carry or how they are operating at a loss from pitiful Medicare payments, most people don't believe it.  They still think we all drive around in expensive imported sports cars, and judging by the profusion of BMW's, Lexuses, and Mercedes in doctors' parking lots, who could blame them?  When families of four have to survive on $40,000 a year, this moaning by "the rich" doctors just sounds petty. 

Does that mean we just roll over and accept whatever punishment is meted out to us?  No. We can work within the system by contributing to various medical PACS and medical societies.  We can write letters to our congressmen and attempt to influence legislation that will benefit physician interests.  Physicians can contribute to candidates who expresses sympathy in helping our causes.  But for God's sake, stop fussing publicly about how we can't live on a six figure salary.  Nobody is listening.

Monday, September 27, 2010

Why I Chose Anesthesiology

Fall is the traditional time of year when medical students finally decide on which residency they want to apply for.  It is not an easy decision.  You are racked with anxiety and uncertainty. "What if I go into this field and realize I made a mistake?  Will I be miserable for the rest of my life?" I field many questions from students about why I went into anesthesiology.  Like everybody else, it was not a clear cut choice for me.

I actually thought I wanted to be an anesthesiologist when I started medical school.  But once you're in school, you are dazzled and distracted by all the different specialties students rotate through. What made it even harder was that my medical school didn't even offer a rotation in anesthesiology, not even as part of the surgery rotation.  So anesthesiology quickly dropped out of consideration, more out of default than anything else.  As I explain to med students, anesthesiology is not a field that is easy to love.  There is no glamor in this field.  There are no TV shows or movies about the bold, courageous, caring, handsome, intelligent anesthesiologists.  Instead we are only mentioned when something goes wrong, like a patient having surgical recall or the anesthesiologist who is caught behind the drapes shooting up and passing out. I think the easiest way to understand why I chose anesthesiology is to first explain why I didn't go into other medical specialties. Then I will discuss all the positive aspects of this terrific and maligned field and why it is the perfect medical practice for me.

Internal Medicine. Are you kidding me?  Couldn't stand the constant rounds every morning during med school.  The endless mental masturbation on the eighteenth differential diagnosis of hemoptysis and fever just bored me out of my mind.  What's worse, once you're in private practice, you are perceived as a mental midget by the subspecialists, someone who couldn't cut it in a subspecialty field.  You are left with the hypertensive, diabetic, COPD, poorly compliant patients that nobody else wants to handle.  Definitely out.

Pediatrics. Love the kids. Hate the parents. (Same reason I don't like to do pediatric anesthesia.)

OB/GYN. There really was nothing I liked about this field.  All the different STD's I saw every day in clinic made me want to scrub my eyeballs and nostrils raw after work.  The birthing process may be a miracle, but it can be really disgusting when feces and urine start flying out with every contraction.  Plus this is becoming a female physician only field.  Sorry guys, you may have a thriving practice now but you are a dying breed.  Most women prefer to have other women examine them and deliver their babies.

Emergency Medicine.  Loved this rotation as a student.  I think most med students get a tremendous thrill in the ER.  You are finally doing fun things like suturing up lacerations or diagnosing and treating acute MI's and DKA's. It was a blast. Unfortunately I didn't have it until April of my senior year, much too late to change residencies. In retrospect, I'm glad I didn't do ER.  I'm not the kind of person who likes to juggle fifteen patients at a time while dealing with the latest trauma that rolls through the door.  This pace leads to pretty fast burnout.  Want proof? You rarely see old ER docs.  I have no idea what happens to them when they turn fifty.

Family Practice. Our school had a huge emphasis on turning out FP physicians.  We had several required rotations in this field.  To me it felt just like Internal Medicine but with added Pediatrics and OB/GYN, which made it a triple negative in my book.

Medical subspecialties. The three years of Internal Medicine pretty much knocked these out of consideration.

ROAD (Radiology, Ophthalmology, Anesthesiology, Dermatology). Radiology was one field I hoped I would love.  Instead I was extremely restless sitting in a dark room every day looking at the same films from the same ICU patients; one day the only change maybe a new line was placed, or the patient was intubated overnight and then extubated a few days later.  That was one rotation I dreaded going to every morning. Ophthalmology, too competitive and really gave me no intellectual stimulation.  Seriously they have a sub subspecialty in vitreous humor? Dermatology was again too competitive.  Why is this field in such high demand?  Are there that many slacker med students who only want 9-5 jobs looking at eczema and prescribing topical steroids?

Pathology.  Didn't like looking into a microscope all day evaluating purple and blue spots.  Hated cadavers.  Cant. Get. That. Smell. Out. Of. My. Hair. Yuck.

Psychiatry.  I actually loved this field.  I had a terrific attending during this month.  He made psychiatry seem so much fun.  You can definitely have great stories to blog about if you are a psychiatrist.  I seriously considered Psych until I realized there was very little we could actually do for these patients.  Seemed like we would try to treat a patient with a drug. If that didn't work we'd try another drug. If that didnt' work, we'd try another one... They all seemed to cover up the symptoms without ever really curing them.  This was a couple of decades ago.  Hopefully newer treatments have been developed since then to improve these patients' lives. This is a field that still makes me think, "What if?"

This is running pretty long.  My feelings about blogs is that they shouldn't take more than two minutes to read so I'll continue this topic in another installment later.  I'll talk about which residency I did match into after graduation from med school, and it wasn't anesthesiology, GASP!

Continue here.

Sunday, September 26, 2010

A Law Only Its Creators Can Love, From A Distance

How much do Democrats love ObamaCare, their one significant piece of legislative victory this year?  Los Angeles Democratic Congresswoman Jane Harman plans to hold a town hall meeting with her constituents this week, by telephone from Washington.  Though she was in L.A. this past weekend, she is not scheduled to talk about health care until Wednesday during the teleconference.  Running away from her voters is nothing new to Ms. Harman, one of the richest members of Congress with assets listed at over $160 million.  During the debates before passage of ObamaCare, she also failed to hold local meetings with her own voters while other congressmen were skewered in their own town hall meetings.

Why would this eight term Congresswoman not want to stand up for something she voted on with such conviction last spring?  Perhaps enactment of the first phase of health insurance reform this last week gave supporters pause.  At the six month anniversary of the passage of ObamaCare, insurance companies had to accept on their child-only policies all children, regardless of preexisting medical conditions.  These policies are popular for their low cost and also for parents whose employers' health insurance does not cover dependents.  The insurance companies feared that parents will now avoid buying health insurance for their children until a health crisis hits, saddling them with sick patients in their insurance pools.  So instead of accepting guaranteed losses on their child-only policies, all the major health insurers just stopped writing them.

What happens in 2014 when everybody has to be covered by insurance regardless of preexisting illnesses?  The law says we all have to buy health insurance to widen the insurance pool or otherwise face a financial penalty.  I doubt the penalties will be enough to force people to buy insurance as the people who can least afford it will be the ones penalized.  Therefore the insurance companies are going to face worsening losses as people decide to buy only when they're sick.  I think the endgame will be when all the insurance companies decide they only want to sell auto insurance and leave health insurance to the federal government.  Thus the back door way to the single payer system will be opened.  European style socialist programs will at last take place in America.

Thursday, September 23, 2010

The Toxic Patient

"Doctor, did you see who's next on the OR schedule," the nurse asks. I take a look and let out an involuntary groan.  We all look at each other with silent dismay.  This was one of those toxic patients that every health care giver dreads.

You know who I'm talking about.  The toxic patient is one who has an endless litany of complaints.  No doctor or treatment is ever able to cure what ails her.  The patient goes through physicians as frequently as she does her antidepressants.  Doctors try to pass her along to some other unfortunate colleague because either they are tired of hearing her grievances and fabrications or the patient fires them, accusing them of incompetence. She is a living hell for the nurses on the ward.  She is constantly buzzing the nurses station making one request after another.  If she wants something that's against doctor's orders, she goes into a hysterical fit.  Then of course the nurses call the doctor to come give her a pain pill, a sedative, or both; just do something about her.

I approached the patient in preop with trepidation.  Her reputation among the anesthesiologists is well known.  She's filed many complaints against our anesthesiologists with the hospital, all of them eventually dismissed.  The only anesthesiologist that she tolerates is Dr. Shafer, and he is not in the hospital. How did I get her on my line up?

I introduce myself, "Good morning Ms. Jones.  I'm Dr. Z. I'll be your anesthesiologist today."

She looks at me with disapproving eyes. "Who are you?  Where is Dr. Shafer? He is my regular anesthesiologist."

"I know. Did you or your surgeon request Dr. Shafer?  He is off today."

"My surgeon was supposed to request Dr. Shafer.  I only want him to do my anesthesia. He is the only one who knows how to treat my pain and nausea after surgery.  You have no idea how bad I hurt after these procedures.  None of you know what you are doing except him."

"Ms. Jones, I've reviewed your old anesthesia records from Dr. Shafer.  I can give you the same anesthesia as he did. I will give you medicine to make sure you're comfortable with your pain and nausea after surgery."

"No. I only want Dr. Shafer to give me anesthesia."

Quietly elated, I page her surgeon.  We discuss her demand to only be treated by Dr. Shafer and how he is not available.  The surgeon talks to the patient and explains that her case will be cancelled if she does not allow somebody else to put her to sleep and that his next available time is two months from today. She is adamant about this and wants to go home if she doesn't get her way.  After much back and forth with the entire OR team waiting for a decision, the surgeon finally cancels the case. She then accuses us loudly of incompetence as she leaves preop holding.  "I haven't eaten all day and took time off from work to come here.  All for nothing! I'm going to write a letter to the hospital," is her final parting remarks.

Whew, I thought.  Got out of that one.  Have a nice life.

Sunday, September 19, 2010

Anesthesia Is Not Easy

Another doctor has learned the hard way that administering anesthesia is not as easy as it looks.  In the hands of anesthesiologists, anesthesia looks like a piece of cake.  Inject some white medicine into a vein and the patient goes to sleep.  Stop the injection and a few minutes later the patient wakes up.  What could be easier than that?

Dr. Rapin Osathanondh has paid the price for trivializing the risks of anesthetics.  The Massachusetts doctor was performing an abortion on Laura Smith in September, 2007.  Apparently he gave the sedation himself as no staff in his office was trained to monitor anesthetized patients. Ms. Smith was totally unmonitored; no ECG, BP, or pulse ox were present.  For that matter, no supplemental oxygen supply was found either.  The patient suffered cardiopulmonary arrest after the procedure.  The doctor then failed to call 911 promptly and lied to investigators about his attempts to resuscitate the victim. Under a plea deal, Dr. Osathanondh will serve six months in jail but is eligible for parole after three months followed by nine months of home confinement.  He also will pay the family $2 million in penalties.

Does any of this sound familiar?  That's right, I'm looking at you Dr. Conrad Murray.  We anesthesiologists have years of experience giving anesthetics and monitoring for its potential deadly effects.  Specialists make procedures like colonoscopies, cardiac caths, and abortions look effortless. But that doesn't mean doctors who aren't similarly trained should perform them. So why do some physicians insist they can give anesthesia when they have no idea how it is supposed to be done properly? Let's hope this is another tough lesson that nonanesthesiologists can take away from and stop jeopardizing patients' lives in order to expedite their own practices.

Friday, September 17, 2010

How Bureaucrats Would Close A Patient

The retained foreign body in a surgical patient.  That is one of a surgeon's worst fears and a hospital administrator's biggest public relations headaches.  Nobody wants it to happen.  Despite meticulous rules and multiple counting and recounting by the OR staff at the end of a case, this unfortunate event still occurs.  In our hospital's latest attempt to eliminate this scourge once and for all, the bureaucrats in the administration have devised a new set of rules for OR staff to follow before a surgical wound is allowed to close. 

Normally a surgeon only needs to say, "Stitch!" to declare he is ready to start closing. The new rules only require six additional steps that needs to be undertaken before the surgeon is handed his closing sutures.

1. The surgeon has to verbally announce in the OR that he is ready to close the patient.

2. No distractions allowed. That means the music is turned off in the OR. No superfluous conversations are permitted. Anesthesiologist, stop that yapping with your investment manager.

3. The nurses' counting of instruments cannot be interrupted.  Therefore nobody is allowed to pop their head in to ask about lunch breaks or scheduling conflicts.

4. The surgeon announces he is starting his wound exploration for any retained foreign body.

5. The surgeon announces he has finished his wound exploration.

6. The nurse announces that all instrument and sponge counts are correct.

7. At last the surgeon is given his closing sutures.

There is a checklist for every patient where all these steps have to be checked off.  The surgeon, nurse, and anesthesiologist all have to sign off on this checklist to verify that it took place.

Will this eliminate the possibility of retained foreign bodies in a patient?  Highly unlikely.  Let's face it, nobody intentionally leaves a sponge or instrument inside a patient unless under extraordinary circumstances ie/ trauma. Every surgeon finishes his case with counts confirmed correct by the nurses.  It is only when there is an unrecognized mistake in the counting that this accident can happen.  Ultimately, it is the quality of the count at the end that will catch a retained FB.  These elaborate new rules still depend on that action to prevent this error.  But since we're only doctors working in the OR, we're not the ones making the rules.  People who work nine to five and attend their committee meetings all day long without any clinical responsibilities are the ones calling the shots. That's how these idiotic rules come to be.


Have you ever noticed how anesthesia monitors keep getting stacked on top of each other?  Look at this generic Google image of an operating room.  The monitors are stacked so high that one needs to be standing up to make any adjustments.  This is most annoying when you are sitting at the machine, reading your Kindle, when the surgeons' cautery causes the monitor to alarm.  Unless you have arms like Clyde in Every Which Way But Loose, you are forced to stand up to push the "Silence" button on the machine.  Very inconvenient. 

During one of my more inspired, and slacker, moments, I thought, "Why not use a pointer to extend my reach so that I don't have to exercise my quads more than necessary to shut up that stupid alarm?" That's when I came up with the Z-Stick.  As you can see from the picture, the Z Stick allows me to reach up to the monitor while staying in my sitting position and push the "Silence" button on the touch screen we use in our hospital.  The beauty of the Z-Stick is that it is readily available; it is the endotracheal tube stylet found in every anesthesia cart. It is also extremely cheap and very portable.  If you still use the old monitors with physical push buttons you're out of luck as the Z-Stick will probably not allow you to generate enough force to push a physical button, but for the touch screen it is perfect.  (It doesn't work with the iPhone or iPad as those require you to touch the screen with your skin.  Damn you Steve Jobs.) You'll get sneers and eye rolls from your surgical colleagues as this only confirms their worst suspicions about anesthesiologists, but who cares.  If I wanted to stand all day and develop spinal stenosis by my 45th birthday I would have gone into surgery.  I'm an anesthesiologist. My anesthesia throne is sacrosanct.  Nothing will come between me and that comfortable cushy chair, even an irritating, twitchy OR monitor. Try it.  You'll never go back to standing again.

Monday, September 13, 2010

My Last Word Regarding Gulf Oil Spill

Full disclosure: I am an angry disgruntled shareholder in BP

I am only going to talk about the Gulf oil spill one last time since this blog is mainly about anesthesia and health care.  However I feel like I have to speak up as a growing body of evidence shows the Gulf oil spill has only had a minor effect on the Gulf of Mexico ecosystem.  Back in May, when the Deepwater Horizon exploded and there was mass hysteria about oil soaked sea birds and turtles, beaches closing up for the summer, tourist businesses disappearing adding to worsening unemployment rates, I wrote that the affects of the oil will be much less than people think.  Talking heads and so called scientists were predicting an Exxon Valdez II but on a much wider scale.  Network news were replaying 20 year old images of oil covered rocks in Prince William Sound with hundreds of workers using high pressure hoses to fruitlessly wash off the gunk.  I noted that this time is different.  The Gulf of Mexico holds an estimated 660 QUADRILLION gallons of water.  The amount of the spill was far greater than I first estimated, currently thought to be around 200 million gallons.  If you do the math, it is clear the amount of oil spilled is still a tiny, minute, microscopic fraction of the content of the Gulf. And the Gulf of Mexico is not a stagnant body of water; it is constantly circulating with the greater Atlantic Ocean.  Therefore I thought it was obvious the oil spill would not have nearly the detrimental effects on the Gulf as the so called pundits were screaming about.

Now in the latest in a series of articles, the New York Times has come to the same conclusion.  Scientists can barely find any trace of oil in the water.  Hundreds of thousands of birds that were thought likely to die have not come to fruition.  They can only find a few thousand oil stained dead birds and how many of those that died from natural causes and washed up into the oil is still being determined.  Dead sea turtles initially thought to have died from asphyxiation or ingestion of oil on necropsy have shown no trace of oil internally.  The only pictures of oil on the shore are usually highly magnified small clumps of hydrocarbon surrounded by expansive snow white beaches.  Marshes that were predicted to die off and expose fragile bird sanctuaries instead only exhibited a few feet of oiled grass closest to the shore.  The miles and miles of wetlands behind this oil line is unchanged.  We now know that new grass is even growing within the oiled areas.

But I reserve my greatest ire for the Obama administration.  This incompetent president, in an attempt to hide his inept handling of the situation, strong armed and blackmailed BP to steal $20 billion from shareholders to pay damages from the spill.  At the time the effects of the spill were still unknown.  BP was not the only company operating the doomed oil rig but it was the only one singled out for compensation.  Like crooked lawyers, the president and his advisors reached into the deepest pocket and fattest wallet they could find and extorted billions of dollars before a single shred of evidence of culpability was discovered.  Billions that should have gone to shareholders, retirement accounts, and research and development disappeared into a black hole of government bureaucracy instead of helping our economy and decrease our oil dependency on the Mideast. 

What about the supposedly giant plume of oil that sits 5000 feet underwater?  What about the microscopice droplets of oil found in shrimp larvae?  What about all the fish and birds that feed near the oily shoreline? Scientists, in their attempts to justify their existence, still insist that the long term effects of the spill are still unknown. Well, I suppose these scientists still have families to feed.  But it is now clear that the apocalyptic predictions last summer were off base. They have to look really hard to even find any evidence of actual damage from the oil. In the meantime, this presidency's unprecedented wealth distribution continues. The president's extortion of BP would not pass muster in any U.S. court if BP decided to challenge the compensation fund it was forced to create. He still insists on raising taxes next year on people who are the most likely to create desperately needed jobs in this country.  The only ones doing well lately are his Wall Street friends and attorney buddies. These are dangerous times indeed.

Friday, September 10, 2010

Post Vacation Despondency

Some people say vacations are necessary to renew the spirit and revitalize the senses.  In Europe, mandatory month long vacations are practically a birthright. For me vacations are beneficial only up to a point.  A three day or four day weekend is about all the off time I can handle.  Anything more than that and rejuvenation turns into lethargy.

I just finished a ten day vacation that has left me feeling slow and wavering back at work.  Everything seems to take just a half second longer to perform.  Which drawer holds that Miller 4 blade?  Where is that ampule of atropine in the drug tray? What is the phone number for Preop? Ugh. For this reason I sometimes wish I didn't take vacations.  After working for months without an extended vacation, I am an anesthesia Terminator. I am precise, uncompromising, relentless.  I may be tired. I may be short tempered. But I am a machine.  Everything is functioning almost on automation.  My confidence in my ability to handle any anesthesia situation is nonpareil. Somehow that self assurance slowly slips away for every day I am not sedating somebody.  It will take me a few days of work to get back to that level of efficiency.

Did I have some mind blowing life altering vacation that has me distracted at work?  Far from it. It was just a staycation this year.  We are in the final stages of our home remodeling project so there was no opportunity to travel. To keep the kids and myself from going bonkers while we had all this "quality" time together, we explored local educational opportunities like the Aquarium of the Pacific in Long Beach and Griffith Observatory. These places are definitely much more involving than the stuffed animal museum otherwise known as the Museum of Natural History my children visited on their school field trip. When I was not trying to instill their impressionable little brains with knowledge, we watched a lot of Phineas and Ferb, my new favorite kids show.  They have the catchiest theme song since Gilligan's Island or The Beverly Hillbillies.  Check it out on the Disney Channel. You and your children will love it. Now back to work.

Wednesday, September 1, 2010

"Housecall" From Hell

The body of an internist in Bakersfield, CA was found stuck in the chimney of her boyfriend's house. Dr. Jacquelyn Kotarac was reported missing by her office two days prior to her death.  She had attempted to forcibly get into her boyfriend's house with a shovel.  When that failed she climbed a ladder to the roof and slid herself down the chimney.  In the meantime her BF escaped from the house.

A house sitter smelled a foul odor a couple of days later. She noticed fluids dripping down from the chimney (Ewww. One reason I didn't go into Pathology). When they shined a flashlight up into the chimney they discovered Dr. Kotarac's feet wedged inside. Took firefighters five hours to dismantle the chimney and remove her body. Now her ex is stuck with repairing a broken chimney and depressed housing value. Thanks a lot doc. Just goes to show doctors are imperfect (occasionally frighteningly crazy) humans after all.