Friday, January 20, 2012

The Road Not Taken

The odor was excruciating. It seemed to permeate through every nook and cranny of the operating room. There was no escape. I put on two masks to halt the stench infiltrating my nostrils but it was no use. Most of the O.R. staff had rubbed mastisol on their masks to hide the smell. But like overly applied perfume on a person who hasn't bathed in days, it didn't do anything to eliminate the noxious fumes. Somebody had the bright idea of bringing in a cup of coffee grounds into the room to mask the stench. Now the operating room has the unfortunate aroma of a Starbucks with an overflowing toilet. I guess I won't be stopping there after work today. Everybody who ventured in the room was immediately driven out again by the stink, involuntarily covering their noses despite the masks that were already on their faces.

I tentatively peered over the ether screen to see how the surgeon was progressing. Through my watering eyes, I could tell he was making some advances. He was now able to get his whole hand in the patient's rectum. The floor bucket at his foot was filling up with a nauseating mixture of blood and stool. Soon he had half his forearm in the patient's colon, scooping out thick, hard, malodorous feces by the handful.

"How much longer do you think?" I asked expectantly.

"Not much longer," he replied. "Just a little bit more I think before we hit the liquid stuff."

I sighed to myself. Time to give a little more muscle relaxant to relax the sphincters. Between the vasovagal reactions the patient was experiencing from having an arm stuffed up his colon to the exquisitely putrid bouquet of impacted stool, this case has not been any fun. Looking over the drapes, the surgeon now has his arm up to his elbow inside the patient. Just a little bit more, I think hopefully to myself. Then finally, he hit the jackpot. A gusher of liquid stool started pouring out of the patient. What a relief, for the patient and us. But the smell got even worse if that was even possible.  The blood and liquid poop poured over the surgeons pants and shoes. It seemed to be going everywhere. But the surgeon looked satisfied.

He looked over at me at sighed, "I went $200,000 in debt to put my hand in somebody's butt and clean out his poop. I should have gone into anesthesia and have a nice clean job just twiddling knobs and looking at monitors all day."

I laughed at him and said, "I'm sure you make your mother proud."

As the nurse attempted to finish the case and clean up the patient, the surgeon quickly ungowned and rushed to the locker room to change, leaving a trail of stool and bloody footprints in his wake. I woke up the patient and moved him off the disgusting O.R. table onto the clean, dry gurney, ready for transport to recovery. Once outside, the fresh air filling my lungs felt like the first day of spring. The lack of any smell in the hallway itself was intoxicating. Looking back, I see the disgust of the cleaning crew as they enter the O.R. to do their jobs. I don't envy what they are about to do to make the room presentable for the next case. I smile to myself, yes it's good to be an anesthesiologist.

Wednesday, January 18, 2012

15 Minute Coverup

It's sad to read about fellow anesthesiologists who perform below standard of care, because to be perfectly honest, the standards of care are the minimum we are all expected to achieve in order to safely guide a patient through surgery. The LA Times yesterday reported on the state of surgery centers in Los Angeles that are affiliated with the ubiquitous Lap Band procedures that are advertised all over the city. Five deaths have occurred in these places over the last two years. The centers are now being sued by former employees who alleged that they were fired because they reported the "horrific and gruesome conditions" of these places. They also alleged that patient care was poor in order to maximize profits for the centers.

As an example they cite the death of Paula Rojeski from Orange County. In the lawsuit, the plaintiffs complain that there was a coverup by the anesthesiologist and the management of the surgery center over how the patient expired. According to the suit, the anesthesiologist, Dr. Deming Chau, did not heed the multiple warnings on his anesthesia monitors when something went wrong. Supposedly the patient's oxygen supply had somehow become disconnected during Rojeski's Lap Band operation. Then it sounds like the IV fell out, causing medication to pool on the O.R. floor. At one point the alarms were so incessant that the surgeon, Dr. Julius Gee stopped the procedure because the patient started to move and to ask if anything was wrong. Dr. Chau replied that the machines were malfunctioning. After the surgery the patient became apneic and pulseless. Dr. Chau reportedly did not notify anybody or ask for help for at least fifteen minutes. When the paramedics arrived he did not tell them the patient had been pulseless for all that time. She was pronounced dead at the hospital. The owner of the surgery center, Michael Omidi, instructed Dr. Chau to gloss over the fifteen minute delay in reporting the patient's dire condition. He also ordered all equipment in the operating room to be switched before inspectors from the coroner's office came to evaluate the center.

Sigh. If these allegations are even close to the true story, it just highlights how little autonomy we anesthesiologists have in deciding our future. We are completely dependent upon the surgeon and the hospital to give us work. If we're hungry enough, we will give anesthesia to anybody with a pulse. It doesn't matter if the patient is morbidly obese, has severe coronary artery disease, aortic valve stenosis, or any other critical conditions, some anesthesiologist somewhere will do the anesthesia. For most of these patients the outcome will be favorable. Unfortunately for others, they won't be so lucky.

Monday, January 16, 2012

Best Operating Room Practical Joke Ever. The O.R. Turd

This is one of the best O.R. gags I've ever seen. It comes courtesy of one of our orthopedic surgeons who's a real practical joker. I present to you the O.R. turd. Mind you, this is NOT a real piece of human feces. However it looks uncommonly real, good enough to be displayed at some hypothetical museum of human turds.

How was this model of poop created? No, not from the organic way. The stool facsimile was made from common O.R. objects, mainly plaster. Since the creator is an orthopedic surgeon, he's had plenty of time to play with plaster. He simply dunked a wad of plaster into water to soften it up. Once it was nice and pliable he molded it with his hands into a long, irregular, cylindrical shape. He then poured Betadine on it to give it the distinctive color of feces. Voila, a model of human turd.

The great thing about this model is that initially it feels soft and warm, like the real thing. Once the exothermic reaction of the plaster wears off, it becomes hard and cold, like a fossilized feces. But it still looks uncanny in its resemblance to the real thing. Lay it anywhere to surprise and annoy your friends. The anesthesiologist's chair. The scrub nurse's table. The employee refrigerator in the break room. The possibilities are endless. Don't say you never learn anything reading anesthesiology blogs.

Thursday, January 12, 2012

Looking For A Job In Anesthesia?

During times of economic uncertainty it is understandable that people will look afar to see if the grass truly is greener on the other side of the fence. It happened during the Great Depression in the 1930's when millions of people transplanted themselves from economic devastation to far off lands hoping for a better life. During our current slump I have to admit that I have been peeking over the fence just a little to see if perhaps something better might be just beyond the proverbial fence.

To help me do that, I've been using an anesthesia job listing site called GasWork.com. No I am not shilling for the site. I've never been contacted by anybody at GasWork or have received any compensation for mentioning and linking to them. I just find their site to be very useful and I'd like to share this information with my readers.

I've looked through their site on and off since residency. While most plum jobs are passed down through word of mouth, supposed you are moving to a distant city or state and you don''t know anything about the job market there. This site can help you locate jobs in that general area and give you a head start. It's also interesting to see what kinds of pay packages and benefits are offered by other groups. For instance, I'm envious of those jobs in the Midwest and South that offer weeks of paid vacation time, signing bonuses, meager call schedules, health insurance, malpractice insurance, and even dental plans as part of their benefits. Out here in the Golden West the employers pretty much assume you want to live here anyway and don't offer nearly as many incentives.

GasWork also has job listings for CRNA's, anesthesia assistants, and anesthesia techs. In 2011, one shouldn't have to cold call anesthesia departments in different hospitals to locate a job. While having formal contacts are always the best way to find open positions, this site can help you get started on the kinds of jobs and benefits you can expect to find in a given location. Hope you soon-to-graduate residents and bright eyed optimists find this information useful.

Wednesday, January 11, 2012

Hospital Slump Now Confirmed

Back in November, I wrote about the decline in the number of patient visits to the hospital. We had feasted on the seemingly good fortune of being in an ever expanding sector of an economy otherwise mired in the Great Recession. We built new hospital buildings and hired extra personnel to alleviate the burden of all these patients that were inundating our wards and operating rooms. Then seemingly at the drop of a hat, at the end of the summer, our patient census slumped. My intuition at the time, as well as many others, was that the economy was the cause. People who have lost their jobs frequently also lost their health insurance.

Now we have confirmation of this decline. The latest government statistics showed that healthcare spending increased only 3.9% in 2010. While 3.9% may not sound bad during a recession, this is the slowest growth rate for healthcare in over fifty years, according to the Department of Health and Human Services. The only segment of the healthcare sector that had increased substantially was Medicaid spending which increased 40% between 2007 and 2010. That is perfectly understandable since the jobless had little money and were forced to rely on Medicaid for assistance.

Needless to say, this is not good news for healthcare, which has consistently added jobs to the economy every month even while every other sector is just barely starting to return to normal. How much longer can hospitals and surgery centers keep hiring if people don't have the means to pay? Will healthcare, the engine that has kept the American economy afloat for the past two and a half years, suddenly become an anchor dragging the economy down if we stop hiring? Will ObamaCare devastate the medical economy anyways in 2014 and make the current slump appear like the Gilded Age of American medicine? Only time will tell.

Tuesday, January 10, 2012

Government Funny Money

The headlines today say that the U.S. Federal Reserve made $77 billion in profits last year, which it promptly turns over to the U.S. Treasury. So let me try to get this straight. The Federal Reserve prints the money which it then invests in government treasuries and government entities like Fannie Mae. These purchases pay the Fed interest on these investments. The interest collected by the Fed is then turned back to the government as a profit. There is some circular logic behind this that I just can't get my feeble non-MBA brain around. And I can't even get Medicare to reimburse me if my billing sheets are off by one minute.

The Real One Percenters

Apple CEO Tim Cook received $378 million for 2011. The company even chips in $14,700 for his 401K and $1,820 for his life insurance.

Leo Apotheker, former CEO of HP, received $25 million in 2011 for 11 months of work as caretaker of a flailing company while it searched for its next CEO.

A Manhattan penthouse in the tallest residential building in the city has just increased its asking price to $110 million due to expected demand.

President Obama wants to raise taxes on "millionaires and billionaires" to pay for more social services. His definition of a millionaire starts with an annual salary of $200,000 for singles and $250,000 for couples.

California wants to cut Medi-Cal reimbursements to doctors by another ten percent. At that rate an office visit by a Medi-Cal patient will only pay a doctor $11.  The minimum wage in San Francisco is $10.24 an hour. The price that some billionaire will pay for a single New York City penthouse would allow for 10 million people to have a checkup with a doctor.

More doctors are now selling their private practices to hospitals to become employees or declaring bankruptcy.

So who are the real one percenters in this country?

Wednesday, January 4, 2012

Why Surgeons Don't Understand Anesthesiologists

We anesthesiologists consider ourselves men and women of science. We went through vigorous years of study in college, medical school, and residency training to earn the privilege of administering drugs that literally put patients into controlled states of coma. Yet anesthesia, like much of medicine, is really an art. No matter how many times one reads about Fa/Fi ratios, cerebral perfusion pressures, or GABA receptors, the skills required to be a successful anesthesiologist take years of clinical practice to develop.

Anesthesiologists in particular seem to be very individualistic in their methodology. While there are all sorts of guidelines to aid in treatment of ailments like acute MI, stroke, or diabetic ketoacidosis, there are few studies to prove that one mode of anesthesia is safer than another. In an editorial in the January 2012 issue of Anesthesiology, Dr. Sachin Kheterpal from the University of Michigan School of Medicine writes a very insightful view of anesthesiologists and why there is so little uniformity in our practices:

Although firmly rooted in science, the field of anesthesiology has had a bias toward the art of medicine. There is a strong individualism component to the practice of anesthesia, with providers spending long and lonely hours behind the surgical drape. Unlike surgeons and medical specialists who constantly direct a team of operating room and floor personnel, anesthesiologists are often a one-person team. This leads to clinical creativity and diversity, with a resulting abundance of epidural anesthesia "cocktails" and airway management techniques. Because the anesthesiologist is at the point of care making and executing second-to-second decisions, there is limited institutional oversight or checks and balances of anesthesiologist decisions. All in all, what our field lacks in randomized controlled trials, we make up in "random clinical decisions." Even during a single operation, the hemodynamic and pain management techniques may completely change as a result of provider handover.

Whenever I take over a case from another anesthesiologist, I rarely continue the exact same method of anesthesia. I may decide that I'd rather use sevoflurane instead of desflurane. The previous anesthesiologist may have used a combined technique of inhalational agents plus propofol infusion while I may feel to use only gas instead to provide anesthesia. I may lower the patient's tidal volume setting to decrease the peak airway pressure and increase the respiratory rate to maintain minute ventilation. Does that mean that I'm a better, or worse, anesthesiologist than my colleague? No.It just means there is more than one way to provide the same level of safety and care to the patient. Again, think of anesthesiology as an art. If you ask ten artists to paint a bowl of fruit, you'll get ten different paintings but they are all ultimately the same bowl of fruit. Same thing with anesthesia.. Ten different anesthesiologists will administer anesthesia ten different ways for the same case but the ultimate goal of patient safety still remains.

So to answer the question, "Why don't surgeons understand anesthesiologists?" the answer is that because there is no one correct way to give anesthesia. While one anesthesiologist may recoil at giving anesthesia to a patient with a potassium level of 5.8, another anesthesiologist will plunge right in.  Whereas one anesthesiologist will give propofol sedation to a morbidly obese patient with sleep apnea, another one will insist on first intubating the patient via awake fiberoptic. So it can be hard for surgeons to understand why they can bring a particular case to the O.R. one day then on another day a different anesthesiologist will insist on a preop medical clearance and stress echocardiogram. Like artists, we anesthesiologists have individual visions of constructing a work of art. But please bear with us; the ultimate goal is still the same: to ensure the safety of the patient as we guide them through their surgical procedure.