Friday, April 29, 2011

Doctors Are Irrational

What rational lawyer would have signed on to represent the Concepcions in litigation for the possibility of fees stemming from a $30.22 claim?
April 27, 2011 Justice Stephen Breyer in AT&T vs. Concepcion

So this justice of the Supreme Court of the United States doesn't think it's rational for a professional with years of education and experience to work for $30.22. Funny that is more money than many doctors are forced to work for in this country. Thanks to EMTALA, declining Medicare reimbursements, and health insurance denial shenanigans, many doctors and hospitals actually take care of their patients for much less, as in free. And the courts have no problem with that. There have been multiple court cases that have ruled it is the obligation of physicians to treat patients even if they have no means of paying them back for their services.

Well, health care is a universal right and nobody should be allowed to be sick in this country, right? What about other universal human rights our modern civilization cherish, such as the right not to go hungry or to sleep in a cardboard box? Nobody is giving away food or houses under a court mandate. In our litigious country, having a lawyer on speed dial is practically a business necessity. Isn't legal representation a universal, or at least an American, right? But Justice Breyer feels that no lawyer should work for less than what they think they're worth, even if it is to represent a poor innocent client who clearly has a moral superiority over a big bad corporation. Yes some lawyers perform pro bono work, but that is mostly voluntary. And if you have a pro bono lawyer, you're probably not getting the best attorney out there to represent you. However all across our country some of our best doctors in major academic centers are treating indigent patients for free with no expectations that they or the hospital will be paid a single cent. Yet this work carries all the same malpractice liabilities as any other work. Where's the fairness in that?

Imagine a world where anyone can just show up at any legal office in the country, from Manhattan Beach to Manhattan N.Y. and demand to be represented by the best legal mind in the firm. Then the client proceeds to question every recommendation made by the lawyer. The lawyer is by law not allowed to transfer the client to another firm without the consent of the client. The client can sue the lawyer and firm for legal malpractice if he doesn't win his case and get the exact monetary damages he wants. And he won't have paid a single cent for all this trouble. He may actually get money from the beleaguered lawyer for all the pain and suffering he has endured. Welcome to our world.

Anesthesiologist Behaving Badly

Would you want to be sedated by an anesthesiologist who was on probation from the state medical board? How about if he was once arrested for swinging a meat cleaver at a government official? That is the resume of Dr. Daniel Shin, an anesthesiologist who is implicated in the death of a patient after lap band surgery. The autopsy report on a patient who died three days after receiving her lap band at the Beverly Hills Surgery Center placed the blame on poor postoperative care by the anesthesiologist. It also details the troubled history of Dr. Shin.

In 2006 he was being served with some unspecified paperwork by a process server at his home. When Dr. Shin opened the door, he screamed, "Get the hell out of here!" at the man. He then swung a 6 inch meat cleaver at him. The server ran next door and called police who arrested the doctor. He was placed on three years probation by a judge who also ordered him to undergo anger management classes (you think?) and community service. The state medical board placed him on probation for two years and ordered a psychiatric evaluation but he did not lose his license.

All this sordid history is now being used by the family of the deceased to sue the surgery center. The report blamed the anesthesiologist for leaving the patient in Recovery Room with a nurse for 80 minutes when the doctor should have been there personally. The patient reportedly had severe obstructive sleep apnea requiring a machine to help her breathing (CPAP or BiPAP was not specified). Plus the ASA's own recommendations are for patients with severe OSA should only be operated on in a hospital setting, not an outpatient surgery center.

I can't defend Dr. Shin's actions with his meat cleaver, but it seems to me he left the patient in Recovery as a normal routine perianesthetic care. I've never read where a patient with sleep apnea requires the anesthesiologist to sit at bedside during the whole recovery process. If the recovery nurse failed to call Dr. Shin back to the patient's side quickly enough, that is not his fault. As far as having a hospital being the only place for sleep apnea patients to have surgery, that rule would probably shut down most of the surgery centers around town. Since this Beverly Hills Surgery Center specialized in bariatric procedures, this guideline would probably lead to its closure. 

Dr. Shin is currently on leave of absence from the surgery center.

No Fuddy Duddy

If you have a mental picture of a doctor, who do you see? A gray haired old fuddy duddy wearing a stethoscope around his neck who drives around in a Buick, right? Well this doctor proves that not all physicians are cut from the same medical school designed pattern. Dr.Venus Ramos is a physical medicine and rehabilitation specialist who works in the city of Long Beach. But she has more credits than just a medical degree on her wall.

You see, she is also an accomplished beauty pageant contestant and has appeared in television too. In fact, a couple of weeks ago she became the Miss Toyota Grand Prix of Long Beach, besting out girls a decade younger than her. She has appeared on the reality programs "American Gladiator" and "Temptation Island". Dr. Ramos is also an entrepreneur. She has marketed a series of exercise videos called "SeXercise".

As you can see, there is life outside of medicine. All those people who bemoan how burned out they are with their practice aren't really trying hard enough. Maybe if they got a copy of "SeXercise", they can get a new improved body and start living for real. At least one doctor has shown the way.

Wednesday, April 27, 2011

The Doctor Is Sick

I've been sick for the last several days. Cough, rhinorrhea, sore throat. The usual minor flu symptoms. The operating room feels more frigid than normal. I should call in sick and take a few days off. But as any doctor will tell you, it is really difficult for physicians to take time off. Being an anesthesiologist makes it a little easier to take time off, but not much. True unlike surgeons and primary docs I don't have to cancel a whole day's schedule of office patients when I take a day off. But that doesn't mean I'm not needed at work. When I request sick leave somebody else has to do the work I was scheduled to do. God forbid they cancel an OR room because the anesthesiologist calls in sick. That means another anesthesiologist who is scheduled to take a day off, either on vacation or post call, has to come back to work. This will not make you many friends in your group.

This flu that's been going around the hospital has sidelined a sizable number of other employees. By contrast the nurses, techs, and other staff seem to have no qualms about taking time off. In fact, they call in sick at the drop of a hat. On Good Friday, the OR almost had to cancel some cases because some many nurses in the Recovery Room called in "sick".

So as you can see, it is not out of a false sense of machismo that I continue to work even though I'm coughing and hacking out a tonsil behind my face mask. When doctors call in sick, the disruption to multiple lives is tangible.

Thursday, April 21, 2011

The Difficult IV

Few things cause me as much anxiety as a difficult IV. When I place a tourniquet on someone's arm and can't see or feel a single vein, I can start feeling a few beads of sweat forming on my forehead. Some patients are notorious for having tiny spidery veins that make inserting an IV extremely difficult. Patients who are on hemodialysis, cancer patients, IV drug abusers, or anyone with a chronic illness who has been in a hospital for an extended period of time will have had all their good veins "used up" over the course of their admissions. This makes it very hard to find a good vein that is not thrombosed or weakened to insert an IV catheter.

Unfortunately patients judge our anesthesia skills based on our ability to start an IV. While this is patently unfair, there is little they know about anesthesiologists to make an assessment of our competency. No other physicians are judged in such a trite manner. A patient has no idea how knowledgeable his internist is. The internist may secretly get all his information from UpToDate and the patient wouldn't have a clue. They'll still brag to all their friends about how great their doctor's bedside manner is. A surgeon may royally screw up an operation but the patient is asleep when it happens. When he awakens, all he knows is that the operation is finished. But an anesthesiologist is unable to hide. His skill at putting in an IV is the first time the patient has had a chance to assess the anesthesiologist, usually about five minutes after first meeting.  Multiple attempts at placing an IV instantly brands the anesthesiologist as incompetent.

The patient who presents with difficult veins usually knows it. They may even tell you where their best vein is for inserting a catheter. One anesthesia pearl is to always listen to your patient when they tell you where to place an IV. They are usually right and will save you from fruitlessly stabbing the patient in all the wrong places before you eventually go back to the vein they directed you to in the first place. What's worse though are the patients who claim they've never had a problem with an IV before and why is it I can't get one in today. Statements like that really are not helpful or conducive to placing a successful intravenous.

People seem to have a mistaken belief that anesthesiologists have the best skills in putting in IV's. I can't help but groan when the preop nurse can't get an IV then cheerfully tells the patient the anesthesiologist will do it easily. While I may be the best physician at this task, I am definitely not the most skillful hospital personnel at it. Truth be told, the hospital's IV nurse can place IV's in a patient where I didn't even suspect a vein existed. I may put 3 or 4 IV's a day at most. An IV nurse will put in dozens. Also if you can wrangle one, a pediatric nurse is also excellent at putting in IV's. They're just used to working with tiny veins.

So what should one do when confronted with virtually no veins? First of all, try not to have a crowd around the patient's bed. Having a plethora of family members observing you fumble multiple attempts at inserting an intravenous can be really humiliating. Next remember that your first shot is your best shot. You may see one solitary vein on the entire patient and think you can get an 18 GA catheter in there. But that would be a mistake. While it may happen, many times that is the same vein everybody else has attempted and it will still be difficult. Always use a smaller catheter than you think the vein will accept. You can always start another IV after the patient is asleep and the veins are engorged from venodilation due to the anesthesia. Give yourself a set number of attempts at this endeavor. It does not help you or the patient to have four puncture marks on one arm and five on the other arm and still have no IV's to show for all your efforts. I let myself try three times. Then it's time to give yourself and the patient a break from this torture.

What should you do next? Frequently the patient is cold because of the ambient room temperature. Wrap the arms in warm blankets for five to ten minutes. This will diltate the veins sufficiently that you may see a vein that you didn't notice before. Think about having a colleague attempt an IV placement for you. Sometimes it just takes a fresh pair of eyes and hands to put in an IV. If that doesn't work, the IV nurse may need to be called. By now, you've probably delayed your case so a few more minutes waiting for the nurse is not going to make much difference. If all else fails, you may have to fall back to the choice of last resort, the dreaded central line.

There is no getting around a challenging IV in the course of an anesthesiologist's day. But having an algorithm and a course of action will help reduce the anxiety. Having a sense of humor may decrease the tension you experience with your patient. And try to remember that your ability to insert an IV says nothing about you as an anesthesiologist. So what if the patient thinks you're an incompetent boob. All that matters is the patient survives the surgery with no anesthetic complications. That's the marks of a good anesthesiologist, not if you can insert a 24 GA IV into a vein in his pinky.

Wednesday, April 20, 2011

ASA Classification. Hmm. What Is It Good For? Absolutely Nothing!

Well, almost absolutely nothing. The ASA classification of physical status has been around for decades. Anesthesiologists rank patients every day based on the this system to determine their health risks. Ever since anesthesiology residency I've been doing mental categorization in my head as I talk to my patients to classify them into one of the six levels of the ASA scale. I would present the patients to my attending as a so and so ASA Class X patient presenting for this surgery. Every single anesthesia record has an area where we are supposed to document the ASA physical status of that patient. As you can see, the ASA classification is pretty pervasive in anesthesiology. But why do we do it?

When I went through medical school, I must have presented hundreds of patients to dozens of attendings and not once did I preface my patient with an ASA classification. No other medical fields use this scale to describe their patients. Yet as soon as anesthesiology residency started we were all indoctrinated on the use of this system. If you look at the scale, it is immediately obvious why I don't think it is useful. The ASA classification is just too vague. Daily I rack my head trying to decide if a patient is an ASA 1 or 2, or maybe even a 3. And does any of this matter in how I anesthetize my patient?

In reality 95% of our patients are ASA 1-3 which makes it harder to decide which one a patient belongs to. Let me give you some examples of the difficulty of pigeon-holing countless patients into these few groups. 

A 24 year old morbidly obese patient for carpal tunnel repair. The patient has no other medical problems. No hypertension, diabetes, sleep apnea. She is physically active. Is the patient an ASA 1 or 2? Or is she a 3? What if the surgery is more complicated, like spinal fusion? Does that change the ASA class?

A 75 year old male who is physically active, plays tennis three times a week. No history of hypertension, coronary artery disease, or pulmonary disease. Is the patient a 2 or a 3? Or maybe he is a 1? What if the patient is 85 years old who plays golf several times a week and again has no apparent cardiovascular disease. Is an 85 year old an automatic 3?

A 34 year old patient with complex regional pain syndrome who is on massive amounts of narcotics to control her pain. She is poorly functional because of her severe problems. She has no other systemic medical disease. Is the patient a 1 despite her debilitating pain but no systemic illnesses?

Does a patient with diabetes an automatic ASA 3 as some people advocate? What if the patient is 18 years old? If then you decide to make the patient an ASA 2 because of age, when do you advance the patient up to a 3. 30 years old? 50 years old?

I could go on and on about how confusing this system is. The funny thing is the ASA classification isn't really necessary. I can only think of two scenerios where having the ASA classification is useful. One is in research where it is helpful to categorize patients by their ASA status. But since the scale is so subjective, I think this adds little scientific objectivity to a study.

The second case where the ASA classification is useful is when I'm billing the insurance company. An ASA 3 or higher usually gets a higher reimbursement, or a reimbursement at all, because of the supposedly increased complexity of an ASA 3. I've sometimes been advised by our billing company to find ANY potential reasons for upping the severity of patient's illness so that we are more likely to collect payment. However other physicians like hospitalists and internists are able to document a higher complexity patient to receive better reimbursements. Why can't anesthesiologists do the same thing?

Other than that I can't think of any good reasons to keep the ASA physical status classification. It is an antiquated method of evaluating a patient that really has no place in a modern H+P. If you're going to present a patient to me in preop, just give me the facts. Don't skew my assessment of a patient by prefacing it with your opinion of what ASA level he is. I'm a busy doctor. I don't even want to waste ten seconds pondering what ASA class a patient belongs to. I'll give my anesthesia based on the patient's various diseases and how it affects him as a whole, not on whether he is an ASA 2 or 3. Let's just get rid of this system and stop wasting time pondering if they should have invented an ASA 2- or 3+ that would more properly fit my patient's problems. I'm pretty sure not having an ASA classification will not affect my patients' surgical outcomes.

Friday, April 8, 2011

Why Can't I Lose Weight After Gastric Banding?

I overheard this conversation recently between two friends in the cafeteria.

Friend 1: How are you doing since your stomach banding?
Friend 2: I'm okay. But I'm not losing much weight.
Friend 1: Why? What foods are you eating?
Friend 2: I try to eat the same things every day so my new stomach can handle it okay.
Friend 1: What are you having for lunch today?
Friend 2: Same thing I had yesterday. I got an enchilada with rice, sour cream, and an avocado. I drink it with some diet Coke.
Friend 1: Maybe you just need to give it more time.

I'm paraphrasing some here but this is the essence of the conversation. You got to love good friends who support you through thick and thin.

How To Aggravate Hospital Employees First Thing In The Morning

We have a parking lot war going on at our hospital. One of the persistent complaints from our hospital employees is the parking situation in the structure. You see, the hospital has painted the lot with small car spaces marked "compact" and regular sized unmarked spaces. The trouble is they have designated 80% of the spaces as compact. They claim this allows more cars to be parked in the lot. Plus they hope people will buy more small fuel efficient cars this way.

Well it hasn't worked out too well. People buy cars based on their needs and wants, not because of the size of the parking spaces at their place of employment. I've taken two pictures in our parking lot to illustrate the problem. As you can see, the large spaces are supposed to be used for large cars. But unfortunately everybody wants to park there. I've seen cars as small as Miatas and Minis parked into these large spaces. After all, nobody wants to get their cars dinged by a neighboring car opening its doors. These large spaces are the first ones to fill up every morning.

This leaves the "compact" spaces for everybody else, including the large SUVs and trucks about half the employees drive. These compact spaces are so tight that even midsize cars like a Toyota Camry or Honda Accord have a hard time squeezing in and still leave room to open the driver's door. What usually happens is the car will park to the right to allow the driver to get out but then leave a gap of just a few inches for the next car over, preventing the driver of that car from opening his door to get in.

It has become a simmering irritant between owners of small and big cars. In the hospital newsletter, the small car owners accuse the big car owners of crowding the small spaces, preventing people from parking next to them thus depriving people of a scarce parking space. The large car owners accuse the small car owners of taking all the big spaces, causing the problem to begin with. Each side wants the parking lot attendants to fine the owners of the other side for parking in the wrong spaces. The hospital refuses to redraw the lines to more realistic widths, mainly because we are already short of parking spaces for all the employees. Their advice is for everybody to be courteous and park in the proper designated spaces. Yeah right. This standoff is not going to disappear anytime soon. In the meantime employees learn to come to work early, or plan on circling the lot for awhile to locate a decent sized space. Thank goodness at least the hospital recently opened a Starbucks on the premises.

Tuesday, April 5, 2011

Just The Facts

Another excellent post from our friend Anesthesioboist. She reproduces a letter from an anesthesiologist to an unsuccessful medical school applicant on a physician forum. The anesthesiologist questions the student's reasons for going into medicine and all the impediments this country raises to discourage bright young students from entering this field. Very sobering and well worth the read.

Saturday, April 2, 2011

The Wretched Hour

The beeper goes off. Groan. What time is it? My hand fishes around for the pager in the darkened call room. Good God it's 5:10 AM. Jeez, the surgeon just booked an appendectomy to start ASAP. I stumble my way to the operating room. The bright lights of the hospital hallway are like electroconvulsive therapy on my optic nerves. My eyelids feel like they are lined with sandpaper. My fingers rub my eyeballs raw trying to wipe the crud out of my inner canthus. I hate starting a case during this wretched hour.

If patients want to know what a doctor looks like to his or her spouse first thing in the morning, come to the O.R. during the predawn hours. It is not a pretty sight. Bedhead? Halitosis? Dark baggy eyelids? Check, check and check. It is the antithesis of a professional presentation. And grumpy? Though we try really hard to keep a cheerful demeanor, it can be a losing battle when we haven't had a shower and that first cup of coffee. 

This twilight zone period of the anesthesia call is the most painful time get a case going. It's too early to have the morning anesthesiologist come in to do the procedure. The case will start late enough that I will finish it past the end of my shift. Though it's tempting to ask the morning shift to come in just a little early so that I won't have to do this case, I know from personal experience what it feels like when I get that phone call in the morning to come in early when the night shift doesn't want to work anymore. It is aggravating and won't make you many friends. So I go ahead and start the case despite the sun starting to peek over the horizon.

Surgeons think they can just squeeze one more case into the night before the start of the OR schedule. But getting patients into the operating room never occur that smoothly. There are delays all along the way. Between getting the patient out of the emergency room to the paperwork that needs to be processed in preop, the case usually doesn't get started until it is dangerously close to the first scheduled start of the day.

Inevitably the surgeon will be in a rush to get the case finished. He will complete his work with great flourish, proudly waltzing out of the room right before the the morning cases start. But of course he doesn't factor in the time it takes for me to wake up the patient. Also the room needs to cleaned and turned around. The surgeon whose case was delayed will be pacing in the doctor's lounge, grumbling about operating room inefficiency.

For me, I don't care anymore. My shift has ended. I stumble to the parking lot, heading into the teeth of the morning rush hour on my way home. Time to catch up on my sleep before work resumes the next day. And I will have brushed my teeth and combed my hair by then.

Friday, April 1, 2011

School Bus, L.A. Style

You know that Porsche commercial where they show a Porsche 911 being used as a school bus? You may scoff and think who would use such an expensive car to transport kids to school. Well, I live in Los Angeles, CA. We are the center of the universe for conspicuous consumption. A Porsche here is pretty common and proletarian. These pictures show L.A. ostentation at its best, or worst. The extraordinarily expensive cars were used to transport their little passengers to the local preschool. In a parking lot packed with SUV's and minivans, these two luxury vehicles certainly stood out. People complain Angelenos are flamboyant and pretentious. And you know what, they may be right. And no, the owners are not physicians.