Friday, October 28, 2011

LMA Failure

During the just concluded ASA national conference in Chicago, a study was presented that pointed to potential causes of failure in LMA insertion and ventilation. Satya-Krishna Ramachandran, MD and Michael Mathis, MD, both out of University of Michigan, observed 15,795 patients from 2006 to 2009 who had a laryngeal mask airway placed. The LMA was considered a failure if it had to be removed from the patient and an endotracheal tube placed instead. They found that 1.1% of LMA usage failed.

The researchers discovered four factors that could lead to the LMA not functioning properly. They are an elevated BMI, poor dentition, male sex, and the operating table turned away from the anesthesiologist. It's understandable that patients who are obese or have bad or missing teeth have higher rates of LMA failure. The table being turned 90 to 180 degrees away from the anesthesiologist increases the likelihood that the LMA could get dislodged by the surgeon or his assistants. I'm not exactly sure why being male increases the incidence of LMA failure. Maybe the larger oropharynx leads to more air leak around the LMA compromising ventilation.

We were always taught that LMA's shouldn't be placed in patients who are morbidly obese. They potentially have a full stomach despite hours of fasting and worse ventilatory efforts. In fact, lawsuits have been filed because of severe consequences of LMA failure in the obese patient. However I usually find the highest predictor of LMA failure are in patients who are edentulous. When a patient has no teeth, the soft tissue in the oropharynx just collapses, making it difficult for the LMA to seat properly. I asked our LMA rep one time about this. He said he's heard this complaint before and suggested I use the LMA Supreme, a model with a flatter tube and higher angulation. Of course it is also more expensive. When I tried it on my next edentulous patient, it didn't work all that much better. It was harder to place due to the sharper angulation, and it still didn't sit that well in the oropharynx. So the search goes on for the perfect LMA and ventilatory device.

Obamacare Preview--Scarier Than A Halloween Zombie

Want a preview of the state of medicine once Obamacare kicks in in 2014? Take a look at California. The Department of Health and Human Services has just given permission for the state of California to cut Medi-Cal's reimbursement to health providers by another 10%. The state is running a perpetual budget deficit and one of the fattest, juiciest, and lowest hanging fruit is physician compensation. This cut is projected to save $623 million from Medi-Cal's $14 billion budget.

It is so easy for politicians to cut doctors' salaries. They know that by law we have to treat patients regardless of their ability to pay. Consequently any study to determine if patient access to physicians is compromised by lower reimbursments show no such impediments. By comparison, the government is having difficulty deciding how, or if, patients should also shoulder some of the rising costs. Undecided is a proposal that will have patients pay a $5 copay when they see a doctor, $50 for an emergency room visit, and $100 a day for inpatient services. Medi-cal patients would also be limited to seven doctor visits a year. That just wouldn't be right for patients to pay something out of their own pockets to see a doctor even as they gladly fork over cash to buy their cell phones, go to fast food restaurants, and see the latest installment of Transformers at the movie theater.

The California Medical Association has calculated that a Medi-Cal patient will only reimburse a doctor $11 for a visit. Think about that for a minute. If the patient has a fifteen minute visit, which may not be realistic because these patients usually have multiple medical issues, that would work out to $44 per hour for the doctor. Out of that $44 the physician has to pay his office staff, office expenses, insurance, taxes, and finally himself. Clearly a doctor who sees Medi-Cal patients is working for sub-minimum wage despite all the risks of hungry malpractice lawyers and thousands of dollars in student loan debt.

Now multiply California physicians' predicament with the projected effects when Obamacare is implemented. Suddenly there will be 30 to 50 million new patients waiting to see doctors who will get paid at Medicaid rates. What happens when the budget is busted and Obamacare potentially bankrupts the government? Here comes the knife at physician reimbursements. There is no scarier vision this Halloween than the future of American medicine.

Tuesday, October 25, 2011

Necessity, The Mother Of Invention

In the category of "why didn't I think of that?" comes this brilliant idea from across the pond. Trevor Prideaux of Sommerset, England was born without a left forearm. He was having no problem being a productive citizen despite this disability. However, he found that operating a smartphone with only one hand was challenging. It's difficult to text with one hand while trying to balance the device on the prosthetic.

Mr. Prideaux thought of a plan to place his phone directly into the limb for stability. He contacted Nokia, the maker of his cell phone, and his prosthetic maker. After six weeks, they fashioned an artificial arm with a built in phone cradle. Freaking amazing. Now he can answer the phone by putting his arm up to his ear, or use the speakerphone. Texting and other functions are also much easier with the phone in this stable position. It's too bad the arm doesn't charge the phone at the same time but I'm sure somebody can configure that setup in version 2.0.

Friday, October 21, 2011

Anesthesiologist Behaving Badly, Again

It's a shame these stories about misbehaving anesthesiologists keep popping up. This time, an anesthesiologist in Fredericksburg, VA was arrested for impersonating a police officer. Dr. Gerald Bellotti almost got into a motor vehicle accident when he pulled in front of another driver, causing her to nearly rear end his car. At one point he started yelling at her and saying he had a gun in his car. He even threatened to arrest her. The distraught woman went to the police station who then tracked his license plate. Dr. Bellotti could face up to a year in jail for this stunt. Doctors, can we all just behave like responsible professionals, above reproach, and with the best interest of our professions in mind? Please?

Friday, October 7, 2011

Mandatory Flu Vaccinations For Healthcare Workers. Good Policy or Fascism?

The flu season is almost upon us. In our hospital, there's been talk about requiring all employees to get a flu vaccination. The idea was floated by the Infectious Disease doctors and has received general support from the hospital staff committees. An informal poll of the doctors at our facility revealed that about two thirds of them get a flu shot every year. The CDC recommends that at least 90% of healthcare workers get vaccinated.

In order to facilitate 100% compliance, different ideas have been expressed to "encourage" acceptance of the vaccination. Among the tactics include forcing any medical worker to wear a mask at all times in the hospital if he hasn't been vaccinated, a sort of "scarlet letter" if you will to shame the employee into getting vaccinated. In the "money talks" category, some advocated a financial penalty on those who won't get the shot. Some of the more orthodox staff even recommended suspension from work until the employee gets vaccinated or perhaps even termination from his job.

A firestorm of protests erupted after these draconian measures were made public. Many called these ideas un-American or fascist. Others cited the British Medical Journal article that questioned the efficacy of flu vaccines. Some pointed out that the state allows parents to exempt their children from getting various vaccinations before entering school but the hospital won't let medical professionals decide for themselves if they want to forgo the far less proven flu vaccine. A few simply stated that they had severe egg allergies and could not get a flu shot.

Some pointed to the possible severe side effects of a vaccine. A couple of years ago, at the height of the H1N1 swine flu panic, people couldn't get the flu vaccine fast enough. We had workers going to different departments of the hospital to make it easier for the employees to get their swine flu vaccine. The H1N1 pandemic never materialized to the extent that was drummed into the public. However the adverse effects of the vaccine are real. One of our surgeons, after getting the H1N1 vaccine, developed a Guillain-Barre type of illness. He suffered profound weakness and had to be admitted to the ICU. He was almost intubated due to poor respiratory effort. He was out of work for months while he received physical therapy to regain his strength. Luckily, after a long recuperation, he is back at work and doing an excellent job.

So should healthcare workers be forced to get the flu vaccine? How many vaccination injuries are acceptable in order to protect the public at large? Have doctors lost control of their own bodies, a natural extension of our loss of autonomy from government meddling in our professional lives? Our hospital is still debating the issues.

Thursday, October 6, 2011

Best Foods For The Operating Room

Okay, right off the bat, I'm going to give you the official rule about eating in the operating room. NO FOOD IS EVER, EVER, EVER ALLOWED IN THE OPERATING ROOM! Got that? Never, ever, ever.

Now that I have that out of the way, let's talk about eating in the O.R. Yes we all know it is wrong. But sometimes for humanitarian reasons, anesthesiologists are forced to eat in the operating room. We try to eat what we can get in the doctor's lounge in the morning (hence the RAPERS reputation), but that alone can't possibly last through a ten to twelve hour workday. The nurses get lunch and snack breaks because they have strong union rules. The surgeons get to eat between cases, all the while complaining about the long turn around time they are suffering through. Anesthesiologists? Nobody is there to give us a break. When the surgeon leaves after putting in his last skin staple, he is heading down to the cafeteria. In the meantime, we have to wake up the patient, take him to recovery, give report and make sure the patient is stable, come back to the O.R. to set up for the next case, interview the next patient in preop and digest his entire life history in less than five minutes if possible, start an IV, get my medications ready, wheel the patient into the operating room, induce the patient, then call the surgeon to let him know we are ready for him. All in under 30 minutes, preferably under 20. So you can see, there is little opportunity for anesthesiologists to eat outside the operating room. Therefore we have to be creative in order to keep from getting malnourished and hypoglycemic. It would be unseemly to have an anesthesiologist collapse behind the ether screen because his blood glucose is 32.

So what kinds of food work best for munching in the O.R.? There are several rules I think should be followed. The number one rule is the food should emit no odors. Anything that will draw attention to your eating is absolutely unforgivable. Thus something like popcorn is out. Coffee is the rare exception that most staff in the O.R, including the surgeons, have brought in with little protest.  Next the food must be easily handled. No knife and fork or other utensils should be necessary to eat it while working.  The food should be compact in size. It should be able to fit under your mask while eating, preferably bite size pieces so you're not holding a piece of food in your hands between bites. No greasy foods. That means french fries and nachos are out. Leaving greasy fingerprints on your machine and anesthesia records cannot be tolerated. No loud foods. Potato chips commit the double felony of greasy and loud. So they're out. Nothing too watery. That can leave a mess and make you need to go to the bathroom in the middle of the case. Finally, no choking hazards. The surgeons don't like it if they have to unglove to perform a Heimlich maneuver on you.

Okay, so now that we have the basic rules for the kinds of food that should not be eaten in the operating room, let's look at a list of stuff that should pass muster. Some are sweet, some are savory, but there should be something here for everybody.

1. Power bars or granola bars. This is the standard by which all other O.R. foods are compared. There are infinite varieties to choose from. They are small, compact, and easy to eat. They are quiet when chewed and they fit easily into your briefcase. Just remember to get the ones that don't have crinkly wrappers. The wrappers will draw too much attention to your activities.

2. Grapes. They're sweet, healthy, and a good source of hydration in a compact size. Definitely get the seedless variety as you don't want to be spitting out seeds all over the O.R. floor. Just make sure you don't eat too many of them lest you need to urinate during the case.

3. String cheese. A good source of calcium and protein. Small and easy to eat. The kids love them and I do too.

4. Peanut butter and jelly sandwich. This is a surprisingly good fit for the operating room. Cut into small squares, they fit easily into the mouth. It is a quiet food, loaded with protein, satisfies both the savory and sweet tooths, and doesn't leave crumbs behind. Just be sure nobody in the room has a severe case of peanut allergies.

5. Juice box. This is good for a quick hydration and glucose pick me up. The small straw that comes with the juice box makes it easy to drink under your mask. Multiple varieties to choose from. Just try to avoid the slurping sound it makes when the box is almost empty.

6. Fig newtons. An ideal cookie for the operating room. They don't have a strong smell like chocolate chips cookies can have. They are bite sized. And they leave few crumbs behind.

7. Small crackers. Examples include Cheez-Its and bite-sized Ritz crackers with or without fillings. Being bite-sized helps make sure there are no crumbs all around the anesthesia work station. Also little munching noise is made when you can chew a whole cracker with your mouth closed.

8. Small pretzels. Mini pretzels work well. You can fit an entire one in your mouth at one time making little noise and few crumbs. They are loaded with carbs to keep your energy going. They are also low in fat and taste good. What else could you ask for?

Those are my dietary recommendations for replenishing yourself in the operating room. Again, you should never, ever, ever eat in the O.R. But if you have too, you can't go wrong with any of these choices. Have I left anything out? Please give me some of your suggestions in the comments below. I'm always willing to try something new from my fellow anesthesiologists.