Learning From The Mistakes Of Others

The California Department of Public Health routinely publishes a list of fines to hospitals which have made egregious errors that caused the death or permanent injuries to patients when the proper safety protocols are not followed. The fines can range up to hundreds of thousands of dollars for facilities with multiple recurring mistakes. The state conveniently publishes the results of their findings so that others might learn from the mistakes of others. This month the list includes twelve hospitals. Many are the "routine" so called never errors like leaving a lap sponge inside a patient during surgery. However I'd like to highlight one particular case that I thought was very instructive. The case involves one of our local SoCal hospitals: Kaiser Foundation Hospital of Harbor City.

According to the report, the patient was admitted to the hospital in 2010 for hematemesis. A nurse reported the patient vomited bright red clots of blood. After the patient was intubated in the ICU, she was taken emergently to the operating room. During the procedure the surgeon noted that the patient was coagulopathic. He requested Factor VII be given to help clotting. The CRNA in the case told the state investigator that he gave a drug that was given to him by the supervising anesthesiologist without ever confirming its contents because he "put his trust in [my] supervisor and took the bottle of medication" and pushed it into the patient. The patient made it out of the OR but continued to bleed profusely. When the surgeon asked for more Factor VII to be given in the ICU, the pharmacist said he had not sent any to the patient. He had sent Activase instead. Activase actually prevents blood from clotting and is used to treat patients with blood clots causing an ischemic stroke or heart attack.

When interviewed by the investigators, the circulating nurse in the OR said he had written down Activase on a piece of paper when the surgeon made the Factor VII request. When the drug arrived to the OR, he repeated "Activase" three times to the surgeon. The anesthesiologist in the room said he heard the surgeon call out for Factor VII but admitted that he never looked at the medication he was given by the nurse before giving it to the CRNA. He concedes that the protocol is to confirm the identity of every drug by reading its label before administering it to the patient.

The patient eventually died later that day. The cause of death was listed as "periprocedural administration of alteplase". (the generic name for Activase) As usual, when a catastrophic error occurs, it is not a single mistake that happens but a series of chain reactions. The surgeon said he asked for Factor VII, which was confirmed by the anesthesiologist. The nurse said he heard Activase and confirmed three times with the surgeon. The nurse gave the drug to the anesthesiologist who did not read the label because he either put his complete faith in the circulating nurse and pharmacy or he was too busy with a critically ill patient. He drew up the drug and gave it to the CRNA who did not look at the drug label either because he he never questions his supervising anesthesiologist. And the patient died as a result of all the mistakes committed by several different people.

Though it's tough to air your dirty laundry in public, this is how medicine polices itself. Though Kaiser was fined by the state for $50,000, hopefully this will be a small price to pay to ensure that other hospitals won't make the same missteps and tragic outcomes.

Anesthesiologists Can't Have Nice Things

Anesthesiologists don't always get the special attention we feel we deserve. Unlike the surgeons who get the most advanced laparoscopic equipment or the internist who has access to the latest antibiotics or antihypertensives, anesthesiologists are usually relegated to equipment so old it would make a used car salesman blush. I have seen anesthesia ventilators that are still in use even though they were purchased when Elton John was still considered heterosexual.

But perhaps there is a reason for that. You see, we anesthesiologists don't really have a personal stake in the equipment that we use. The anesthesia machines are paid for by the hospital. So are our offices. Unlike other doctors who have to pay rent and take care of their own office equipment, some of us are not as caring that comes from personally paying for things out of our own pockets. I can't tell you how often the anesthesia machines are banged up and scratched. Or the laryngoscope handles get accidentally tossed out in the trash. But here are just two recent examples in our hospital of anesthesiologists who don't give a s*** because, well, they didn't pay for it.

Here is a picture of our anesthesia lounge recently. It is not a pretty sight. Somebody decided to take a nap on the sofa and brought some hospital pillows and blankets with them to make it more comfortable. Unfortunately he, most likely a he, did not bother to take them away when he was finished and just piled it up in a big heap. I guess his mother never taught him to make his bed and clean his room when he was growing up. And what's this stuff on the floor? Why it's cherry flavored hospital jello that somebody, don't know if it's the same person, brought to the lounge to eat and decided he didn't want it. Instead of finding a trash can to throw his food away, it got dumped on the carpet. Classy.

Another disgusting example is this picture of our damaged video laryngoscopy equipment. These things cost thousands of dollars. However they are worth every penny as a difficult intubation can usually be completed with one of these technological wonders. However, some people in our group didn't feel the need to maintain the equipment so that other people might be able to use it. As you can see, our group is lucky enough to have several of these in use, and two of them have been damaged. The screens have been cracked and will require several thousand dollars to repair. You wouldn't see an anesthesiologists treat their personal iPads with such cavalier attitudes. For comparison, here is what a new one looks like.

Maybe there is some justification for making anesthesiologists use old outdated equipment. Many have not demonstrated the maturity or the responsibility to handle new things. So now the rest of us will have to make do because of the childish behaviors of a few.

Q: How Does A Doctor Make Money In California? A: You Can't.

The wise judges of the 9th Circuit U.S. Court of Appeals in San Francisco has decided that the state of California was within its rights to cut Medi-Cal reimbursements to physicians by ten percent. Medi-Cal is California's version of the federal Medicaid health insurance for the poor. The state first passed a bill, AB97, in the summer of 2011 to lower physician payments in an attempt to balance its woefully indebted budget. The bill would have allowed Medi-Cal to pay just $11 per office visit and $100/day to hospitals for inpatient care. Hospitals and doctors' groups immediately sued to stop the bill. An injunction against its implementation was placed on it until now.

According to the appellate judges, "prior to reducing rates states need not follow any specific procedural steps, such as considering providers' costs..." To add insult to injury, the judges further point out that, "Neither the state nor the federal government 'promised, explicitly or implicitly' that provider reimbursement rates would never change."

Hmm. So the state doesn't have to consider the costs of providing a service when it decides how much it is willing to pay for the service. And even when it does, it can change it at will without input from the people who has to provide the service. Doesn't sound like much of a business case for doctors. The state argues that with the expansion of Medi-Cal due to ObamaCare, doctors here will at least be reimbursed for treating patients that previously were uninsured and uncollectable, even if the payments are very low. That sounds like a version of the old business joke where a store owner loses money on every sale but he'll make up for it with volume. The bottom line just doesn't work out. It's no wonder most doctors in this state refuse to accept any more Medi-Cal patients.

California has said that it will monitor the ability of Medi-Cal patients to get physician access. If the state feels that its patients are not able to find doctors willing to take Medi-Cal, it will "take immediate action." Does that mean it will raise reimbursement rates to attract more doctors into the program? Hardly. There is talk that the government may obligate California physicians to accept a certain percentage of their patients from Medi-Cal as a condition for licensure. In other words, indentured servitude. If California really is the trendsetter for the country, we are witnessing the implications of ObamaCare in microcosm.

The California state government has helpfully provided a list of Medi-Cal reimbursements for all procedures listed by CPT codes. If you're contemplating on moving to the once Golden State, it may be worthwhile for you to spend a few minutes looking at it to see how it may impact your income if you decide to move to the land of low payments, exorbitant taxes, and onerous business rules. Also remember that these rates are subject to an immediate ten percent cut due to AB97 and more cuts in the future whenever the politicians feel like it.

Moonrise

When I left for work before 6:00 AM this morning, I saw this gorgeous image that literally had me stop my car in the middle of the road. Don't worry. It was our neighborhood street with no cars traveling at that ungodly hour.

It is the image of a very thin crescent moon hanging over the eastern horizon. Right above it is Venus, rivaling the moon in its brightness. Below the moon, closer to the horizon and just off the side of the picture, stood Mercury. You can see a little bit of the horizon on the bottom of the picture to give you a perspective. I quickly whipped out my cell phone and snapped a picture but it really doesn't do the scene justice. To the naked eye the moon appeared much bigger being so low on the horizon. The earth's reflected light on the dark side of the moon was intensely bright to the point that I could almost make out the different craters and seas on its surface.

Little can be said for leaving for work so early every day. But sometimes, you get to see amazing images that all but disappear by the time most people wake up for their first cup of coffee.

The Yacker Tracker

In the spirit of expensive medical devices with questionable patient benefits, our hospital recently installed the Yacker Tracker in our recovery rooms. Many studies have linked a noisy environment with poor patient satisfaction and outcomes. We've all been in the ICU where alarms are going off nonstop throughout the entire ward. It drives us insane just being there for five minutes. Pity the poor patient who's stuck in his bed for weeks at a time while the alarms are blaring all around him.

In response to patients and families complaining about our recovery room being too noisy, the hospital has decided that we need the Yacker Tracker to tell us when to pipe down and stop gossiping about what so and so did at happy hour last Saturday night. It works best for noise that is sharp and loud, like a book dropped directly in front of it. It doesn't seem to work as well for the ambient noise that is more prevalent in in the recovery room. Several people were talking near the machine in a normal conversational tone and not a peep came out of it. In fact I did my best Gangnam Style impersonation directly at the device and it didn't alarm. Oh well. It seems like a nice idea in trying to raise the ever more important patient satisfaction score.

Surfing In The O.R.? Go Ahead. It's Okay.

Surgeons routinely complain that anesthesiologists aren't working hard enough. Whenever they peer over the ether screen, they see the anesthesiologist reading a book or newspaper, or more likely nowadays, surfing the internet. I've seen surgeons call up the O.R. director over their irritation with their anesthesiologist's inattentiveness to the patient.

Well now we have a study which says that distracted anesthesiologists may not be such a bad thing. Answering a question that many people have been wanting to know, David Wax, M.D., et. al. at Mount Sinai School of Medicine in New York has published a study in the December 2012 issue of Anesthesiology that looks at the consequences of anesthesiologists who are busy looking at the internet and not at their patients. In their study of 1,061 cases by 171 clinicians (anesthesiologists, residents, and CRNA's), they found that there was no correlation between how long somebody was using the computer to do something else besides charting the patients' anesthesia record and any hemodynamic instability in the patient. The results show that there were no differences in the rates of hypertension, hypotension, or tachycardia between the times spent on the computer for anesthesia record keeping vs. times not doing so. Zero. Nada.

They could accomplish this because the anesthesia workstations had internet access and were able to track what the clinicians was doing with the computer at that time (hello Big Brother). The researchers found that the clinician was more likely to be using the computer for non patient use if he was an attending anesthesiologist working alone in the room, the patient had a lower ASA score, the case lasted a longer period of time, and the patient was given general anesthesia.

For cases lasting less than one hour, the median time not used for record keeping was only one percent of the total case time. In cases that went on for 1-4 hours, the amount of time on the computer not used for the patient stretched to 21%. In a four hour case that would work out to 48 minutes of surfing time. For cases taking longer that four hours, a median of 29% of the time was being used for something else. A five hour case would presumably mean the anesthesiologist was not monitoring the patient for 87 minutes. Overall, a median 16 minutes of time was spent on non anesthesia related work on the computer over the course of a median 80 minute procedure.

There are some weaknesses in this study. The authors were not able to distinguish between the computer user surfing the net for pleasure or using the workstation to look up a patient's labwork.  They of course also couldn't tell if the clinician was busy using his own tablet or smartphone to surf the net instead of using the workstation.

In an interesting editorial, Drs. Karen Domino and Daniel Sessler compare the anesthetic experience to driving a car on a long boring stretch of road. Keeping your eyes fixed on the road soon lead to fatigue and boredom. Sometimes the brain needs some distractions to maintain its vigilance. They note that previous studies have shown that anesthesiologists spend less than 5% of their time actually looking at their patient's computer monitor. Only about 25% of an anesthesiologist's total time in the operating room is actually devoted to monitoring the patient. The rest of the anesthesiologist's time is presumably taken up moving the O.R. table up and down per surgeon's request, changing the radio station to the surgeon's preference, or turning down the thermostat to freezing so the surgeon feels comfortable.

Though this study shows that not staring at a patient's monitor every second in the O.R. isn't the sin it's been construed to be, if you ever get into a malpractice suit for not paying attention to the patient crashing on you, you'll pay for it. In the Anesthesiologists' Closed Claims database, thirteen claims of injury due to a distracted anesthesiologist have been filed. In 91% of the cases, the care was judged to be substandard. In 83% of the cases, money was paid to the plaintiffs at a median payout of $725,937. Ouch.

So doctors, surf the net in the O.R. at your peril. While this study says it is unlikely anything untoward will happen while you're looking up MarketWatch, if your patient crashes and burns, you and your malpractice insurance company will be paying for the transgression dearly.

Want To Be An Anesthesiologist? Only Perfectionists Need To Apply.

One of the toughest things about being an anesthesiologist is that we are always striving to give the perfect anesthesia. I guess you could call us the Goldilocks of the operating room. You never want to do too little or too much for the patient. If your practice deviates to either extreme, you will be doing your patients a disservice. Let me give you some examples.

First, let's take general anesthesia. It is considered one of the most important developments in the history of medicine. Yet despite over a century of use, its application can still be extremely challenging. While modern anesthesia machines are leaps ahead of the old copper kettle, it still harder to use than a toaster. It still takes years of training and experience to judge just the right level of anesthesia to give. If you allow too little anesthesia, you'll be hearing from the patient's lawyers about how the patient suffered surgical recall and remembered feeling every slice of the scalpel on her body while she was totally paralyzed. Give too much anesthesia and the patient's blood pressure could bottom out, causing a heart attack or a stroke. It is not an easy balance to maintain during the course of an operation.

How about pain control? We anesthesiologists are considered experts at relieving pain since, well, we invented the field way back when. But it is no easier now than a hundred years ago to give just the right dose of analgesics to make the patient comfortable. Every patient has a unique level of pain tolerance that no computer model can replicate. We have all experienced the anxiety of having a patient screaming in pain in the recovery room despite having been given twelve milligrams of hydromorphone in the past one hour. At the opposite extreme you might give a patient half a milligram of hydromorphone and suddenly the patient goes apneic and you're calling for the Ambu bag and a bolus of naloxone. Pain management is tricky as hell to do perfectly but that is often what is required of anesthesiologists.

Let's not forget the complex business of blood transfusions. In this age of scarce blood supplies and possible viral transmissions, it is vital that just the right amount of blood be given to a patient. We are always trying to keep the patient's hematocrit around thirty for the best combination of oxygen carrying capacity and blood viscosity. We do this even though we may be giving the patient liters of crystalloid fluids while the surgeon is losing hundreds of cc's of blood at the same time. If we transfuse too little blood the patient could die from hemorrhage or end organ failure. Give too much blood and the hospital starts questioning you on the waste of this precious resource. Transfusing blood products is not to be taken lightly.

These are just a few examples of why anesthesiologists need to be perfectionists. There is little room in this field for approximations. Unlike internists who can keep adding antihypertensives to a patient until the blood pressure is just right, we usually have only one shot at doing right by the patient. We don't have days or weeks to fine tune our treatment plan. Surprisingly we are successful more often than not. It is not often that I go home at night and worry myself sick over what I could have done differently. Of course there are always cases where I ruminate for hours on the what ifs of a particular case. But these are the exceptions, not the rule.

So if your idea of practicing medicine is to sit in the doctor's lounge, drink coffee, and munch on a Krispy Kreme while discussing patient histories with your fellow physicians for hours on end, anesthesiology is probably not for you. We like our colleague fast thinking, resolute, and faultless. Because our patients demand nothing less than that from us.

My State's Legislators Are Getting Feted In Hawaii While I'm Buying My Pens From Costco

I've finally used up the last of my stash. After years of accumulating drug rep pens, I have finally run out. They have all been used or the ink has dried up inside so they won't write. Well it was fun while it lasted. I remember the good old days when the salesmen from the pharmaceutical companies would bring breakfasts or lunches to the doctor's lounge. For five minutes of my divided attention I could get a nice pasta or baked chicken lunch while getting educated on the advantages of their latest product offerings. Of course I would try to grab a few pens and notepads on the way out.

This was all strictly educational of course. I had no control over what kind of drugs I could use. That was controlled by the hospital pharmacy. I decided in the operating room which drugs were best for my patients, not what the drug rep told me was the best on the market. I'm not so greedy as to use medications just because somebody bought me a sesame bagel with a large schmear of lox for breakfast.

But a a few years ago our wise politicians decided that doctors were being bribed by drug companies into prescribing expensive meds. They believed this was the reason healthcare costs were rising at unsustainable rates. How can doctors possibly not be affected by all the free gifts that were being showered on us? Who couldn't resist the sales pitches of these oily drug reps as they try to push the latest antibiotics and antihypertensives on us poor helpless physicians? Therefore doctors and hospitals pretty much succumbed to political pressure and bad P.R. and stopped accepting gifts of all kinds, even from grateful patients and families. Now I use scratch paper from the back side of junk faxes and buy my own pens from Costco.

On the other hand, the politicians themselves don't seem to have any second thoughts about receiving presents from the myriad of lobbyists that surround them every day. Even though the election is not even a month old, our good old California elected officials are already grabbing at every freebie they can get their pudgy little hands on. The LA Times reported on a group of newly elected state representatives enjoying a basketball game together in AT&T's luxury box in Sacramento. Says Jose Medina, assemblyman from Riverside, hobnobbing with lobbyists is "part of my job. At the end of the day I'll make my decisions based on what is best for the people I represent." I'm sure the free food and drinks in the luxury suite will have absolutely no bearing on how he votes.

Then there is the group who jetted out to Maui after the election for a five day "conference" on matters important to Californians. The trip was sponsored by a tobacco company, various drug companies, utility companies, and state public workers' unions. As one freshman representative tried to rationalize his reason for flying to Hawaii to learn about California's many problems, "I was learning about the issues. There were some things I didn't know--such as how businesses really need help to flourish here in California." Others flew as far away as Brazil, Australia, and China, on lobbyists' expense, to gain insight on how to help the people who just elected them.

The hypocrisy would be laugh out loud funny if it wasn't so disheartening. Politicians accuse doctors of not being able to tuck a few cheap pens into our pockets without being influenced into prescribing expensive drugs while they have no qualms about accepting tickets and hotel rooms to exotic locales from lobbyists in the name of education. I feel gypped. If I have to accept Obamacare and its impending reimbursement cuts, at least let us have our old pens and notepads back.

All Choked Up

In general I think all eating contests are disgusting. It's pretty gross watching people stuff massive quantities of food into their gullet. Not only is it nasty, it is downright dangerous. I'm always surprised that not more people die of asphyxiation at those pie eating or hot dog eating contests. But this one really blew my mind.

A man in West Palm Beach, Florida won a cockroach eating contest last month. His prize was supposed to be a python. He wound up eating a bucketful of roaches, 60 grams of meal worms, and 35 three-inch long "superworms." Shortly after he won, he started retching and died. People wondered whether eating the cockroaches led to an anaphylactic reaction or he was poisoned by those nasty critters. Turns out to be neither. The medical examiner ruled it an accidental death due to asphyxiation from aspiration of gastric contents. The man choked on cockroach parts. Ewwww! Could you imagine the EMT intubating the man and finding a mouthful of roach bits inside? The horror!.

Hope you all have digested your Thanksgiving dinners by now.

The Free Lunch Society

Americans love to get something for nothing. We doctors are acutely aware of this attitude. People go to the emergency room hoping and expecting to get medical care for free. Patients refuse to pay their insurance copays. A physician's medical bill somehow gets placed at the end of the line for payment, behind other life necessities like cable TV, cell phones, and Netflix.

Here in California, the election last week fully exposed how society has become accustomed to receiving freebies. There were two propositions on the ballot: Proposition 30 and Proposition 38. Millions of dollars were spent trying to get both propositions passed, or failed, during the election. The funny thing was that both were ostensibly written for the exact same purpose--increasing funding to the schools. The main difference was that Prop 30 would increase the state income tax by 1-3% for the millionaires and billionaires of California ie/ anyone with incomes greater than $250,000. It also increased the state sales tax by a nominal 0.25%. However, though Gov. Jerry Brown claimed otherwise, nothing in the proposition specifically says all the tax money had to go to the schools. It could be directed by the state legislature to any government project it judged worthy.

Prop. 38, on the other hand, increased the state income tax on everybody, anywhere from 0.4% to 2.2%. But it was written so that the money would be specifically directed towards school funding.

Well guess which one passed? Proposition 30 sailed through by 54% to 45%. Meanwhile, Proposition 38 failed 72% to 28%. So all those voters, particularly the young people who came out en masse for Obama, decided that they want more money for schools. They just don't want to pay for it themselves. California now has the highest state income tax level in the entire country. The Hollywood and Silicon Valley liberal elites, big proponents of Prop 30, will barely blink an eye over paying an extra 3%. The majority of the electorate won't be affected. But somebody has to pay for more money for the teachers' pension funds. Everybody wants to enjoy the good life, as long as it's not coming out of their own pockets.

The Most Important Article In The History Of NEJM Is...

This is really amazing news, especially for somebody like me who loves reading about history. After a survey of its readers, the New England Journal of Medicine has declared that the most important article in its two hundred year history is the description of the first ether anesthetic ever published. What's even better is that NEJM has made the article available for download in its entirety in pdf format.

The article is titled, "Insensibility During Surgical Operations Produced By Inhalation." It was published on November 18, 1846 in The Boston Medical and Surgical Journal, the precursor to NEJM.  It was written by Henry Jacob Bigelow, M.D., described as "one of the Surgeons of the Massachusetts General Hospital." Dr. Bigelow starts the article with a brief description of the first public demonstration of ether by Dr.William Morton on October 16, 1846, which to this day has been immortalized as Ether Day.

He goes on to describe the history of ether and the various experiments in its development. I find it interesting that in his far ranging discussion of ether's development, he even quotes a French journal. How many American physicians even know French, much less read French medical literature? Dr. Bigelow then lists several case studies, including a patient who apparently received an overdose of ether. The patient's heart rate was noted to drop while his pulse became weaker and his hands grew cold. As there was little knowledge about how to revive patients who received too much ether, they revived the patient the only way they knew how--they treated him like an unconscious drunk. The doctors put a cold towel on his head, sprayed water into his ears, and held ammonia under his nose. When that failed to revive the patient, they hoisted the patient up and walked him around the room. Eventually the ether wore off and the patient woke up after about an hour. You can't make this stuff up. A modern hospital's ethics committee would have a stroke if such incidents were happening today.

By all means you should download this article and read about the birth of anesthesia. Then you can appreciate how wondrous anesthesia has humanized medicine, without which we would truly still be in the stone age of medicine. It truly deserves to be considered the most important article in the illustrious history of the New England Journal of Medicine.

Dr. Andrew Harris Reelected To Congress

Congratulations to Dr. Harris of Maryland for getting reelected into Congress. He won in his district with an overwhelming 63% of the votes. That is a bigger win than his first election two years ago. As the first and only anesthesiologist to serve in Congress, we are watching his career with special interest. And as a fellow Republican, I also have to congratulate him on being the token conservative in the blue state of Maryland. Now if you can do something over the next two year about that pesky fiscal cliff, Medicare cuts to physicians of 29% in January, unfair anesthesia reimbursements by Medicare, the IAPB, and the socialization of American medicine we would all be truly grateful.

ECG Computers Are Not Infallible

We are always told to read our own electrocardiograms. Though each ECG printout has a reading at the top as interpreted by a machine, we're advised to read it with our own critical eyes and make our own judgements. However, it is all too easy to quickly look at that computer interpretation while we are scrambling to get the next patient into the operating room instead of poring through every single lead on the page. Sure the computer interprets "antero-septal infarct, age undetermined" so often that we don't even bother to check if it is correct. As long as there a reasonable correlation between the reading and the the wave forms, we feel adequately informed.

The ECG above however is so egregiously off that I felt compelled to use it as Example A as to why we shouldn't rely on machines to do our readings for us and make clinical judgements based on them. As you can see, the computer read this ECG as "Sinus tachycardia with 2nd degree A-V block with 2:1 A-V conduction". That would be a pretty impressive ECG, almost like the kind they use to test us during ACLS. But even a cursory glance shows how off base the reading is. First of all, it's nowhere near being sinus tachycardia. As the printout shows a little to the left, the heart rate is only 61 beats per minutes. Then of course there is no evidence of a 2nd degree A-V block. These are all just overzealous interpretations made by the ECG computer. That is why an actual human interpretation is still essential in making clinical judgements in medicine. Even if it's just a disgruntled cardiologist making $20 for using his years of training and expertise to provide this critical life saving service.

Obama Lied. Anyone Surprised?

During the tumultuous debates leading up to passage of Obamacare, President Obama promised Americans that if they are happy with their employer sponsored health insurance they will be able to keep it. Well somebody forgot to inform the administration about the laws of economics.

Today's Wall Street Journal article reveals that many corporations are now planning to hire part time instead of full time workers precisely because of the effects of Obamacare. They cite companies like Darden Restaurants, owner of Red Lobster and Olive Garden, who have decided that replacing full time workers with part timers will be much more economical. The reason is that companies have to pay a penalty of $2,000 for each employee who works more than 30 hours but isn't offered health insurance. The penalty goes up to $3,000 for each employee if the company health insurance is considered inadequate under the health care law.

Anna's Linens, a chain of stores that sells bedsheets and towels, began cutting the number of hours their full time workers could have each week, rendering them to part time status. Their CEO, Alan Gladstone, says that offering the comprehensive insurance coverage the new law requires for all 1,100 of their sales associates will be too expensive and the law prohibits companies from offering sparser but cheaper insurance. Their only alternative would be to raise prices, which would drive customers away.

Notice the insidious nature of these cuts. Many of these employers are in the service industry with razor thin margins. The employees who will be affected are usually the young, working at their first jobs. In this economy they are lucky to have a good job with any kind of health benefits. Now with Obamacare, that first step up the ladder to responsible citizenship has been pulled up and away. Without that first full time job leading to future career advancement, many of these kids will wind up in dead end part time employment, eventually dependent on the government for handouts. So Mr. Obama, we don't want four more years of laws that could lead to European levels of youth unemployment. If you win the election this week, I hope you have the tolerance to accept criticisms of this imperfect law, as no law is perfect as written the first time, and make meaningful changes to protect vulnerable employees. If you lose, well there will be few tears shed among the medical and business communities.

The Infuriatingly Incompetent Inpatient Intravenous

Our surgery schedules can get pretty hectic at times. With impatient surgeons pacing in the hallways and tightly packed starting times, a fast turnover of the operating room is essential. That's why it's a relief when I see that my next patient will be an inpatient. Half of the time I spend on my preop interview with a patient can be eaten up by starting an intravenous. Between spiking an IV bag, collecting the IV supplies, and starting the IV on the patient, this process can easily take ten minutes, longer if the patient has difficult veins.

With an inpatient though, the IV is supposed to be already in place. Thus it should be a breeze to just walk into the room, chat with the patient for a few minutes, then roll him into the operating room. Simple as that. Except it is usually not that easy. Unfortunately, for some reason, many of our inpatients don't come to the OR with a functioning IV. Often the patient comes down without any IV fluids running, just a heplock. When I hang an IV bag in preop and hook it up to the heplock, the bag won't drip freely. If I try to flush the line, nothing will go in. The IV has clotted, which it is prone to do if there are no fluids running to keep it open. It is especially true with the tiny IV's many of our patients seem to receive on the floor, like 22 or 24 GA sizes.

What's worse are the patients who come from the floor with an IV pump dripping some medication into the catheter at a glacial pace, like 10 cc/hr. You are deceived into thinking the IV is working. However, when I try to check the integrity of the IV by flushing a small syringe of fluid, the patient complains of pain. I check the IV site and realize the little bolus of fluid revealed the ugly truth about that IV, it is not actually in the vein. The slow rate of the IV pump masked the fact that the medication has extravasated into the tissue but was not felt by the patient.

Sometimes inpatients come down with no IV's at all. I always found it curious that a person who is sick enough to be admitted into the hospital would have no venous access for medications, or heaven forbid, an emergency resuscitation. Our hemodialysis patients usually fall into this category. They have difficult veins to begin with and they are prone to fluid overload. Thus many of them don't get IV's while they are in the hospital. Until they finally come down to the operating room for a procedure and guess who has to start one.

These inpatient IV mishaps occur surprisingly often. I would guess it is at least a third of the time our inpatients arrive in preop without a working catheter. It happens so often that I'm always pleasantly surprised when an inpatient comes down with one that actually works.

CNA vs. CMA. Political Activism vs. Patient Advocacy

We are in the home stretch of the 2012 election. Every time I turn on the TV or listen to the radio I hear another political ad telling me to vote yes for something or no for something else. At the end of the commercials there are always a list of sponsors who paid good money to put this drivel on the air.

Curiously, many of the ads list as a sponsor the California Nurses Association. Their endorsements in the election include such non-nursing issues as how car insurance premiums are calculated and how out of state corporations are taxed in California. I wondered, why in the world would the nice nurses at my hospital care about such topics? We discuss subjects such as patient safety in the operating room and improving hospital efficiency, but never about changing the definition of California's three strikes law.

Finally I decided to go to the source of this political activism, the website for the CNA. I was immediately struck by how political the CNA is. Throughout the home page are advice on how to vote next week. There is a link that takes you to a page that contains a nice little cutout you can take to the polling booth to show you who to vote for and how to vote on each California proposition. In addition to all the voting directives, the home page also contains pictures of nurses holding picket signs and kudos to nurses who were able to negotiate higher paying contracts. There is virtually nothing on the home page about improving patient health, as one would expect from a website run by nurses.

By contrast, when I go to the California Medical Association website, there is almost nothing on the home page that directs physicians how to vote in the election. As a matter of fact, you have to scroll down a bit before you even see any news about political activism, a little tidbit about how the CMA supports California's climate change law. (As an aside, I think the CMA is trying to kiss some legislators' asses by endorsing this measure. California is already losing major corporations to other states because of onerous and over the top taxes and regulations. This ill conceived climate change law will do nothing to help global warming around the world but will make companies think twice before opening another factory here in the state. When good companies don't come here, their well insured employees don't either. Does the CMA think we doctors prefer to treat MediCal patients instead of privately insured ones? There must have been a medical marijuana shop nearby blowing their fumes into the CMA's conference room when they endorsed this law. This message fully endorsed and sponsored by ZMD.)

Anyway, I go back to the CNA's website to see what's going on. To get to the bottom of the story, you have to click on the About link. Then right there, in the first sentence, is the answer. "Founded in 1903, the California Nurses Association/National Nurses Organizing Committee/AFL-CIO is a premier organization of registered nurses..." So the CNA isn't really an organization for patient teaching and nurses training. It is a political union no different from the Service Employees International Union or the United Autoworkers Union. It's no wonder I have an almost totally opposite viewpoint of how I will vote next week. They have hijacked the good name of nurses to promote their political causes. They are using the trust patients have of nurses and abusing it for their own motives. For shame.

The CNA should stop deceiving people about what kind of organization they are. Virtually none of our nurses are the activists the CNA would like the public to believe. They work long hours, do jobs we doctors wouldn't want thrust upon us, and take crap from patients and their families all day long. Yet they are still able to show compassion and respect that many of those patients don't really deserve but still receive. To me, that's what the nurses are all about, not how they will vote on genetically modified food labeling. I bet the CNA would be much less successful in persuading voters if they really knew that they are just another arm of the AFL-CIO.

The Easy Way To Decide What Kind Of Doctor To Be--Take A Test

It is an eternal fear and frustration faced by all medical students: what kind of doctor should I be. For me it was both gut wrenching and emotionally exhausting. Though I had some inkling that I wanted to be an anesthesiologist while in medical school, I was led astray that took years of soul searching before returning to my true love and destiny. Little did I know that, though it might not have existed at the time, there is an online test to help students navigate through these treacherous waters, the Medical Specialty Aptitude Test.

Hosted by the University of Virginia School of Medicine, this test has been around for awhile. You can surf through various medical blogs and it will keep popping up time and time again. It is a nice resource that every generation of medical students, especially the current technologically astute classes, keeps coming back to. The test consists of 130 questions you answer based on how strongly you agree or disagree with a statement. Many of the questions seem to repeat themselves, such as variations on if you're a thinker or a doer. How much do you like working with people? Do you like to see immediate results? Only a few questions were truly unique, like do you enjoy research? Or are you mechanically adept?

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The test says it should take about 15 minutes to complete but I did it in less than five. I tried not to think too hard about the questions and answered what came to my head first. So here are the results. As you can see I knew myself in medical school better than I thought. The specialty that I matched best with according to the MSAT is in fact General Surgery. Surprise, surprise. In fact, of the top ten choices, five are in the surgical field. But my instincts weren't entirely baseless. Anesthesiology ranks right near the top at number four. This confirms my feelings that I still love being in the operating room. It's just the lifestyle of general surgery that I detest.

What's also interesting about my results are what's at the bottom of the list. According to the test, and the last two got cut off on this screen shot, the specialties I would be least likely to succeed and find solace in, are: Family Practice, General Internal Medicine, and Pediatrics. They were all fields that I had absolutely no intention of entering.

One specialty that I'm surprised by the ranking is Psychiatry. As I mentioned in a previous post, I loved psychiatry as a student. But here, the test ranks it fourth from last. As many students know, a good attending can make a clinical experience better than what it really is. My psych attending was excellent and made me seriously consider it as a career. Ultimately it looks like I made the right decision by not going into it.

Right now medical students all around the country are getting ready to apply for residencies to fields they hope they will like but really don't understand. It has always been a guessing game based on clinical experience, mentor's advice, and gut instinct. Here is one more resource that can serve as an aid in this life changing decision.

EMR Is Destroying The Nursing Profession

We've all seen this before. You're walking through the wards of the hospital. All around are the beeps of IV pump alarms blaring from the rooms. The call light has been activated from a room where a patient wants some medical attention. Yet all you see are the nurses sitting at their stations, noses pressed up close to the computer screen or down at their keyboards, busily charting their patients for the electronic medical record system.

It has become all too common to see this as nurses are so busy documenting their patients on the computer that they have little time for actual patient care, or even recognition. When we implemented our new EMR a few months ago, it brought a dramatic slowdown in admission of patients into our outpatient surgery center. The electronic implementation of the preop admitting note is so onerous that the nursing manager told the nurses to cut corners, not all of it beneficial to the patient.

The EMR was forcing the nurses to ask their patients many nonessential questions that delayed admissions but had no practical implications for the patient' hospital stay. Questions that had to be answered on the computerized records include: Do you always wear your seatbelt when riding in a car? What religion are you? Do you use contraception when you have sex?

Because all these mundane questions were delaying the start of cases, the nursing manager decreed that some questions don't need to be asked. You know, such trivial stuff like what kind of meds the patient is taking. Some patients were taking fistfuls of medicines every day. All these drugs had to be entered into the EMR individually, along with the dose, the frequency of intake, and the last time the drug was taken. This could easily eat up fifteen to twenty minutes of preop time. Therefore the manager said that was not important for nurses to know. That information was for doctors to get from the patient and should not take up any nursing time.

Another time saver that was cooked up was the disregard for a patient's lab work. The preop nurse was not to waste any effort looking up a patient's labs. That information too was not worthy of a nurse's time. Laboratory work was the responsibility of the surgeon and anesthesiologist to look up and analyze before surgery, not the nurse.

As you can imagine, many of the nurses were appalled by the new rules. They had just been demoted to being computer entry clerks. The job of the preop nurses was no longer to evaluate the patient for appropriateness for surgery. Instead they're supposed to find out if the patient had gone to the bathroom that morning and enter it into the computer. Everything else squandered too much time to be bothered with.

How sad for our nurses and the nursing profession.

What Your Breath Reveals To An Anesthesiologist

Apparently breath analysis is becoming a hot research topic. By studying the contents of a person's breath, multiple medical maladies can be diagnosed. For instance, nitric oxide levels in the breath are elevated when the airways are inflamed thus signaling an asthma attack. Irritable bowel syndrome sufferers may show increased hydrogen levels due to bacterial overgrowth. The possibility of making meaningful diagnoses without expensive invasive procedures or painful blood draws certainly merits more research.

However we anesthesiologists are already experts at evaluating a patient simply from the odor of his breath. As masters of the airway, we are frequently up close and personal with a patient's exhalations. Thus after years of experience I can tell you what somebody's breath reveals about their health.

You tell me you haven't smoked in six months just so you can get that transplant? Then why is it that as soon as I open up your airway during direct laryngoscopy, I feel like an ashtray has been emptied into my nostrils? I may not be able to tell whether you've been lighting up with Marlboros or Winstons but I know you haven't quit smoking like you claimed to have done. Case cancelled.

How about your claim that you haven't used marijuana and are now living a clean and sober lifestyle. Again one peek down your airway and my face is assaulted by the atmosphere from a Grateful Dead concert. You just couldn't make it down for your surgery without a quick stop at the local "medical' marijuana shop? Don't tell me it's to alleviate postop nausea either.

Then there is the trauma patient brought emergently to the operating room after driving into a tree. What a freaking mess. I do a quick rapid sequence intubation to get the case going. As I do so, my nose is confronted by the uniquely rancid odor of blood, alcohol, and partially digested food emanating from the mouth. As soon as I drop down an orogastric tube into the stomach, I am proven right. Out comes hundreds of cc's of the patient's last pitcher of beer and what looks like a pureed mixture of nachos and pepperoni pizza.

Yup we anesthesiologists have developed quite an acute awareness of our patients and their breaths. We don't need any special sniffing equipment either to tell us what we already know from years of experience. And we even do it for free.

I Am Not A Cocktail Waitress

As doctors continue to lose control of their livelihood, the politicians are ratcheting up new ways to make life miserable for us. One scheme is to make sure our patients are happy and satisfied with their medical care. This year, Medicare will take away 1% of hospital reimbursements and redistribute the money to the facilities that make their patients happier based on a questionnaire developed by politicians. Starting in 2016 that goes up to 2%.

The public may not understand it, but hospital pretty much run on profit margins that would make most other businesses run away from this industry. Between all the free care hospitals by law are supposed to give and the decreasing reimbursements from the government and insurance companies, most hospitals have profit margins of about 1% or less. At Grady Hospital in Atlanta, they made $1 million on revenue of $650 million this year. That's a profit margin of 0.15%. After Medicare reduces reimbursements due to low survey results, the hospital will lose $230,000 from the government. By comparison that iPhone 5 you hold covetingly in your hands probably gives Apple a 50% profit margin.

Questions on this patient survey include subjective inquires like, "How often did doctors treat you with courtesy and respect?" And, "Did you receive help as soon as you wanted it?" To indulge the patients, doctors are being cajoled into pulling up a chair and sitting down next to the patient when talking to them.

Excuse me? I am not some cocktail waitress who sits next to you when taking an order in hopes of getting a fatter tip. My life does not revolve around making you feel you had a delightful experience at the hospital. I am here to treat your illness, not feed your id.

As anyone who has ever worked in the service industry knows, it is impossible to please everyone all of the time. Some people just can't be appeased no matter how hard you try. Especially in a hospital setting, the nature of human illness makes people even less likely to see the sunny side of their stay. As one nurse related at Grady Hospital, a patient they had rescued from a massive stroke and managed to walk out of the hospital gave the facility low evaluations because the food was not to his liking. This is the kind of mentality we are supposed to kiss up to?

One hospital here in Los Angeles tried to make patient happiness the center of its mission. When Century City Hospital opened in 2007, there was much fanfare about how it would steal patients from the nearby powerhouse hospitals Cedars-Sinai and UCLA Medical Center. They were going to do it with state of the art surgical facilities, fancy flatscreen TV's in every room, and gourmet meals conceived by none other than Wolfgang Puck himself. Well the idea was nice. But they forgot one thing: people like nice things but they don't want to pay for it. Century City went bankrupt in 2008, taking millions from the physician investors who bought into the concept. Perhaps their doctors didn't pull up a chair when they were talking to their patients. Maybe their nurses should have performed lap dances to raise their patient satisfaction scores. At least patients might willingly pay for that.

How can we reverse this situation?  We need to vote these rascal politicians out of office. But wait, these incumbents are usually entrenched in their positions, using the millions of dollars they have at their disposal from political donations provided by special interest groups. We doctors on the other hand aren't even allowed to receive lousy pens and notepads from drug reps anymore because somehow that will influence how we treat our patients. Looks like doctors better get familiar with service with a smile. And learning a few lap dance techniques can't hurt.

Worst History And Physical Ever, Thanks To EMR

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I was looking for my preop patient's history and physical written by a consultant in our new fangled EMR system the other day. Scrolling down hundreds of notes from physicians, residents, fellows, nurses, physical therapists, social workers, etc. I finally located what I wanted. At least I think it's the preop clearance note that I wanted.

Reading through this note felt like the worst case of cutting and pasting I have ever come across. It appears to have come straight from the hospital billing office. The only thing the note was missing were the ICD-9 codes after each unspecified diagnosis. How can a physician produce a history for a patient and label virtually every diagnosis "unspecified"? It makes you wonder if the patient actually has the disease or whether the consultant was too lazy to write more specifically in his note. In other words, this H+P was total garbage. Thanks to our new EMR, this kind of shenanigan is all too common.

Yes we can read doctors' notes more easily now. Unfortunately, what's typed in makes even less sense than before.

Finally, My New TV

Some of you may have been following my saga of buying a new 3D TV. After years of waiting for the perfect combination of size, price, features, price, picture quality, and price, I finally settled on the Samsung 65ES8000 to fill out my newly remodeled home theater. Alas, when my TV arrived from Amazon, it was immediately obvious that somebody had dropped the bloody thing. There was an internal crack in the screen, not visible with the TV off, that severely marred the picture. Well, back to Amazon it went.

Unfortunately, a couple of months ago this TV was in severe short supply. When I sent the TV back, they had no others to replace it. Not until just recently did Samsung have more of this model to ship out and I finally got my replacement. But thanks to the delay, I got a free Samsung 7 inch tablet thrown in for free. Yeah. As you can see, there are no more cracks or rainbow distortions in the screen. The picture is gorgeous. The family and I are watching more TV than ever, which of course is a mixed blessing.

However, despite the price, the set is not perfect. The 3D is cumbersome to implement and rarely used. It has a feature called AnyNet that automatically turns on my home audio whenever I turn on the TV. It is supposed to be an asset but in fact is a pain in the ass because if I don't want to turn on the surround sound it will get turned on anyways. But the biggest drawback is what the folks at AVS Forum call vertical banding. That's the dark vertical shadows visible when there is a uniform background color on the screen like this snowy picture in the movie "Ice Age". I'm probably the only person in the household to notice this since I read nerdy forums like AVS. The bands are not visible during motion scenes, which is most of the time, or with mixed colors, again most of the time.

So after years of saving and scrimping, I finally have the TV of my dreams. But this thing is already obsolete. From what I've been reading, the next big thing is no longer 3D, or even glasses free 3D. The next revolution in television will supposedly be in wide circulation at next January's Consumer Electronics Show: 4K TV. That's a TV with four times the resolution of today's 1080P.

Sigh. Time to start saving my pennies again.

Are CRNA's Better At Treating Chronic Pain Than Most Anesthesiologists?

That seems to be the question the Centers for Medicare and Medicaid Services is trying to answer. CMS has until November 1 to decide whether Medicare will reimburse CRNA's at the same rate as physicians for treating chronic pain, including invasive injections and prescriptions for narcotics. If Medicare does approve this plan, then the consequences will snowball as private insurers follow the lead of the federal government.

It appears that the main excuse for allowing CRNA's to start independently performing and billing chronic pain procedures is the lack of access of many patients to board certified pain specialists. As always, they pull up the old canard about having few anesthesiologists willing to work in rural settings, forcing patients to travel hundreds of miles to see one.

So from the logic of the discussion, the CMS will conclude whether 45,000 CRNA's are as qualified to perform pain procedures as 2,000 pain specialists board certified by the American Board of Pain Medicine. These 45,000 CRNA's will intuit on their own whether they will inject drugs into somebody's back with potentially life threatening complications, something that most general anesthesiologists who have had training in treating chronic pain but are not board certified to do so, would rather not touch. When the lone CRNA working in some rural clinic a hundred miles from the nearest specialty pain center encounters a patient complaining of low back pain, he or she is now suddenly able to diagnose and treat chronic pain right then and there because the government has given the green light to do so since the patient otherwise won't have "access" to more specialized professionals.

Does this make any sense at all? The CMS is saying it's okay for rural and poor patients to be subjected to minimally trained nurses injecting drugs into their backs and joints just because, well, there is nobody else around who will do it. The key to increasing the availability of well trained board certified pain specialists is not to go downmarket by using lesser trained nurses (two years of nursing and two years of CRNA schools vs. four years medical school, four years anesthesiology residency, and one year pain fellowship). Instead the CMS should be increasing the Medicare reimbursements for anesthesiologists, thus making Medicare patients more attractive. As it stands, Medicare screws anesthesiologists with the lowest reimbursement of any medical profession, just 33% of what a private insurer pays for the same service.

The CRNA's who are clamoring to get into the specialty pain business may regret doing so. They are going to find that Medicare reimbursement isn't that great. Their malpractice insurance will surely skyrocket. And in a few years, well, Medicare may decide that even CRNA's can't work cheap enough for all patients to be seen. They may decide that PA's are just as qualified as CRNA's to diagnose and treat chronic pain. They are starting a downward spiral that could hurt chronic pain patients most of all.

Anesthesiologists Do More By 8:00 AM Than Most People Do All Day

It is dark when my alarm clock blares. 5:15 AM. I have gotten up at this time so often that my internal alarm clock had already brought me back to consciousness three minutes ago. Quietly I slip into the bathroom for a quick shower and shave. I dress silently so as not to disturb my wife still dozing comfortably in the warm bed. She too is so used to my routine that my noises don't even disturb her anymore.

As I leave the house I wonder if it will be dark again before I get home. Hopefully I'll return before the kids go to bed tonight or it'll be two days that I won't see their smiling faces. I'd like to think that they miss my company but this has happened so often that I think they hardly notice anymore.

The streets are still fairly deserted when I get on my way. Other than the lone exercise fanatic or the dog walker who irritatingly changes my green stoplight to red when he pushes the crosswalk button, there are only a handful of cars sharing the lonely asphalt. The freeway is a whole different story however. It is already starting to get congested. If I leave the house ten minutes later my commute would take twenty minutes longer. Such is the traffic calculus of Los Angeles.

Pulling off the freeway I see all the same usual cars going to the same destination as me. The hospital is like a self-contained city, with hundreds of people with different responsibilities all converging to make sure it runs efficiently and on time. I recognize fellow anesthesiologists, nurses, and various hospital staff all pull into the parking lot ready to start another day.

I go straight to my assigned room to get started. I have a difficult case this morning. No time today to go to the doctors' lounge to chit chat and grab a coffee and bagels. After preparing thousands of cases over the years the basic setup is rote. Do an anesthesia machine check. Make sure there is enough inhalational agents in the vaporizers. I hate it when some fool of an anesthesiologist leaves his last case of the day without turning the vaporizer completely off and the oxygen still gassing out eight liters per minute all night. Check the suction. One of my worst weaknesses is failing to remember to have a proper suction in place. It was a problem during residency and it still dogs me to this day. So suction? Check.

I notice that the anesthesia tech has already set up the arterial and central line transducers. Thank goodness we have such great techs, always thinking ahead to what the patient will need instead of my having to ask them for it.

Now for the drugs. I draw up the induction agent, the paralytics, the antibiotics, the resuscitation drugs. Almost ten syringes in all. Then I mix a couple of bags of pressors and hang them on the IV pole. Taking one last look around I don't think I'm missing anything egregious. Glancing at the clock, it is now 6:45 AM. Time to go meet the patient.

Like an actor about to walk out onto the big stage, I take a deep breath, put on my happy face, and enter preop holding. The room is its usual morning chaos. Patient beds are lines up against the walls. Nurses, residents, medical students, and staff are all trying to talk to the same patients simultaneously. Some patients have compared the din to the aural assault in a too-hip dance club.

If the nurses aren't too busy or they're feeling extremely generous, they may put in the IV for me, or at least have the IV supplies ready. No such luck today. I go into the IV fluids cabinet and assemble my favorite bag of crystalloids, taking up precious minutes. Then I go to the IV supply cart and get the things necessary to start one: tourniquet, local anesthesia, IV catheters, alcohol pads, and tape. More minutes tick by.

Arms fully loaded, I walk over and introduce myself to the patient. In order to save time, I go over the patient's history while simultaneously starting his IV. Sure I had perused his chart the night before but surgeons' H+P's are notorious for being next to worthless when it comes to describing anything about the patient besides the chief complaint. I've been surprised by undocumented cardiac disease, adverse previous surgical experience, or even wrong site surgery on the schedule.

With just minutes to go I rush to the closest computer workstation to enter my H+P. New Joint Commission rules say the patient cannot enter the operating room before the anesthesia note has been written. I then go to the Pyxis and wait in line for my turn to get the narcotics. Luckily the surgeon is late, surprise surprise.

Finally he arrives. He says a quick greeting to the patient then asks why he isn't in the room yet. The patient gets a quick squirt of Versed, which nearly all patients appreciate, and is moved to the OR. The anesthesia tech is already waiting for us. Once the patient is on the table, the tech prepares him for an arterial line. By the time I have put on the usual standard anesthesia monitors, the patient's wrist has been prepped and draped for my a-line insertion. Luck is with me today as I feel a strong radial pulsee and put in the line on the first shot. Few things are worse than holding up the case trying to futilely find a pulse to get an a-line in.

I then walk back to the head of the bed and put the oxygen mask over the patient's face. In my most soothing voice I ask the patient to imagine himself relaxing at his favorite vacation spot as I start the induction. In seconds he is unconscious. Intubation is a cinch. I tape the tube securely along with the eyelids. I make sure the anesthesia gas has been turned on. The patient returned his twitches so I push some muscle relaxants. The tech is now preparing the neck for a central line.

A quick check of the monitor shows the patient is hemodynamically stable. An ultrasound machine is rolled towards my line of sight. To me this contraption still feels novel as I grew up when men were men and anesthesiologists could place central lines by anatomic landmarks alone. But it does make the procedure easier and with more certainty, like today.

Another brief glace at the computer screen shows the patient continues to do well. I quickly give a push of IV antibiotics before I forget. One last review of the patient. Vitals? Check. Anesthetic? Check. Twitches? Check. Fluids? Check. The surgeon calls a timeout. Yeah yeah, we all agree on the procedure. The scrub nurse then hands the surgeon his scalpel and makes the incision. Another life about to be improved at the point of a knife.

I finally sit down and start documenting my day so far. It is 8:00 AM.

How An Apple Store Is Mightier Than A BMW

Okay this one gave me a good laugh on an otherwise dreary Monday morning. Last month burglars rammed into the Apple store in Temecula, CA with their SUV and absconded with a bunch of store display iPhone 4s and iPads. Unfortunately for them, despite the massive BMW X5 they were driving, they had quite a bit of difficulty getting out of the store, as you can see from the video.

In the process of trying to escape, they lost their license plate and blew a couple of tires. Once they got out, they stopped at a nearby convenience store to change a tire and then rob the 7-Eleven of a can of Fix-a-Flat. When they realized they had lost the license plate, the owner of the BMW went back to the store, with the keys of the car in his pocket, to retrieve the plate. The police were very happy to see him return to the scene of the crime. Easiest arrest they've made all year, I bet.

Stupid Is As Stupid Does

 File this one under "Don't Try This At Home, Or Anywhere Else". Jose Luis Gomez Nava was convicted in an Orange County courtroom of driving while under the influence of nitrous oxide. He pleaded guilty to one count of vehicular manslaughter with gross negligence while under the influence.

On November 10, 2010 Mr. Nava was driving 80 miles per hour in a 45 mile per hour zone in Santa Ana while inhaling balloons filled with nitrous. He eventually lost control of the car and crashed into a tree. The car ignited and burst into flames. One fifteen year old passenger was killed. Two other passengers suffered severe injuries. Mr. Nava himself is still in a wheelchair. When the police arrived, they found unfilled balloons in the driver's pocket, a cylinder of nitrous along with a control valve at the crash scene.

I thought I've heard it all but this one really takes the cake. How can anybody be so idiotic as to drive while inhaling an anesthetic? It's not like he drank some beer at a bar then got into his car to go home. He had to heave a cylinder of nitrous into his car to accomplish this feat. And how can his passengers be as dumb as him, riding in a car that was obviously being driven by a man who was under the influence of a drug that's designed to make him high as a kite. Of course they were probably all high at the time so they probably didn't even notice him swerving into the tree.

Well for all the injuries and carnage, Mr. Nava got off surprisingly light. He only needs to serve one year of jail time and five years of probation. With time off for good behavior and prison overcrowding, he'll probably be back on the road within six months. For all you fellow drivers in Orange County, look out for the man with a car filled with balloons. If he's not wearing clown makeup, give him plenty of space all around.

Senior Day In The Operating Room

A long, long, time ago, well actually a little more than a decade ago, we used to talk in anesthesia residency about the anesthetic implications of geriatric patients. You know, the ones over the ripe old age of 65. During morning report, if anybody had a patient who was in his 60's or greater, the discussions would cover the topic of geriatric anesthesia. The attendings would go over the finer aspects of the elderly patient, such as rising closing volumes, worsening diastolic dysfunction, and decreasing glomerular filtration rates. How much propofol would one use for induction? Maybe propofol isn't even appropriate in this particular patient. How do you titrate muscle relaxants in somebody with poor renal function? How do you maintain cerebral perfusion in somebody with 70 year old arteries? Should an arterial line be placed? This was a minefield that had to be waded through with the utmost care. Yes, sexagenarians and older were really scary patients.

How quaint those discussions seem now. I recently had a scheduled lineup of cases in my room involving a 94 year old, a 92 year old, and an 88 year old. These cases involved two hip replacements and a gastrostomy tube placement. They were all in various states of altered mental status. One had happy dementia. She didn't know who you were or why she was in the hospital, but she was just the cheeriest talkative patient you ever had the pleasure to meet. She greeted everybody with a pleasant hello but otherwise couldn't give you a snippet of her medical history or her chief complaint. Which was okay. People don't mind happy dementia.

Another had angry dementia. This patient was constantly screaming out for some long deceased relative and caretaker. We had to put her on the far side of preop holding to minimize the disruptions and anxiety to the other patients in the room. Placing an IV in such a patient is nigh near impossible, with tympani rending screams and multiple hands for restraint. Such outbursts always have me worrying about somebody calling 911 to report to the police about elderly abuse in our operating room.

The last one had sleepy dementia. He was just barely arousable, nonverbal, and slipping inexorably towards the "O" sign. These are always the saddest patients. Their minds have already deteriorated beyond repair but their cardiovascular system refuses to comply with the inevitable so they just linger on and on. Seems like medicine is confronting more and more such late stage patients.

What I've learned through experience is that when patients reach such advanced age, their physiology is surprisingly robust. Sure they may not have the ejection fraction of a Michael Phelps but they certainly do better than some patients who are in their fifties or sixties with severe coronary artery disease and cardiomyopathy. Patients who reach this age probably won't die from CAD. They are more likely to expire from aspiration pneumonia, or urinary tract infection, or failure to thrive. Therefore I don't become as fearful of a cardiovascular collapse as I used to. Not that I'm not still vigilant but for me the sweaty palm anxiety of anesthetizing the extremely elderly patient has become much less acute.

So now, when I see on my schedule a patient who is only 68 years old for a hemicolectomy, I'm thinking, "Bring it on!" That person is just barely past his prime. My mind doesn't even go into heightened alert anymore unless they were born before the Great Depression. In modern medicine, ninety is the new seventy.

Thank You Joint Commission For Raising The Cost Of Medicine

The Joint Commission was established to monitor the competency of hospitals to treat patients. In many ways it is good because it forces medical facilities to improve any deficiencies that might affect patient safety. But like any regulatory body, it is all too easy to go too far and start demanding practices that have minimal if any relevance to patient care. They suddenly seem like they are just making it up so they have a reason to exist.

After our last inspection, the JC demanded that we label all syringes with the name and concentration of the drug within, date and time the syringe, and your initials. This rule applies to ALL syringes, even the sterile drugs we draw in the course of preparing for a regional anesthetic. The only exceptions are drugs we draw up then immediately push into the patient without our hands ever leaving the syringe. You can see how that can be problematic if you're wearing sterile gloves and have to label sterile syringes.

Despite months of protests and letter exchanges, even with the backing of the ASA, the JC would not back down from their demand for labeling sterile syringes. So this is the solution our department has concocted. On every regional anesthesia package, we now tape a sterile marker to the box for use to label the sterile syringes. Now we have a solution for a problem we never knew we had. Thank you TJC for looking after patient safety. I'm sure this will save as many lives as your rule for placing the dirty laundry basket at least five feet away from the trash basket.

Pain Management By Committee

People don't like pain. We anesthesiologists devote our entire lives to helping people live pain free. If patients experience too much pain while under our care, it makes us cry. Okay. It doesn't. But our whole raison d'etre is to make sure our patients are comfortable, therefore that is our first priority. Unfortunately the ugly side of pain management is that if a patient feels he's not getting adequate analgesia, they can sue you for medical malpractice. That is when the hospital administration starts noticing and caring about the adequacy of pain control in the patients residing within the hospital's walls.

In that light, one of our hospital's multitude of committees has decided upon a course of action to help detect and eliminate pain from our surgical patients. Besides our usual vigilance as anesthesiologists in treating pain, the committee has decreed that we should also recite the following to our patients in preop, word for word:

Your anesthetic plan is specifically designed to optimally manage your intraoperative pain while also enabling a smooth transition to the recovery period. It is important that you communicate any special pain issues and that you describe your pain using the pain scale to your recovery room nurses, floor nurses and pain team so that your pain can be appropriately assessed and treated in an effective manner. Do you have any other questions for me regarding the plan for pain management?

Word for word. Does that remotely resemble a doctor's conversation with his patient? George Clooney couldn't make those lines sound convincing, even in his "ER" days. It sounds more like a lawyer reading off a contract. This is what happens when the practice of medicine is subjugated to fear and group-think. With ever increasing intrusion by third parties, witness the creation of the Independent Payment Advisory Board in Obamacare, this may just be the beginning of things to come.

I Learned To Distill Alcohol From Purell. Best Fire Safety Class Ever.

Every few years, our hospital requires that all employees take a class in fire safety. It's usually pretty boring. We learn about the different fire extinguishers in use, how to set off the fire alarm, and map out where all the fire escapes are around the facility. Useful to know, but not a lot of fun on a weekend morning.

This year, the instructor demonstrated something more entertaining. We got into a discussion on the ubiquitous presence of hand sanitizers throughout the hospital. There used to be some trepidation about placing bottles of sanitizers in hospitals because they contain 63% alcohol, an apparent fire hazard located by the door of every patient room. To illustrate the flammability of the Purell, he poured some of the gel into a shot glass and lit it with a cigarette lighter. Sure enough, the gel burned with a faint bluish alcohol-fed fire. Luckily there has been no increase in the incidence of burns in hospitals since Purell dispensers were installed.

Since our society simply abhors any form of bacterial contamination, hand sanitizers were quickly mandated in most places where large groups of people congregate and live, like prisons and nursing homes. Much to the administrators' dismay, people were soon abusing the Purell as an alcohol substitute. How did they do it? The moonshiners can't just build a still in their bedrooms and start making alcohol. It has to been done with mundane household items that were easily accessible. They discovered that nothing was more mundane and common than the salt shaker present at every table in the cafeteria.

Our fire safety instructor then showed us how prisoners and old folks were able to easily transform hand sanitizers into a party drink. He first poured some gel into a glass. Then he tapped some salt out of a salt shaker into it. With a few swirls of a swizzle stick, the gel began to liquify. He then poured the liquid into another common household object, a coffee filter. The distillate from the filter was drinkable alcohol. We didn't taste it--it didn't look too appetizing. However if you're thirsty enough, you could mix it with some juice or margarita mix and have yourself a grand old party at the nursing home with this 120 proof concoction.

So we learned about Class A, B, C fires, how to single-handedly carry a patient out of a fire, and make alcohol from hand sanitizers. Yeah, that was the best fire safety class ever.

QE3? What About QE Me?

The U.S. Federal Reserve has once again decided to goose the nation's economy by instituting Quantitative Easing, Part III. They will be buying billions of dollars of mortgage backed securities each month for as long as they feel is necessary to drive the economy out of its funk. As a result, the stock market staged a huge rally today, to within just a few percentage points of its all time high.

Well, isn't that special. What I, and many in this country, want to know is, what have they done to help me? I assume the Fed buying MBS by the truckload will resurrect this country because that's what all the news analysts are saying but it still seems pretty obscure to me. Median inflation-adjusted income in this country has fallen to levels last seen in the 1990's. The poverty level in the U.S. is over 15%. The rich are getting richer and the middle class is shrinking. Seems to me the govenment buying an obscure monetary unit like mortgage backed securities will only benefit the rich, who probably do own these things. How many of your neighbors do you think own MBS? Unless your neighbor is Bill Gross, so called Bond King at PIMCO, how is the Fed's buying of MBS going to make your life better? The only people who make out well, as usual, are the Wall Street traders and bankers who own and handle MBS. Notice the sharp rise in bank stocks after the Fed announcement. These are the people who actually get face time with the Federal Reserve governors and White House invitations for suggestions on how to improve the economy. Is it any wonder real estate prices in Manhattan and London are at all time highs?

All I know is that the Fed has been keeping interest rates close to zero for years now, decimating savings accounts. The elderly are ever more dependent on their Social Security because their savings are being destroyed for lack of compounded interest earnings. Starting next year, we are facing the so called fiscal cliff where taxes will be raised on income, dividends, capital gains, and payroll. Gas prices here in California are over $4 per gallon. I'm getting nickeled and dimed to death every time I get on an airplane. There are almost thirty kids in each of the classrooms of my children's elementary school. Thousands of students are not able to attend college because of budget cutbacks and tuition increases yet the state will spend billions on a high speed train to nowhere. Doctors are facing a 29% cut in their reimbursements for treating Medicare patients. This is my reality. Color me unimpressed with the Fed's plans today. Where is the quantitative easing that will make a real impact in my world?

IV Creativity

Breast IV. Don't try this at home.

I've seen some pretty creative IV's in my career. Some patients are almost impossible to start a peripheral IV. Consequently I've seen patients come to preop with some pretty bizarre locations for their intravenous. I've found them dangling off the knuckle of their fourth finger. I've noticed them inserted over the shoulder and upper chest wall. Then of course there are the foot IV's.

But this one really made me do a double take. The patient was obese, with an AV fistula in one arm and multiple hospitalizations. These are the deadly criteria for trying to find a decent vein. The IV nurse on the ward, in her ingenuity, inserted this catheter into the patient's breast. It was the most unusual place I've yet spotted. Of course being located on the breast made for an awkward tape job trying to secure that IV. But it ran fine and we were grateful for it.

CPR. Are We Too Quick To Concede Failure?

How many times have we all run to the ICU or the ward after the hospital's overhead speakers scream "Code Blue!" Once there, as we fight through the throngs of people gathered around the patient, we start calling out the ACLS protocol for cardiopulmonary resuscitation all the time wondering how successful it will be this time.

Now a study in the journal Lancet claims that CPR is more successful than we think, if we try a little bit harder. The authors of the study say that prolonging CPR will increase the survival rate of patients who have a cardiac arrest. Hospitals with the longest average CPR efforts were 12% more likely to achieve spontaneous recovery and patient discharge compared to hospitals with the shortest CPR attempts. The study is based on data from 64,339 cardiac arrest patients from 435 U.S. hospitals. The difference between the longest and shortest mean resuscitation times was only nine minutes (25 vs. 16 minutes).

Physicians stopped CPR in only ten minutes in 16% of the cases while the majority, 77%, concluded efforts within thirty minutes. Overall 49% of arrest patients were able to be revived and 8% needed at least 30 minutes to do so. Going against common assumptions, 81% of patients suffered no major neurologic deficits if revived within 15 minutes of initiation of CPR vs. 80% with intact neurologic functions at 15 to 30 minutes and 78% who were functionally intact after 30 minutes of CPR.

This study makes a pretty compelling argument for going the extra mile and continue CPR for just a few minutes longer. You never know if that next chest compression or that last bolus of epinephrine will bring the patient back. And there's the added benefit that the much feared vegetative patient after prolonged CPR shouldn't be of much concern--most patients will regain full brain function once revived.

However, after reading through the information, I couldn't find how the authors break down the patients by different criteria, like age, sex, comorbidity, etc.  Honestly, would you consider performing an extra ten minutes of chest compressions on an octogenarian with multiorgan system failure that hasn't left the hospital in three months but the family wants everything done? By contrast I've seen and done CPR on relatively younger patients that has gone on an hour or longer. The study doesn't say whether the longer CPR survivors were younger or healthier than the shorter CPR patients. So this still leaves a question mark about how long to continue CPR. In the end, it's still up to the judgement of the medical team to decide when is the ideal time to give up the ghost, so to speak and allow one the satisfaction of a dignified passing, not having their ribs cracked, tubes placed into every orifice of the body, while being infused with every stimulant known to mankind.