Monday, February 28, 2011

Hooray! My TV Broke

My TV broke yesterday. Well not exactly broke. It developed a picture defect. It was just fine when I was watching American Idol last week. Then over the weekend when I turned the TV on a fine black horizontal line appeared across the middle of the screen. At first I thought maybe it was only on a particular channel. But then I tested it on different channels and a DVD and the line was still there. Yup. The TV is starting to give up the ghost. I can only see the line on a picture with a light background. If the screen is showing a dark picture the line is hardly visible.

At first I was thinking "WTF!" Then I realized there is a huge bright side to this dark line. I can finally get a new TV! I had designed the entertainment center in my man cave to accommodate a much larger screen than what I currently own. But the ole missus has always said there's nothing wrong with our TV. Why spend money on replacing something that works perfectly fine? She has a point. Plus after our remodeling project after buying the house, our cash was running a little low anyway. A spanking new mega TV was not in our budget. But it's a new year. The piggy bank is starting to replenish itself a little bit. And now there is a clear indication for a new giant flatscreen 3D TV.

It's disappointing how quickly this TV developed a defect. It is only four years old. Yes I know that is an eternity in technology. Computers are made to be replaced every three years. Cell phones are designed to last only the standard two year phone contract. Apple releases a new iPhone every year and everybody dutifully ditches their old one for a slightly newer and improved one. But I am old enough to remember when electronics were built to work for years, even decades.

One of my earliest TV's was a portable 13 incher from Zenith. It was "portable" in name only because it weighed about 30 pounds. This TV had the density of plutonium. It had a built in carrying handle on the top which made it portable. The TV had two tuning dials: one for VHF and one for UHF. Remember VHF and UHF? This baby lasted from my junior high years when my parents got it for my bedroom all the way through high school, undergrad, medical school, residency, and attending. The picture, while small, was sharp, colorful, and gorgeous. If you had a good reception from its antennas, the picture was better than any cable channel. Unfortunately I finally got tired of lugging around the little TV from one location to another. I finally donated it to a friend who I'm sure will use it for years to come. I'm getting misty eyed just thinking about it. Here's to the great American manufacturing quality that long ago disappeared with our current account surplus and meaningful physician compensation. In the meantime I'll be watching a lot of dark programming on my defective TV. How many times can I watch "Pitch Black"?

Sunday, February 27, 2011

What's A Nurse To Do?

I saw these two signs over the head of the bed of a patient the other day. One sign reads in big bold blue letters to keep the head of bed flat at all times along with a big exclamation point for emphasis. The other sign reads "Aspiration Precautions". Then in smaller letters it says "Keep HOB elevated 30 degrees". Hmm. Is it any wonder when nurses scream in frustration over their jobs?

Tuesday, February 15, 2011

Give Me Propofol, Straight Up

There is a study in Gastrointestinal Endoscopy this month advocating the use of balanced propofol sedation (BPS) over what the authors call conventional sedation (CS). BPS consists of propofol along with the use of midazolam and meperidine while CS is just BPS without the propofol component. The study consisted of 222 patients who underwent therapeutic EGD or ERCP. At the conclusion of the study, they found that there was no statistical difference in complication rates. However BPS was found to statistically improve patient cooperation along with health care provider and sedation nurse satisfaction with the procedure.

Now I have to admit that I've only read the abstract that's available on the Gastro Endo website. I don't have a subscription to the journal. What do you expect, I'm an anesthesiologist. But I found their rate of cardiopulmonary complications quite appalling. The abstract does not delve into their definition of cardiopulmonary complication (hypotension? MI? Aspiration?). For BPS the rate of complications was 8.8% while for CS it was 5.8%. Transient interruption of procedure was 2.9% for BPS vs. zero for CS. Neither sedation caused termination of the procedure or required assisted ventilation.

Again I haven't read the entire article. I'll have to go to the medical library to see if they even subscribe to it. But a 9% cardiopulmonary complication rate seems quite excessive. Even 5.8% sounds high. My question is, why use a cocktail at all? My preferred sedation for endoscopies, including therapeutic procedures like ERCP and EUS, is straight propofol, and nothing but. Let me tell you my experience from giving thousands of sedations for GI docs.

I find that Versed adds virtually nothing to propofol sedation. You might give it for excessively anxious patients in preop or pediatric patients, but most adults can handle the brief 2 minute or less transport from preop into the procedure room. They may say that they need something to calm them down but when you explain to them that Versed will prolong their post procedure stay for up to an hour, most people won't mind a little anxiety before the start of the procedure.

I rarely give narcotics either. Again narcotics add almost nothing to the propofol sedation. Some procedures that are excessively painful, such as biliary or pancreatic duct dilation, may require narcotics during the course of the procedure. In those cases I would only give short acting narcotics such as fentanyl. But giving narcotics routinely for sedation only increases the risk of intraop apnea, hypotension, hypoxia, and postop nausea and vomiting. The last thing you want as a GI anesthesiologist is a PACU full of unhappy wretching patients that the nurses are unable to discharge home.

So this study asks the wrong question. It's not which sedation cocktail is better for therapeutic GI cases. It's whether anything besides propofol is required to sedate a patient adequately for the gastroenterologist to complete his procedure. Trust me. You don't need to complicate your life by giving anything else besides propofol. Cheers.

Doctors Without Borders? How About Doctors As Border Guards

The Arizona legislature is considering a bill to require all patients entering hospitals to provide proof of residency. Illegal immigrants cost the state millions of dollars in unreimbursed medical care. Since hospitals are not allowed to turn away anybody seeking medical care, the bill requires doctors to treat their emergency cases first then inquire about residency status afterwards. If the patient is found to be in the country illegally, the hospital will then notify the INS about the patient's status.

Rightfully the medical community in Arizona is outraged by this proposal. There is legitimate concern that fear of getting caught will keep illegal immigrants from seeking medical care until it becomes a much bigger and more expensive problem to treat. I, like everybody else, wish we didn't have so many people in this country illegally. The path to residency and citizenship has served this country well for over 200 years. It's not right that millions of people have decided to break our laws by coming here and taking jobs from millions of unemployed Americans.

But using doctors as border agents is despicable. Our border is just to the south, a simple line that runs through the desert sands that clearly demarcates who is here in the country legally. Wouldn't it be easier to spend the state's resources to enforce that single border? Now there will be multiple borders, at each hospital entrance, to check for residency papers. Maybe the state just doesn't want to spend their own money to keep illegals out and instead pushes the responsibility and the expense onto the hospitals.

Even if the hospitals do report all the illegal immigrants in their wards, what is anybody going to do with that information? I could go to any INS office right now and tell them exactly where the illegals congregate. Just go down to any Home Depot or U-Haul parking lot and you'll find dozens of illegals loitering around. I'm sure the INS knows this too. But is anything done about it? No. Instead they conduct expensive raids on businesses like Chipotle or Tyson Foods when they can just drive up to big box stores and pick up thousands of illegal people around the country for practically nothing.

No, I say this Arizona bill should not be passed. This is just passing the buck by the government to the medical establishment. We pay millions of tax dollars so that our state and federal governments will enforce our own laws. They shouldn't abrogate their responsibilities just because they are too lame to perform their sworn duties to us citizens. If they are too fearful to stand up to pro-criminal liberal groups like the ACLU then we need to elect officials who will stand up for the laws of our country.

Sunday, February 13, 2011

What Children Eat At Birthday Parties

Spaghetti tacos! That's the food being served at children's birthday parties these days. Does not look the least bit appetizing to me. But my daughter, who's the pickiest eater in the world, ate all of her taco without complaint. Oi vey!

Friday, February 11, 2011

Man Up!

A nurse in Minnesota has been accused of stealing narcotics from a patient during a surgical procedure. Sarah Casareto was giving conscious sedation to a patient during a nephrostomy tube placement when the patient started complaining about severe pain. Ms. Casareto told the patient she could not give him too much narcotics and to "man up". She tried to soothe the patient by saying "go to your beach...go to your special place." Ha ha. That is a good one. The pain was so intense the staff had to physically hold him down to finish the procedure.

The operating room staff noticed Ms. Casareto was slurring her words and unsteady. They even noticed she was falling asleep in the procedure room. She had checked out 500 mcg of fentanyl (!) for the procedure but had given the patient only 150 mcg. For some reason, it was not mentioned in the article, the patient contacted the police after his excruciating procedure. That's when Ms. Casareto refused a drug test and resigned.

It's sad for the patient that he had to go through such torture for a pretty simple and routine procedure. It's worse that the doctor doing the procedure didn't suspect something was wrong when the patient had to be physically restrained on the operating room table because he wanted to get the heck out of that torture chamber. But it seems unconscionable that if the patient was experiencing so much discomfort that the staff didn't call somebody else in to assist with pain control and sedation. The doctors noted that this procedure normally isn't that painful. But when it is for this patient, it baffles me that they didn't do something about it instead of just holding him down while a clearly intoxicated nurse was falling asleep instead of watching the patient. There were no anesthesiologists around that could give an urgent assist to the operating team? How would any of those people like to have a large catheter jabbed into their kidneys while being held down against his will. Sounds like some torture routine from an Iranian prison. Clearly Ms. Casareto has a lot of explaining and cleaning up to do. But the staff,who were not under the influence of narcotics, also need to clear things up with the patient, the hospital, and the police as to why they allowed this battery of the patient to continue.

Thursday, February 3, 2011

Why I Live In L.A.

 Picture of Chicago after the great blizzard of 2011.
Now I remember why I love living in L.A.

Wednesday, February 2, 2011

Witnessing History

Sometimes history has a way of catching up with us, grabbing us by the neck, and not letting go. The revolution currently underway in Egypt has been both terrifying and inspiring to watch. From the comfort of our sofas in the U.S., it's easy to root for the anti-Mubarak crowd as they try to overthrow their despot of over thirty years. We can sit back in our comfortable recliners and cheer them on, but these people are not playing chicken with the government's tanks and militia. They are real flesh and blood human beings on the streets of Cairo fighting for their livelihoods and their very lives. 

There have been few incidents in recent world history that have aroused such sympathy around the globe. Some rebellions have been successful in removing the tyrants that oppressed their people for generations. A few examples that come to mind include the 1980 Gdansk revolution in Poland that was the beginning of the end for the Iron Curtain and the 1983 People Power rebellion in the Philippines that removed Ferdinand Marcos from power after 21 years of tyrannical rule.

History has unfortunately also supplied examples of rebellions that failed. The most noticeable are the Islamic Revolution in Iran in 1979 that brought with it not a democracy but religious tyranny to its people. And of course the video images from Egypt are eerily similar to the Tienanmen Square uprising in China in 1989 that was ruthlessly crushed by the government just weeks later. Its students leaders were all either imprisoned and "reeducated", killed, or exiled.

Will today's unrest in the Middle East be an inspiration for individual rights around the world or end in another heartbreak as people realize that dictators are not easily, or frequently, brought down. At the moment any thought of blogging about our healthcare system or funny anecdotes of life in anesthesia feels trivial and petty. My eyes are glued to 24 hour cable news right now. Any witty observations about life in a comfortable hospital here in the relative stability of the United States will just have to wait for now.

The Customer Is Always Right

You've got to love American democracy. Here we have the right to religion, open protest, carry firearms, and gorge ourselves to death. Witness Carl's Jr.'s latest concoction, the Footlong Cheeseburger. Made of three burger patties stuffed between a twelve inch roll, this baby packs 850 calories, 45 grams of fat, and 2490 mg of sodium.

Despite all the nagging from the government, doctors, and scientists to eat less, these restaurants know what their customers want, and that is to get as much food as possible for the least amount of money. And the customer is always right even if he is killing himself in the process. Who wouldn't want to buy this monstrosity at only $4 a pop? It's cheap, filling, and satisfying. And if you can't finish it you can always share it with a friend or three or save it for another meal later in the day. In America we are allowed to abuse ourselves any way we want. Just don't foist your hospital bills on me later when you're getting treated for your diabetes and coronary artery disease.