Monday, December 20, 2010

How Much Do Anesthesiologists Make, 2010 Edition

Here is the latest statistics on compensation for anesthesiologists, courtesy of  My previous write up about this was from the U.S. Department of Labor whose numbers are drawn from 2009. This survey was conducted for the current year so hopefully it will be much more relevant.

According to the report, anesthesiologists on average are paid $362,450 per year. Partners in an anesthesia group averaged a whopping $405,346 while an employee anesthesiologist made $337,187. Male anesthesiologists as usual made more than their female partners, $368,654 vs. $313,529.  As expected, the years of experience also weighs in on compensation. Those with less than five years made $339,055. For those with six to ten years of work, they averaged $330,192. The most experienced anesthesiologists with greater than ten years of experience made $377,121.

Is it any wonder anesthesiology residency is still highly coveted by graduating medical students? The ROAD to success in our field has not diminished. If the ASA is ever successful in convincing Medicare to compensate anesthesiologists fairly (33% of private insurance payments for anesthesiologists vs. 80% of private insurance for other physicians), we will have one more great story to tell the best and brightest students to join our esteemed profession. Hint: contribute as much as you can to ASAPAC, the most successful medical PAC in the country.

Sunday, December 19, 2010

A Colleague's Betrayal

We like to think that anesthesiologists are all congenial, selfless individuals looking out for each other and our patients. Anesthesiologists get accustomed to being screwed by the surgeons or the operating room. It can be pretty exhausting during the course of a day dealing with all the nonmedical issues we have to put up with. It is nice to believe your partner has your back and can be depended upon to help out. Therefore when you get the shaft from your own anesthesia colleague, it can be really disappointing.

I'm not talking about patient related emergencies like a difficult airway. I like to think I can still depend on them to help out in such a dire situation. I'm thinking more about personnel issues that should be the last thing we have to worry about. For instance, we have an overnight call team that starts their shift at 3:00 PM and is responsible for all the appendectomies, D+C's, traumas, etc. that roll in through the course of the evening. When we're on that shift, we usually can count on having the day free to run errands, take the kids to school, or just sleep in. But on more than one occasion, when I've been on the night shift, a colleague will simply not show up for work and all attempts to reach them are futile. So guess who gets called in to do the morning cases and still have to work all night, essentially a 24 hour shift?

Sometimes it's the other way around. The surgeons may decide to keep adding cases far into the night. As the anesthesiologist in the room, I have the option of having the on call person take over the room so I can leave at a reasonable hour. However I've had instances where the call person (not the overnight shift) has refused to accept this responsibility. He might argue that he's already home and doesn't want to drive back to the hospital. Or he has a long line up of cases the next day and is too tired to take on more cases that night. That's when you dishearteningly realize you are on your own and are stuck with the cases until the overnight person is free and can finally take over your room which might be anywhere from 10:00 PM to 2:00 AM.

Granted this disgraceful behavior is decidedly uncommon within our group and is relegated to a few usual suspects. Complaints to higher ups usually get a "we'll deal with it" reply and not even a noticeable slap on the wrist. The fact that this happens at all though is frustrating and adds another level of stress to our already taxing profession.

Thursday, December 16, 2010

Stages of Grief, Computer Crash Edition

Denial--(Turn on office computer and screen stays blank.) Hmm, I guess I didn't push the ON button hard enough. Push a little harder this time. Still nothing? Is the monitor off? No. Check the plug at the wall outlet. No that's still good. Try pressing the ON button again.

Anger--Goddammit! Who's been messing around with my computer? Did somebody in here touch my computer?  This is f***ing unbelievable. I have a talk due next week and this stupid piece of s*** decides to die on me. Who in the office last used this computer? I want to know exactly what you did to cause this mess.

Bargaining--(Call in IT help) Please, please you have to rescue my computer. I've got all my slides and presentations in there and I need to have this thing working or I'm up the creek. Dear God of Gentle Mercy, if you bring back my computer I promise I'll back up my hard drive every night and tithe 25% of my income to the church. Oh Lord can't you bring it back just long enough for me to offload my files?

Depression--Why is this happening to me? What did I do to deserve this fate? I take such good care of my computer. I never drop it or spill coffee on it. I always have the latest antiviral software loaded. I even use a surge protector. Why did this have to happen to me at the worst possible time?

Acceptance--I'm so stupid for not backing up my hard drive more often.  I think I may have older copies of my work on my home computer. Hopefully I can reconstruct my presentations from those. I never did like that one talk anyway. Now is a good time to improve on it. Que sera, sera.

Wednesday, December 15, 2010

December Stampede

Christmas shopping isn't the only thing people rush to complete in the month of December. Seems like many are also trying to squeeze in their medical care at this time of year. You would think that getting sick would not be a seasonal event, other than getting the flu. But our hospital is always incredibly busy from late November to New Year's Eve. Every operating room is booked for the entire day. Post call personnel are asked to work instead of getting their usual day off. Don't even think about calling in sick unless you are on a vent in the ICU somewhere with multiple pressors running. Everybody complains about the lack of rest and not having enough time to see their families. Then once the clock strikes midnight on New Year's Day, O.R. volume drops precipitously. Suddenly they are requesting, if not scheduling, people to take time off. People finish their O.R. line up by 1:00 PM or sooner. Anesthesiologists are begging for more cases to do. Everybody grumbles about not making enough money to pay their mortgages and children's private school tuitions.

What accounts for this annual health care stampede? I don't have a definitive answer but the consensus around here is that it's all about the money, or to be more precise, free health insurance money. The theory is that by December, most patients have already paid in full their deductibles for the year. At this point, all medical treatments are being paid by the health insurance company from the first dollar. Therefore smart logical people will try to get as much done as possible before the calendar rolls over. Everything semielective and expensive such as surgical procedures are put off until the end of the year. This theory also explains why the number of scheduled surgeries plummets in January. Suddenly people have to start paying their deductibles again. Unless it is an emergency or a necessity, medical treatments are put off as much as possible.

I have no concrete evidence to prove this theory but it makes sense. Rational people will make decisions based on their best self interest. If somebody will pay for your health care for free after a certain set deductible, why not use and abuse it as much as possible? That's why health care is rationed in countries with universal health care, like England. Patients will consume as much medical care as they can get away with if nobody is paying for it. In this country we don't have universal health care; everybody gets to have their goodies for only one month until December 31st. Then a more rational medical consumer reemerges and we anesthesiologists finally get to go on holiday vacation.

Tuesday, December 14, 2010

Most Family Stickers I've Ever Seen On A Car Window

I was driving to work early one morning and saw this minivan with the most number of family member stickers I've ever seen stuck to one window. I don't think the whole family would fit in the minivan at the same time. Sorry about the quality of the picture. You can blame Apple and its evil iPhone's wretched camera.

Trivialization of Anesthetic Risks is International

By now we're all familiar with the fatal consequences of downplaying the risks of anesthesia. This blog has expounded multiple times on the deaths of patients who were administered anesthetics without the proper anesthesia training or monitoring. There is of course Michael Jackson's untimely demise at the hands of a distracted cardiologist. Then there's the case of Dr. Osathanondh, who gave a general anesthetic for a D+C without a single monitor on the patient. Absolutely shameful and without reason.

Now there's news that this underappreciation of anesthetic complications is a shared trait amongst surgeons worldwide. In China, a reality show contestant by the name of Wang Bei was undergoing facial plastic surgery. During her procedure, her airway was apparently not protected. She aspirated blood from the surgery and could not be resuscitated. The Chinese government is now looking at tighter regulation of their burgeoning plastic surgery industry.

When will all surgeons realize the importance of patient safety before they make a cut? Remember, you won't have any referral business if your patient is dead.

Monday, December 13, 2010

Flying Car Caught In Los Angeles

Here's something you don't see very often. A drunk driver in San Pedro, a suburb of Los Angeles, lost control of his car and literally flew off the road. He and his passenger wound up wedged between the sides of two adjacent homes. According to the newspaper article, there were no skid marks on the road leading up to the accident scene. Luckily nobody was killed and the car passenger was well enough that he tried to run away from the car. Bizarre but not surprising in a city where car chases are a secondary form of TV entertainment and driving mayhem has been immortalized into a video game.

Thursday, December 9, 2010

Brain Dead Interventions

The conversations in the operating rooms are not always that interesting or informative. But sometimes it is amusing to hear the surgeons complain about their work. The other day, they were whining about the inane consultations they sometimes receive from internists. They seemed to be trying to top each other with clueless internist referrals.

The first surgeon said she received a call about a patient who had a hematoma under the arm where the blood pressure cuff was wrapped. She goes to see the patient and evaluate the arm. The patient turns out to be ventilator dependent, brain dead, and was about to be terminally extubated per family request. Needless to say she did not drain the arm hematoma.

The next surgeon said he could top that. He got a referral from an internist for a patient with dry gangrene of a leg. The leg was literally black and mummified. The doc wanted to know if the surgeon can do something about that hideous leg. The kicker was that the patient has anoxic brain injury, is ventilator dependent, and is fed through a gastrostomy tube with no hope of being ambulatory ever again. The patient's family was pressuring the internist to do something, anything, for the leg. The surgeon rightly told the internist that since the leg has dry gangrene, nothing needs to be done. If it gets infected and turns wet then an amputation will be necessary. The internist couldn't go back to the family with that answer. Therefore the surgeon acquiesced and ordered a vascular study of this vegetative, bed-ridden patient to appease the primary doc and the family with no intention of ever following up.

Besides what these stories say about the economics of health care in this country, I'm just so glad I decided to become an anesthesiologist.

What Nurses Really Think About Their Patients

I saw this funny (?) sheet posted up in our ICU. It is a sample page on how to admit a patient into the unit. I noticed the pseudonyms given to the pretend patients. Instead of the usual "John Doe" or "Jane Smith" they use the names "Harry Bumm" and "Crazy Old Lady." Hmmm. I wonder if somebody was having a bad day when they printed this out.

Wednesday, December 8, 2010

Simple Way To Reduce Medication Errors

Take a close look at the picture above. If you were looking down into the anesthesia cart drug tray, this is what you would see, a whole drawer of lookalike drug caps. The four drug bottles on the left are different from the ones on the right but you would be hard pressed to tell the difference with a quick glance. The green cap on the left belongs to a bottle of oxytocin while the green cap on the right belongs to dopamine. Think there would be major repercussions if those drugs got mixed up and was given to a patient? The gray cap on the left is metoprolol while the cap on the right is potassium. If you were in a hurry and reached for the metoprolol but accidentally pushed potassium, think the patient will have a problem with that?

Well, you might ask, how about making the bottles of different shapes and sizes. Unfortunately many of the drugs come in one milliliter quantities so even the bottles are practically identical. The picture on the left shows a bottle of phenylephrine next to a bottle of metoclopramide. Identical white caps, identical sizes and shapes of containers. Occasionally I've caught the pharmacy put the wrong drugs into the wrong section because they look almost exactly the same.

I don't understand why drug companies have to choose the same color caps for their medications. With a whole rainbow of colors to choose from they select the same shades of gray or green or blue or yellow. Or they get lazy during their marketing meetings and simply choose white. They could certainly make the bottles different too. Use a colored glass instead. Perhaps the pharmas could even dye the drugs a certain color to make it more noticeable if you're drawing up the wrong medication. Right now it's easy to tell if you're giving a patient propofol because it's the only white opaque drug. (Don't get me started on how it can get confused with intralipids.) What if all the drugs had different colors. Make all the muscle relaxants red. The antihypertensives green. The vasopressors orange. The possibilities are endless.

You say it will drive up the cost of manufacturing these generic drugs? Well, what is the cost of giving the wrong drug to a single patient? Besides the harm to the patient, the cost of taking care of the patient after a major medication error along with the inevitable lawsuit can reach into the millions. With healthcare mistakes causing thousands of deaths a year, I think this is one area that can easily be corrected with minimal expenses to everyone.

Old School Anesthesia Assessment

Once in a while, when I have a few precious minutes to spare from my work and family, I'll get around to reading piles of old material sitting on my desk. Sometimes I'll even discover something interesting and useful in all those unread pages. The other day I finally perused a recent issue of the ASA Newsletter. In a column by Dr. Douglas Bacon, editor of the newsletter, he discusses how anesthesiologists assess the risk for a patient about to undergo surgery.

In the era of modern medicine, we anesthesiologists have a wide assortment of choices to help determine if a patient will survive an operation. Who amongst us hasn't requested that a patient first get a stress echocardiogram or a pulmonary function test to see if we can administer an anesthetic safely? But what if these state of the art examinations were not available to us? How can we assess the health of our patients with something more objective than asking them if they can walk up two flights of stairs without getting shortness of breath? What if they live in a one floor house? How many steps are on their stairs? How tall are the stairs? What is the pitch? Not very objective is it?

Dr. Bacon describes two tests that used to be conducted by anesthesiologists in the early years of the last century. The first one he describes as :

pulse pressure/diastolic pressure

If the answer falls within a ratio of 0.25-0.75 the patient is considered healthy enough for surgery.

Another test he relates is called the energy index:

(pulse rate * (systolic pressure + diastolic pressure)) / 1000

If the number is less than 13 the cardiovascular system is considered weak. If it is greater than 20, it is considered to be carrying an excessive load.

I've never tried these algorithms before when interviewing a patient in preop. I'm going to give a few tries to see how astute the old timers were without resorting to 21st century medical technology. If it works, it certainly would be more expeditious and cheaper than delaying a case to order a stress thallium scan.

Tuesday, December 7, 2010

Elizabeth Edwards



John Edwards: medical malpractice lawyer, failed presidential candidate, philanderer

Elizabeth Edwards: trusting wife, mother of four, cancer victim

R.I.P. Mrs. Edwards

Thursday, December 2, 2010

Do Anesthesiologists Make You Want To Go Pee?

Dear Patient,

Does the sight of an anesthesiologist approaching you give you an urge to pee? How else to explain the all too common phenomenon when I am about to introduce myself to you that you suddenly have the urge to go to the bathroom? It never fails. You can be sitting in preop holding for 45 minutes or an hour, happily lying on the gurney watching TV or reading your iPAD. But the minute I walk up to you, you have to excuse yourself to go urinate. You may be in the OR for a TURP because your poor bladder just can't expel all that urine past your enormous prostate, but the sight of an anesthesiologist opens up your urethra wide like the parting of the Red Sea.

While I can understand that everybody has to go when nature calls, it never seems to happen with your surgeon. When the surgeon ambles up to the bedside to discuss all the potentially deadly complications he is about to inflict on your innocent frail body, you seem to be able to hold it all in. In reality that should be the precise time you should be hurling and spewing your guts out thinking about what you are about to undergo under the guise of "modern health care".

Instead when I introduce myself, you run off to the bathroom. I am left standing there looking at an empty bed, leafing through your (usually) incomplete chart trying to comprehend the scribble of an H+P written by the surgical resident. In the meantime I'm trying to ignore the wall of eyeballs of your family members zeroing in on my defenseless, self-conscious soul. What are they thinking about me behind those steely probing glares? "How old is he? Which medical school did he graduate from? Should I ask him for his phone number?" Frankly, I don't even like to start the IV after you've been to the bathroom; I don't know how well, or even if, you washed your hands after relieving yourself. Did you do #1 or #2? Actually I don't want to know that. It would just cause me to recoil more. All the while the clock is ticking as the OR finds another excuse to classify a late case start as "anesthesia delay".

When should you go to the bathroom? The obvious answer is when you are changing out of your street clothes into the hospital gown. Take all the time you want then. Nobody will object. If you have to go after that, at least try to wait until I've had a chance to talk to you and get you ready for surgery. That way my precisely honed timing for preoping patients will not be disrupted. Your case will then start on time and you, me, the surgeon, and the OR will all be happier for it.


Dr. Z

Wednesday, December 1, 2010

Reflections On A Family Vacation

Well, I'm back. It was the family's first road trip and a nice Thanksgiving vacation.  The children behaved better than expected and we all ate too much over the last week. Time for my ritual diet before the onslaught of Christmas ham and eggnogs. In the meantime, I'd like to share a few observations about our vaca.

People in the South love their buffet restaurants. Everywhere we went there was a Chinese buffet or a Golden Corral. I even saw a place that served a buffet of KFC and Taco Bell under one roof. If I was still in college I would probably live there. Even though this was Thanksgiving and presumably everybody has had their fill of food at home, all of these buffet establishments looked packed.

Children's menus at all restaurants are similar and similarly disastrous for your child's diet. With nary an exception, they all featured (Kraft!) Mac and Cheese, chicken tenders, and corn dogs.  After a week of feasting and eating out, my six year old developed pimples for the first time in her life. Broccoli for the next week now that we are back home.

Children have an endless capacity to ask "Are we there yet?" A DVD entertainment center in the minivan is no use since after a few hours they get restless regardless of what video they're watching. When that gets old, there's always...

Looking out the window, the American landscape is a constant source of fascination, especially for the kids. From the cotton fields in Texas to the windmills of Oklahoma to the snowcapped mountains above Flagstaff the scenery outside the car window offered endless sources of education and enchantment.  Their eagerness to learn about grazing sheep in a roadside field or giant rolls of hay bales makes one proud to be a parent.

After living in So Cal, it was a pleasure to venture someplace more gracious and less crowded. I hadn't taken an extended vacation in years. I think I will do it more often from now on.