Monday, September 24, 2012

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.

Wednesday, September 19, 2012

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.

Sunday, September 16, 2012

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.

Saturday, September 15, 2012

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.

Friday, September 14, 2012

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.

Thursday, September 13, 2012

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?

Thursday, September 6, 2012

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.

Wednesday, September 5, 2012

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.

My Life Is Not Worth $25,000 (Unless It's Other People's Money).

How much money would you pay if somebody possessed a magic potion that could save your life, or at least prevent crippling pain and injury? One million dollars? Ten million dollars? For one scorpion bite victim, she has decided she won't even pay $25,000.

Marcie Edwards, an Arizona resident, was stung by a scorpion at home. She went to her local hospital, Chandler Regional Medical Center, for treatment. The doctor told her they had an anti-venom that can treat the sting. She claims the physician never told her how much the medicine would cost her. That is probably believable since how many of us ever tell our patients how much their treatments cost? As it turned out, the medication cost $40,000 each for two doses. Later, Ms. Edwards received a bill from the hospital for $83,000. Her insurance company paid $57,000. Now the hospital is asking her to pay the balance of $25,000. She has so far refused.

So the hospital saved this woman's life but she feels that they have received enough compensation and shouldn't pay anything out of her own pockets. Is it unfair for the facility to ask for that much money from a victim of a potentially deadly incident? Well, how much money does it cost to maintain a state of the art medical facility in the middle of the desert, staffed with top notch physicians and nurses, fully stocked with the latest medicines and medical equipment? Ms. Edwards was lucky she got stung in Arizona where modern medicine is just a car hop away. What would have happened if the same thing occurred to her in the Sahara desert? How much money do you think she would have given to be taken to the closest hospital? But now that she is treated and well, she decides that she will not pay anything to her saviors. Is it any wonder hospitals all over are losing money hand over fist? Twenty-five thousand dollars here, twenty-five thousand dollars there, pretty soon it adds up to real money, and real debt.