Sunday, July 31, 2011

Doctors Lose

Okay, time for a little political venting. If you don't like to read the rantings of a right wing upper middle class physician, then you can certainly skip today's topic. My opinions may turn off some people and incite others to question and ridicule my thoughts, but hey, it's my blog. I'll write about whatever I want to.

First up, the ongoing farce that is the U.S. federal government and it's attempt to keep us from sinking deeper into banana republic territory by allowing itself to borrow even MORE money so we can pay our creditors the billions of dollars we owe them. The latest news as of Sunday afternoon is that the Senate is close to reaching a compromise for raising the debt ceiling while also reducing the budget deficit. Of course the senators don't have the time or the guts to declare in detail the areas they would cut the federal budget. So they will form a "special committee" that will decide how to cut $1.8 trillion by the end of the year. If the committee can't figure out a way to do that, then the deal would require an automatic $1.2 trillion budget cut, half from the Defense budget, and half from Medicare providers. Social Security, Medicare, Medicaid, and food stamps benefits, ie/ most of the entitlement programs that constitute the majority of federal spending, would be spared. Got that? Another $600 billion lopped off the payments to doctors, hospitals, nursing homes, and anybody who is trying to take care of our sick and elderly. This will just make it easier and more justifiable for doctors to drop their Medicare patients even though there is already a shortage of Medicare providers willing to work for below market rates. How many more hospitals will go bankrupt if more Medicare reimbursments are cut?

Even before the current debt negotiations, there was already talk that Medicare is going to reduce the subsidies it provides hospitals for training medical residents as part of its cost cutting measures. One proposal would slash approximately 60% of the funding for hospitals to train residents. What happened to all the teeth gnashing about the shortage of doctors, especially in the primary care fields? People think we can just keep building more medical schools to relieve the physician shortage, as is already being done. But if there are fewer residency spots open to train all these new doctors, there will be no relief from this doctor shortage. Unless of course people are once again willing to go see a doctor labeled as a "general practitioner" with no board certification as their primary care giver. There's even talk that hospitals might consider charging money to enroll in the more competitive residency programs. How about that you orthopedic, dermatology, ophthalmology, anesthesiology residents? Would you be willing to add to your student debt load by paying to be in a residency program?

Finally I'm sick and tired of hearing about how the "rich" should pay more of their fair share to support the government and get us out of debt. President Obama famously defines the "rich" as any family who makes over $250,000 per year. Not that I agree, but since the average anesthesiologist, and most families who have doctors as breadwinners, make more than that, I guess you can call me "rich". However, I feel like I pay far more in taxes than what should be considered fair. Consider, that I pay the 35% federal income tax bracket. Then add in the confiscatory 10% California income tax. Don't forget the 12.6% Social Security tax, which will go up with the advent of ObamaCare. Also add in 2.9% Medicare tax, also going up with ObamaCare. Then there is the unemployment insurance tax, worker's comp insurance tax, and the disability insurance tax, I'm already at or above 60% of my income being seized by the government for being a productive member of society. I'm not even counting sales taxes, property taxes, business taxes, and various other licenses and fees. In the meantime, over 40% of the nation's population don't pay any federal taxes at all. Yet these are the same people who receive most of the government benefits and bellyache loudest about the "rich" paying their fair share of taxes. The only interaction I have with the government is when they have their hands in my pockets to take more money. To me this system definitely isn't fair, and it's not because I don't pay enough taxes for the comparatively few benefits I receive. And don't lecture me about how the government is paying for the roads I'm driving, the schools my children attend, or the safety of our country. Everybody is receiving those same benefits yet a large percentage of people don't have to pay for them.

This is a dangerous path our country is heading. A preview of the future has already played out here in California. In our state, the top 1% of income earners pay 50% of all income taxes. Yet there is never enough money to go around. The people who pay little or no taxes will have the upper hand in a democracy because there are simply more of them than the rich. They will keep voting in politicians who cater to their needs and demand that somebody else pay for all of it. After all, it's not coming out of their pockets and the "rich" can afford it, right? When 20% of all income in this country comes from the federal government, it is easy to understand that cutting back benefits will be next to impossible. I'd say that to be truly fair in our country's tax scheme, everybody, with no exemptions, should pay some income taxes, sort of like the alternative minimum taxes in reverse. Even if it is just 1% of their income, having a little skin in the game, having something to lose if taxes are raised, will completely change the perspective of people in the country. Yeah you can raise my taxes, but I want to see that EVERYBODY gets their taxes raised.

That is my two cents for the day.

Saturday, July 30, 2011

Time Is Money

We have a surgeon whose entire world view boils down to "time is money". It is annoying, and more than a bit pathetic, to see a grown person go through life living this business mantra. Lest anyone forgets this, he utters these three words repeatedly during an entire procedure.

Since any time not working billable hours is time wasted, he doesn't show up for his cases until the preop nurses page him to let him know the patient is ready to go to the operating room. He then rushes to preop holding and says a quick "hi" to the patient, writes his informed consent in the chart, then dashes out of preop, telling us to page him when we are ready in the operating room. In the meantime he has charting and other business to take care of that will earn him more coin.

We then take the patient to the O.R. He is quickly anesthetized, prepped, and draped. Then the surgeon is called. He arrives and does a quickie rubdown with Purell (must have been a godsend for him now that he doesn't have to do a three minute scrub at the sink, just a few swipes of the Purell up and down the arms). Knife. Slash. Cautery. Buzz. Staples. Clip. If he request something that is not on the circulating nurse's table he gets visibly annoyed and impatient. And he mutters, "time is money" to all in the room.

When the skin is closed after the last staple, he quickly rips of his gown. He writes down an illegible three line op report in the chart and hurries out the door. At this point the patient isn't even awake yet. He rarely speaks to waiting family members afterwards since, you know, talking to family doesn't pay the bills. His assistant is usually tasked with that job. Forget about calling him back afterwards for a missed item on his orders. He is usually miles away from the hospital by the time the recovery room nurses have had a chance to examine them. Talking to recovery room nurses doesn't earn him any dinero. That's what the hospitalist is supposed to take care of.

With all the discussions about crushing student loan debts afflicting most medical school graduates, it's a surprise that attitudes like this don't affect more doctors. I have no idea if this guy has any overwhelming student loans he has to pay off. He has been in practice for over ten years and it would be sad if he was still rushing around like this just to pay his debts. But then again, his luxury German sports car belies any difficult financial burdens he may be facing in his life.

Friday, July 29, 2011

Bucket List For End Of Life Care

Sometimes it seems that nobody in America is allowed to die with dignity. All doctors have witnessed the sad and painful ending many patients suffer through before they reach their final resting place. Even with an advanced directive in place, that piece of paper can be overridden by an anxious and persistent relative. So I present to you the bucket list for dying patients, procedures that are almost universally practiced on these poor souls during their final moments on Earth but with virtually no hope of improving their prognosis.

1. ICU. Because nobody should die in the comfort of their own home or bed.

2. PEG Tube. Nobody is allowed to die on an empty stomach either.

3. Endotracheal intubation. Horrible for family to see a patient gasping for his last breath.

4. CT/MRI. Everybody deserves one last blast of radiation or a four figure imaging study before they pass away, just because we can.

5. Foley Catheter. Can't get up to the bathroom when tethered in bed to all the lines and monitors like Gulliver in Lilliput.

6. Endoscopy. Because the doctors can't figure out why a patient who has been in ICU for three months is having anemia and failure to thrive.

7. Echocardiogram. Because the doctors can't figure out why in a ward of sick patients, the patient is having fever. Inevitably when the echo tech says the transthoracic echo is of poor quality the patient will then undergo an invasive transesophageal echo.

8. Multiple subspecialty consultations, minimum of three. When the expertise of the internist or intensivist just isn't good enough to assuage the relatives. Still can't understand why nobody stays in Internal Medicine anymore?

9. Acrimonious family meeting. Because the reality of bad news is so hard to take for some people.

10. An all hands on board, rib-cracking, chest-thumping, vein-puncturing, drug-pushing, heart-shocking, final shot at life. Because we doctors have to show we care.

As we all inevitably shuffle off into our old age, this is the fate many of us will face in the end.

Tuesday, July 26, 2011

Operating Without Anesthesia, Or A Surgeon

There seems to be an increase in the number of Southern Californians who think they can operate on a human body without any anesthesia, or even a board certification for surgery. A couple of weeks ago, there was the Garden Grove lady who amputated her husband's penis after a domestic dispute. Catherine Kieu allegedly drugged her husband's dinner. When he fell asleep, she tied him down in bed. When he woke up, she used a large knife and sliced off his genitalia. To make sure he wouldn't be good for anybody else, she promptly threw the member into the garbage disposal and shredded it. She later told police he "deserved it."

Now comes word of another individual who tried to perform a surgical procedure without a medical degree hanging on his office wall. A Glendale man was found by police naked outside his house on a lounge chair. A knife was sticking out of his abdomen. When they approached the man, he pulled out the butter knife from his body and cauterized the wound with a lit cigarette he was smoking. His wife told the police that her husband had an abdominal hernia that was bothering him and wanted it removed. At least he was smart enough to know to cauterize a wound.

Instead of getting a background check for only gun buyers, maybe we should have one for anybody who wants to buy a knife. These stories are insane.

Monday, July 25, 2011

Anesthesia's "Easy" Reputation

If there is one thing anesthesiologists vehemently dispute, it is the reputation that anesthesia is a lifestyle choice--that working in anesthesia is "easy". I don't know when or why our specialty got this stigma, but anyone who actually administers anesthesia knows it is not true.

I'll always remember one particular candidate for our anesthesiology residency we interviewed while I was still a resident. He was an older applicant, switching over from Family Practice. He seemed real nice and intelligent. We asked him why he wanted to go into anesthesiology. Since we were just residents in the room, he must have felt he could speak frankly to us. He said that he had back pains from running around a busy office all day and thought anesthesiology would be much more relaxing and less stressful. He thought he wouldn't have to be on his feet as much. Stunned by his ill-informed opinion of what anesthesiology was about, we strenuously corrected his mistaken ideas of the work of anesthesiologists. We promptly reported this guy's attitude to our attendings. He didn't get a spot.

I can think of many medical fields that should have a reputation for being easy but usually aren't. How about Pathology? No live patient complaining about pain or nausea and vomiting in the middle of the night. No emergencies to attend to at 2:00 AM. Perhaps diagnostic Radiology could entice medical students who want an "easy" job. Sure you take calls in Radiology. But with the ubiquity of digital imaging, many radiologists now work from home, reviewing images at night from the comfort of their home computer. Plus they are one of the highest paying medical fields out there. Why aren't Hem/Onc or Allergy and Immunology written about in the same envious tone as Anesthesiology? These are fields where the doctors are rarely bothered at night. Yet people don't think about entering them because they are "easy".

For those who think Anesthesiology is a lifestyle field, let me tell you this. Our days are as busy as any surgeon's for the simple reason that surgeons need anesthesiologists in order for them to do their cases. So if a surgeon has a gun shot wound victim at 4:00 AM, the anesthesiologist also has a gun shot wound patient to take care of at 4:00 AM. If an obstetrician has to do a crash C-section for a decompensating fetus in Labor and Delivery, the anesthesiologist also has a crash C-section and sick infant to deal with at the same time. Anesthesiologists have advanced the quality of patient safety to such a degree that our work may look easy to those on the other side of the ether screen. But make no mistake, the patient's life is on the line every time we take a patient to the operating room. We take that responsibility very seriously. We work just as hard as any surgeon, probably because we are there to keep the patient alive when they are in the operating room. Our hours are no different from theirs. Nobody ever says surgeons have easy hours. Anesthesiologists don't either.

Sunday, July 24, 2011

Shopping At A Funeral

How does a vulture feel when it feasts upon the dead? Probably with less guilt than when I went shopping at Borders bookstore over the weekend. Borders used to be one of my favorite bookstores in town. It was so much nicer than the old mall based bookstores like B. Dalton's or Waldenbooks. It had a huge selection, cozy chairs to lounge in, piped in music, and a coffee bar. I used to go in every Sunday morning, because that was the only day of the week we finished morning rounds early during residency, and just relax and browse through some magazines or interesting coffee table books.

But now Borders has declared bankruptcy and started liquidating all of its stores. This past weekend, our Borders store was a madhouse. The parking lot was completely filled. Like a witness at a gruesome accident scene, I couldn't turn away. I too returned to my favorite bricks and mortar bookstore to see what the commotion was all about. Then I remembered why I stopped shopping at Borders.

The store was festooned with sale signs. "All DVD 20% off!" "All children's books 10% off!" "All romance novels 30% off!" I headed off to the children's section--nothing is more important than keeping your children well read. Even though the books were only ten percent off, most of the good stuff was already cleared off the shelf. Only a few scraggly Harry Potter books were left. Disappointed, I walked to the video section. Now here was something I could appreciate. "All Blu Ray 40% off!" This looked promising. I started grabbing some Blu Ray movies that I had wanted to buy but never got around to it. Then I looked at the list price. $29.99? $39.99? You got to be kidding. They obviously jacked up the price before declaring this huge discount. $45.99 for a Disney Blu Ray? A quick search on my evil iPhone quickly resulted with multiple vendors selling the same disk online for less, plus they're tax free and have free delivery.

I noticed many customers were doing the same thing. With a quick flick on a smartphone, anybody can price shop any item from any store in the world. One is no longer dependent on the pricing whims of the local retailer. Of course this is why bricks and mortar stores are having such a hard time competing against internet retailers. I hadn't bought anything at Borders in years unless it was something I absolutely had to have RIGHT NOW and couldn't wait for delivery. Even then I always felt buyers remorse after paying sometimes twice what I could find on the internet for the same thing.

As I walked out of Borders for the last time empty handed, I looked sadly at the busy employees rushing around the store trying to help all the scavengers showing up for the final feast. They were smiling and friendly but it must have been very difficult to keep their chins up knowing they will soon be one of the millions of unemployed in this country. Seems like the only way to keep a job in this country nowadays is to work at Facebook or be a doctor.

Wednesday, July 20, 2011

Pancreatitis Patients Need Not Apply

Okay, maybe eating out can be fun, especially at the Orange County Fair currently going strong down in the O.C.  I just couldn't resist posting this picture from the LA Times. Granted nobody goes to a fair to find healthy food.  But the outlandishness of the grub being offered borders on genius, if your genie likes to have his food deep fried.

Take a look at that menu. Besides the now standard deep fried Twinkie, there is a deep fried Krispy Kreme chicken sandwich, a deep fried Klondike bar, and even deep fried Kool Aid. Who's the mastermind that figured out how to deep fry an item that is normally consumed in liquid form? Outrageous. Other stands offer deep fried bacon, chocolate covered corn dogs, and even deep fried butter. Imagine, deep fried dairy fat as a food item.

If one time through the hot oil is not enough, how about two. One stand offers deep fried churros, with a twist. Churros, the deliciously sweet and crunchy fried dough, can be had double fried. The purveyor opens one up, fills it with butter, then fries it a second time to give the inside a crispy oily coat. Then it's coated with sugar and whip cream. How awesome is that?

There's one way to make sure you stay thin after eating at the O.C. Fair. Take a spin on one of those twisty, turning, gravity-defying, stomach-churning rides. That will make you barf up all that greasy gunk from your stomach, preventing you from absorbing most of those calories and fat. Just make sure you hurl into a trash can, not onto the ride or your friends.

Tuesday, July 19, 2011

When Did Eating Out Stop Being Fun?

We went to IHOP for Sunday brunch recently. I hadn't been there in a while. I looked forward to some bacon, sausage, eggs, and maybe a stack of chocolate chip pancakes. Mmmm. After an interminable wait in the foyer as we hungrily watched other patrons get their platters of goodies, we were finally seated. I couldn't wait to get the menu and start ordering. I guess it had been a long time since my last visit because I was instantly struck by some large numbers in the menu next to the food items. No it was not the prices, which were quite reasonable. It was the calorie counts printed next to each listing. Holy cow.

California enacted a new law that took effect at the beginning of this year that requires all restaurants with more than twenty outlets to display their menus' calorie counts. If the state wants to kill the restaurant business here (as it seems to want to do to all businesses) this is the way to do it. After perusing the IHOP menu, I had pretty much lost my appetite. There was hardly anything worth eating that didn't surpass 1000 calories. That hearty breakfast with all the protein and the chocolate chip pancakes easily topped 1500 calores. That doesn't even include the pancake syrup (100 calories for one measly little ounce) and drinks. A simple bacon cheeseburger came in at only 780 calories. But then you add in standard sides like fries (300 calories) or heaven forbid onion rings (620 calories). I could feel my waist line expanding just reading the menu. Sure I could have ordered a side of fresh fruit for only 80 calories, but who eats a bacon cheeseburger with a side of stale fruit? Even the children's menu items could quickly add up to over 500 calories, far above what my elementary school kids should have at one sitting.

Now a study published in the Journal of the American Medical Association has discovered that the calorie counts printed on menus can drastically understate the actual calories in the food. Scientists from Tufts University examined entrees from 42 different restaurants. They found that fast food restaurants undercounted their food by an average of 142 calories. Sit down restaurants did even worse, undercounting by an average of 225 calories per item.

Even healthy sounding food can have an enormous amount of calories. A cranberry pecan chicken salad at Bob Evans restaurant was listed to contain 841 calories. When the scientists did their own measurement, it came out to over 1100 calories. The calorie count can also vary by the preparer, even for the same item in the same restaurant. A burrito bowl at Chipotle had over 700 calories on one visit and 567 calories on another. Both numbers are still way higher than the menu, which lists the calories as only 454.

As I looked around the restaurant, I didn't see too many people overly concerned with their caloric intake. Everybody was having a good time digging into their brunch. I closed my eyes and selected what my stomach had been hungering for. After all, it's not every day I have brunch at IHOP. The exercises and dieting can wait for another day, and another, and another...

Should Physicians Go Bare?

How much medical malpractice insurance should a physician carry? Most doctors go for the minimum seven figure insurance coverage. Some opt to buy even more. But does buying more malpractice insurance encourage more and bigger lawsuits? I've heard arguments that doctors should go bare, thereby leaving themselves a smaller target for lawyers. Who is correct? The following case may help answer some of the questions.

A family in Los Angeles has just settled a medical malpractice suit for over $4 million due to a bad circumcision. According to the suit, Dr. Anthony Pickett of the Maternity Center of Vermont accidentally amputated 85% of the baby's glans penis during attempted circumcision. The boy will need multiple corrective surgeries for years to come along with psychiatric care "to deal with the trauma of this incident and resultant surgeries" according to their lawyers. The defendant who will pay this settlement is Integra Life Sciences Holding Corp., maker of the Mogen clamp (warning graphic images in that link) that was used in the surgery. According to the plaintiffs the design was defective which prevented the doctor from seeing the circumcision site adequately, leading to the penile amputation.

What about Dr. Pickett? It seems that Dr. Pickett carried no medical malpractice insurance. He was subsequently dropped from the suit. Though I'm sure Dr. Pickett feels badly about what happened, at least now he can go back to practice without a multimillion dollar judgement hanging over his head.

Does anyone suppose that if Dr. Pickett carried $1 million of malpractice insurance he would be dropped from the lawsuit? What about if he had $3 million, as many doctors carry? I find it unlikely. Like moths to a light bulb, lawyers will gather around the defendant with the deepest pockets, no matter who is at fault and to what degree. The defense lawyer in this case will walk away with $1.38 million. This was justified, the lawyer said, because this case required "extraordinary research, diligent work-up, creative lawyering, and hundreds of hours of hard work." Hmm. Isn't that their job anyway, to represent people regardless of the amount of reward at the end of the case? And how hard is it to try this case when there already have been other successful multimillion dollar product liability suits against the Mogen clamp? It seems this case could have been won on precedent alone. How hard is that?

Monday, July 18, 2011

No More Excuses

How did I miss this juicy nugget of information? A paper presented at Digestive Disease Week in May has finally put to rest the canard that anesthesiologists are not needed in an endoscopy suite. The study, conducted by Dr. Brooks Cash of the National Naval Medical Center in Bethesda, Md, looked at over four and a half million colonoscopies performed over a ten year period. Roughly one third of the colonoscopies were performed with an anesthesiologist present.

Dr. Cash's team found that when an anesthesiologist was present, the rate of detecting a colonic polyp was 37.7%. When no anesthesiologist was there, the detection rate was only 37%. While this may sound like a small difference, with such a large sample the difference was considered significant. Similar positive findings were found when accounting for sex and age differences. What's more, when an anesthesiologist was performing the sedation, the rate of detecting colon cancer within three years of the initial colonoscopy was significantly higher, 1.97% vs. 1.71%.

There you have it. Now there are no more legitimate excuses for not having an anesthesiologist performing the sedation in the endoscopy suite. Anesthesiologists increase the effectiveness of screening colonoscopies, leading to higher rates of early cancer detection thereby saving lives and MONEY for everybody involved. Previous studies have already shown that patients prefer to have a propofol anesthetic for their procedure. They will be more compliant with a screening colonoscopy if they knew how painless it can be with propofol. The patients will then refer all their acquaintances to do the same thing. This again leads to early colon cancer detection which will save even more lives and MONEY.

What about patient safety? GI docs will insist that no studies have found that sedation given by an endoscopist has led to any more complications than one given by an anesthesiologist. While that may be true it's like asking whether a Boeing 747 flown by one pilot is just as safe as having the plane also carry a co-pilot (I don't need to tell you who the real pilot in the endoscopy unit is). One pilot in the cockpit will almost assuredly take you to your destination safely, with all the autopilot and other safety measures present. But wouldn't you feel more comforted by knowing there are two pilots taking you on the journey?

So that leaves only one excuse left for why gastroenterologists don't want anesthesiologists in the room. Do I even need to repeat it? It all comes down to MONEY. They think we slow them down which decreases the number of procedures they can do in one day thus costing them MONEY. How shallow of some of these docs to think our careful evaluation of our patients for their ability to tolerate an anesthetic safely is an impediment to their business plans. That is very egocentric thinking. The big picture is that anesthesiologists are saving MONEY by helping the endoscopists detect early colon cancer. This saves the hospital, the insurance companies, and the government an enormous amount of MONEY in the long run. The patients are more grateful for their humane sedation and successful screening. And another productive member of our society will be able to continue to lead a normal life because we prevented him from getting cancer. Isn't that worth the few hundred dollars it costs to have an anesthesiologist present during an endoscopy? Heck ya!

Sunday, July 17, 2011

How To Place An Endotracheal Tube

What is the best way to determine if an endotracheal has been properly positioned in the patient? For generations the gold standard has been the presence of bilateral breath sounds with auscultation of the chest wall. At least that was the answer when asked during oral boards examination. But as most anesthesiologists know, that is an imprecise determination. The operating room can be a very noisy environment. One may have trouble hearing any breath sounds at all. The chest wall can also easily transmit breath sounds from one side of the chest to the other in a thin patient.

A research abstract out of the Medical University of Vienna General Hospital (Anesthesiology News, May 2011) found that anesthesiology residents were able to accurately place an ETT by auscultation alone only half the time. By contrast, the correct placement of an ETT by looking at tube depth was 88%. The sensitivity for auscultation was 65% and for observation of bilateral chest wall movement was only 43%. However, if all three procedures were done, the ETT was placed correctly in nearly 100% of patients.

Previously, residents were taught that the best tube depth was 21 cm at the lips for women, 23 cm for men. The researchers found that this led to the tip of the tube being uncomfortably close to the carina, less than 2.5 cm (1 inch) from the bifurcation. Their new recommendation is 20/22 cm. But from personal experience, learned painfully, even this is not always accurate.

I remember taking care of a trauma patient one night. The patient was a short adult female with multiple stab wounds in the torso, including the left shoulder. Shortly after intubation, the patient started desaturating. Instinctively, I listened for breath sounds. They were much diminished on the left side. Therefore I pulled the tube back. The O2 sat improved slightly, but it never came back up to 100%. Auscultation again revealed decreased breath sounds on the left side. Again I pulled the tube back. Now the tube depth was only 18 cm at the lips and the O2 sat was not coming up. In fact it was steadily dropping and now the blood pressure was falling too.

With the patient's left sided chest injuries, the next logical conclusion was that there was a tension pneumothorax on the left side. A needle was inserted into the left chest. But there was no hiss of escaping air. The oxygen sat kept falling. The surgeons then quickly placed a thoracostomy tube into the chest but no blood or air returned. They then made a full thoracotomy incision and reached into the thoracic cavity. They found that the left lung was collapsed and not inflating at all. A fiberoptic bronchoscope was quickly retrieved and placed down the ETT. The tube was clearly still down the right main stem bronchus. It was then pulled back until the carina was visible through the scope. The left lung started inflating normally and the patient's O2 sat regained 100%. The tube was then taped securely, at 15 cm at the lips.

This goes to show that even when every standard precaution was made, an ETT can still be placed incorrectly. The new gold standard for proper placement should be a fiberoptic bronchoscope. We do this for every double lumen tube placement. The same principle should apply for every questionable intubation.

Thursday, July 14, 2011

Housing Bubble Continues In Los Angeles

Take a look at this house in the nice West Hills area of Los Angeles. It's a burnt out, condemned structure that has been overrun by drug abusers and vagrants. The original owner of the house died a few years ago and his son took possession of the house. He has not exactly kept it in working condition. The charred garage, the dumpster in the driveway, the unkept weeds in the yard. This place doesn't exactly scream suburban oasis.

The neighbors have been agitating for the city to do something about this eyesore for years. They've petitioned the city for relief. Of course the city councilman claims they have no records of any complaints about the house. The owner of this mess finally sold the house and the last resident moved out. How much do you think a shell of a house like this should cost? Try $290,599! That's the official record of the sales price for this thing. Amazing anybody would pay that much money for it. Who says the housing bubble has almost run its course? At least not in the nicer areas of Los Angeles.

Paying For Other People's Anesthesia

I recently had an enlightening, and infuriating, conversation with one of our gastroenterologists. The guy was grumbling about how our hospital was so inefficient and bureaucratic. His ire came down particularly hard on anesthesiologists. At our hospital, any inpatient that is having an endoscopy automatically gets an anesthesiologist to provide sedation. He proudly proclaimed that at his surgery center, he sedates patients all day long without an anesthesiologist present and he has never had a single anesthetic complication. In fact he says he has had more patient complications with anesthesiologists than without them.

I countered that most of the cases we do on inpatients are much sicker than the prescreened patients he sees at his ambulatory center. I questioned him about who was watching the patient while he's watching his procedure monitor and the nurses were running around taking care of his needs. He claimed he has never had a patient complain about recall or difficulty with the procedure and that for a healthy ASA 1 patient, an anesthesiologist is not cost effective and is more of a nuisance than a benefit to the health care industry. He said he wouldn't want to have his insurance premiums raised just to cover the cost of anesthesia for a healthy patient. Anesthesiologists are part of the problem of exorbitant medical costs in this country. Grrr. Just when you thought you knew a guy after working together for so many years.

That got me thinking. Why don't we use some legislative persuasion to convince insurance companies to cover anesthesia services for more procedures? After all, I'm paying health insurance premiums that covers benefits that I don't use. Things like insulin syringes and glucose strips. I don't use them but my premiums are helping cover the cost for people who do. How about screening mammograms. Covered but I'm never going to need one. The high cost of brand name prescription drugs are spread over the entire population of health insurance beneficiaries, even though only a small proportion of people actually use it. Social services? Mental health benefits? It's all in my insurance benefits though I have yet to take advantage of them.

I remember about a decade ago that there was an uproar when a woman in labor was denied an epidural because her insurance didn't cover it and the anesthesiologist refused to take the woman's cash. This became a national sensation and insurance companies were then mandated to cover labor epidurals in their policies. Insurance companies could argue that nobody NEEDS a labor epidural to have a baby. Babies have been born without them since the dawn of time. But by sobbingly recounting the horrible pain of delivery on TV, the government and the insurance companies were shamed into providing the service. Of course this doesn't come free. The cost of the epidurals are spread to everybody who buys health insurance.

So why don't we, and the ASA, lobby the state insurance commissioners to mandate insurance companies reimburse anesthesiologists for endoscopies and other procedures that they routinely deny payment? While it's true that many people don't require an anesthesiologist present to provide sedation during an endoscopy, the procedure is so much safer and more pleasant for the patient when we are in the room monitoring them. Instead of writing pleading reimbursement letters to the faceless multibillion dollar insurance corporations, we can easily identify patients who can tell heart-wrenching horror stories of having to endure endoscopies while being barely sedated by their GI doctors. Such tales told in front of legislative committees while being broadcast to the evening news will surely persuade our elected officials how terrifying an endoscopic procedure can be for some people. We can give our version of the great satisfaction patients derive from being sedated by an anesthesiologist and how they afterwards would recommend it to all their friends. We can argue that this will increase the compliance with screening procedures that are currently recommended to detect early GI cancers and thereby save costs in the long run. And isn't this anesthesia mandate worth it for an extra, I don't know, $10 a month on somebody's health insurance premiums? We only have to ask one question to the legislators: would they want their mothers scoped with or without an anesthesiologist present. Sounds like a plan to me.

Tuesday, July 12, 2011


Mulholland Drive bridge

If you have not heard about this, you probably will by this weekend. The busiest freeway in the United States, the 405 freeway, is scheduled to close this weekend for a road widening project. In order to make the freeway wider to accommodate more traffic, construction crews are going to tear down the Mulholland Drive bridge over the course of 53 hours, starting from Friday night, to 5:00 AM Monday morning. This freeway normally handles over 300,000 cars every day. This disruption to the normally hectic L.A. traffic has stirred this city into a frenzy. Only the brief visit by British royalty was able to interrupt the nonstop frenzy of talking heads predicting apocalyptic doom that is about to descend on the City of Angels.

You may not know the geography of L.A. Let me give you a quick tutorial. To the north is the San Fernando Valley which is a large bedroom community of almost two million people. To the south, on the other side of the Santa Monica Mountains, is the Westside. This is where many of the major businesses are located. Here you have the L.A. International Airport, the beaches, the fancy malls, the financial companies, the high end restaurants, the movie studios. These two places are connected by one major freeway, the 405.

Of note is that there are two major hospitals that sit right alongside the 405. These are the UCLA Medical Center and the Wadsworth VA Medical Center. But really all hospitals in the Westside are going to be affected. There have been some consternation about how this freeway closure will prevent emergency medical access for patients and if the hospitals can even be staffed adequately during that long weekend. Granted there are small roads that traverse over the mountain range, but these are expected to be completely jammed and overwhelmed over the weekend so that is not recommended. Our hospital has been sending out regular email asking people to trade calls with others who may have difficulty getting to work. Staffers are being asked to leave early Friday afternoon and it will be permissible to come back to work late on Monday. Some people are even anticipating staying over and not going home this weekend.

My goodness, all this hysteria over a road closure. Imagine what will happen when the Big One finally hits Los Angeles and thousands of people are expected to perish or be seriously injured. Massive damage to infrastructure is predicted when an 8.0 or greater earthquake rocks Southern California in the future. That is truly an image of the armageddon that I hope never to see. If this single freeway being predictably closed over one weekend period can cause such paroxysms, God help us when a real disaster strikes.

Monday, July 11, 2011

How To Wake Up Your Anesthesiologist

Anesthesiology can be exhausting work. The long hours, the lengthy monotonous cases (you actually want to have monotony in the OR, not surprises), and the isolation behind the ether screen can lead one to feeling tired, and yes, drowsy, at work. I have to admit that I've caught myself  "resting" my eyes" during a case. The issue is pervasive enough that the latest copy of the ASA Newsletter has an article devoted to the subject of sleeping anesthesiologists and how to prevent it.

The article doesn't really document anything new. Yes, we all should get at least seven, preferably eight, hours of sleep a night. If you don't, you'll build a deficit of sleep that can only be paid back with longer sleep periods on weekends. Sleep deprivation can lead to irritability, impaired memory, decline in motivation, and cognitive deterioration. It cited a study out of Finland which interviewed 328 anesthesiologists. The researchers found that anesthesiologists had the highest workload cases while on call of any medical specialty, including surgeons. Surgeons may scoff at this finding, but if you think about it, a surgeon may book one emergency case in the middle of the night. When he's done, he'll probably go home and sleep until the next morning. The on call anesthesiologist will still have to deal with the other emergency cases that have been scheduled by other surgeons. Because of this high stress level, the Finnish researchers found that 25% of the anesthesiologists had suicidal ideation, more than twice the rate of the general public. Yikes!

So what do the authors of this article recommend? Some suggestions are pretty commonsensical while others are impractical to the point of laughable. Yes, we should try to devote eight hours of sleep each night. If not, be aware that you may not be working at 100% of your mental capacity. They recommend "strategic caffeine" to stay alert. Haven't you ever wondered why doctors are always walking around with a cup of Starbucks or some other caffeinated beverage in their hands? Strategic napping was also suggested. Uh huh. The idea is you would take a few minutes nap while a colleague covers for you. The one critical part of this suggestions is that the handover of the patient from one physician to another be as complete and thorough as possible for the sake of the patient's safety. Somehow I don't think this last one has real world practicality.

For me, when I catch myself starting to nod off, the quickest and surest method of waking up is to stand up immediately. I know it's hard to do that when you've got that comfortable anesthesiologist's chair that's all nice and warmed up. But by standing, it is virtually impossible to stay drowsy. As a bonus, if I walk around a bit, it's good for my circulation, helps prevent DVT's, and reassures the surgeon that somebody is behind the drapes monitoring the patient.

One surgeon told me his method for waking up his anesthesiologist. He claimed it never fails. At the beginning of the case, he told me that the magic words to waking up the anesthesiologist is "skin stapler". I thought that was pretty funny and laughed at the preposterousness of that idea. No anesthesiologist who is studiously monitoring his patient would fall for that. Then halfway through the case, he casually mentioned "skin stapler". Sure enough, like Pavlov's dog, my head popped up over the ether screen to check on the case. When I saw that the surgical wound was still wide open, I knew he had got me. I looked at the surgeon who could barely contain his laughter. Then I slumped back into my chair and continued to read my iPad, I mean monitor my patient.

Wednesday, July 6, 2011

I Wanna Be A Billionaire...Wait, I Already Am.

Bill Gates, founder of Microsoft Corp., recently gave an interview to the Daily Mail in the U.K. In it, he revealed that his young children regularly tease him with the Travie McCoy/Bruno Mars hit song "Billionaire". He even starts to sing it to the interviewer. Hilarious. I think it's cool that the world's second richest man is humble enough to like the same music as the rest of us plebeians. Of course, while I can only sing wistfully one of my favorite songs from last year, Mr. Gates has actually lived the life sung in the lyrics.

I wanna be a billionaire so f***ing bad.
Buy all of the things I never had.
I wanna be on the cover of Forbes magazine.
Smiling next to Oprah and the Queen.

Though he claims he will only give a few measly millions to his children, I hope he doesn't deprive them of the same experiences he has had. In the meantime the rest of us will work our 60+ hours per week for the next thirty years hoping to attain 1/10,000th the wealth this extraordinary entrepreneur has attained. Keep up all your good works Mr. Gates.

Sunday, July 3, 2011

It's Confirmed. Medical Malpractice Does Not Apply To The Federal Government.

Dean Witt
The U.S. Supreme Court has confirmed it--medical malpractice suits can not be brought up against the federal government, only the private sector. In this case, it is the story of Dean Witt, a staff sergeant at Travis Air Force Base. On October 10, 2003, he underwent a routine appendectomy at David Grant Medical Center on the base. Postoperatively, he developed laryngospasm and became apneic. The CRNA who was taking care of him intubated his esophagus but did not realize it. He suffered severe anoxic brain injury and was taken off life support a few days later. The CRNA admitted to the accident and surrendered her license.

His wife Alexis Witt then sued the government hoping to overturn the Feres Doctrine which prevents military servicemen from suing the government for medical malpractice. When the 9th Circuit Federal Court in San Francisco confirmed it, she hoped to take it to the Supreme Court. Alas, the court declined to hear the case, which means the Feres Doctrine stands. The Congressional Budget Office had calculated that if the doctrine had been overturned, the feds could face hundreds of medical malpractice suits every year and suffer $2.7 billion in legal costs over ten years.

I'm sure the government is highly relieved. Imagine the huge costs this would incur on our already trillion dollar budget deficits if Feres had been declared unconstitutional. I guess the equal protection under the law guaranteed in the Fourteenth Amendment of the U.S. Constitution does not apply to the private medical sector of our country. Do I hear "Let them eat cake"? Have a happy Fourth of July everybody.

Saturday, July 2, 2011

Imagine That. Anesthesiologists Are Doctors Too.

I ran across an interesting article on while surfing the web. It's a slide show highlighting jobs that one might not expect would pay $100 an hour. Some of the jobs they list do pay a surprisingly large amount of money (tattoo artist? life coach?). However I was rather shocked, and dismayed, that anesthesiologist made the list. On the very first slide, CNBC does say that becoming a doctor is one of the "easiest" ways to make $100 an hour. But when you click down to the third slide you can sense a feeling of astonishment that an anesthesiologist makes that much money. I've included a screen shot of that slide (click on the picture to enlarge).

The ignorance, and condescension, can be read in the first paragraph. "It's not uncommon for doctors to earn $100 an hour or more but one category you might not expect is anesthesiologist. These are the doctors--yes, they are MDs (my emphasis)--who administer anesthetics, the drugs that knock a patient out, during surgery or other medical procedures."

So let me get this straight. CNBC believes doctors easily make over $100 an hour. But the person providing a humane surgical experience while the surgeon is hacking away at your body is also making that much money because, surprise!, he or she too is an MD. Looks like the ASA has its work cut out for it trying to promulgate the Lifeline to Modern Medicine campaign.

Frankly, sometimes I think it is preferable for anesthesiologists to fly under the radar when it comes to public perception. We know we are physicians, and have the income to prove it. But if the general populace are ignorant of that fact, then maybe they won't label us as part of the "rich" who deserve their scorn and envy. The only people who we really care to be jealous of us are still slaving away in the operating rooms at 7:00 at night while we have long ago driven home in our Porsches to be with our families and have a decent quality of life. Anonymity sometimes ain't half bad.