Misguided Judicial Sympathy

The ghoulish circus surrounding the tragic death of Jahi McMath continues. Alameda County Judge Evelio Grillo has ordered Children's Hospital Oakland to keep her on a ventilator for another week while the family attempts to find a facility that will receive the brain dead girl following complications from a tonsillectomy last week.

I don't know what Judge Grillo is trying to accomplish by prolonging this agony. Multiple physicians, including a court appointed neurologist from Stanford University, have declared Jahi brain dead. Very specific and universally accepted guidelines have been developed over the years to help doctors decide without a doubt when patients are dead. These rules were made to prevent this very type of madness that can occur when grieving families refuse to let loved ones go and doctors are afraid to step up and make the decision for the good of the deceased.

Judge Grillo has taken it upon himself to overturn decades of medical ethics teaching and ruled to keep a human body hooked up to machines despite the unanimous consensus of doctors that Jahi is never going to recover her neurologic functions. Does he think he is doing her family a favor by keeping their daughter on a machine? How can this family ever have closure and grieve properly when they see their child involuntarily twitch to the touch and continue to have a pulse that the machines are providing for her?

What do the actions of Judge Grillo say to doctors all over the country about how their medical decisions can be overturned at the whim of the family and a single non medically trained person wearing a black robe? This is the reason doctors are so leery of stopping treatments for the terminally ill, or in this case deceased, even though all hope of recovery is lost. We are the ones who are at the patients' bedsides every day and are in the best position to decide the best course of action. But because of legal actions like the ones being made by Judge Grillo, any disgruntled family member can make a simple call to a lawyer and effectively make a law judge the patient's caregiver despite having little to no knowledge of medicine. I also find it extremely ironic that the courts will allow a family to keep a dead patient alive on a machine yet at the same time have no difficulty declaring the killing of living fetuses as a constitutional right.

In the meantime the McMath family is trying to find a nursing home that will accept Jahi once she has a gastrostomy tube and a tracheostomy. I don't blame the hospital or its doctors for refusing to perform either of those procedures. It is ethically unacceptible to perform these surgical procedures on a deceased patient. The best thing the family can do is accept the tragedy that has beset them and donate her organs to others who will truly survive with their daughter's gifts. Only then can they come to peace with her fate. After that they can call their medical malpractice lawyer for issues that the courts really are supposed to adjudicate.

Five Hundred Thousand And Counting

It's hard to believe, but my humble little anesthesia blog has just surpassed 500,000 page views. Though that is pretty puny by Amazon, Google, or Facebook standards, it still blows me away that that many people are seeking some sort of information about anesthesia and anesthesiology. As you can see on the map above, virtually every country in the past four and a half years has visited this blog at least once. The only exceptions are the dictatorship of North Korea, who keeps virtually all of its citizens in a technology blackout, and the impoverished nations of sub-Sahara Africa and central Asia.

When I first started this blog on a lark back in July, 2009, it was in response to all of the negative news about anesthesia that was circulating in the media after the death of Michael Jackson at the hands of his pseudo doctor Conrad Murray. I felt that somebody with actual knowledge of anesthesia should have a say about how our drugs are actually supposed to work in the hands of competent and well trained physicians. Since then, I have ventured far and wide in the subjects that I have cared for and written about, everything from food, to humor, to money. Sounds a little like Maxim without the hot models on the homepage.

Ironically, the most popular post I have ever written isn't even about anesthesiology. It was a simple observation that I have frequently made in the operating room. Titled "The Dirtiest Part Of The Body," it has consistently garnered the most views month after month since shortly after it was published in June, 2012. I had no idea there were thousands of people who sat around and wondered which part of their anatomy was the most disgusting.

The second most frequently visited post is a little autobiographical essay that I wrote called, "Why I Chose Anesthesiology." I started that piece to help students and residents decide what they want to do with their lives. As anybody who has ever trained students know, one of the most common questions that is asked is why somebody decided to go into a certain medical field. Everybody has a different explanation but I thought writing this on a blog would disseminate the information more widely. And I was right. I get lots of correspondence from students asking for more information after they have read that article. From there, it turned into a series of posts that chronicled my struggles through residency and its eventual happy ending. I have received many emails complimenting me for my candid story of how difficult choosing the correct residency can be.

So I hope all you readers have enjoyed following me through the years as I've written about medicine, politics, money, and whatever I felt was worth an hour of my time to sit down and write. Thanks to all of you for keeping this blog going for all these years. There is nothing that motivates us blog writers more than the occasional reader comments, whether critical or appreciative. Nothing will drive a blog quicker to its death than apathy. I look forward to hearing from you readers as this blog rolls on into the new year.

Top Ten Blog Posts Of All Time

1. The Dirtiest Part Of The Body

2. Why I Chose Anesthesiology

3. How To Get Into An Anesthesiology Residency

4. Orthopedics vs. Anesthesia

5. The Difficult IV

6. Surgery, A Siren That Will Break Your Heart And Crush Your Soul

7. The Easy Way To Decide What Kind Of Doctor To Be

8. ASA President Defends Anesthesiologists, Feebly

9. Why Is The Operating Room So Damn Cold?

10. Stress Of Being An Anesthesiologist

Why We Love Southern California

This is the reason we love living in SoCal. On this Christmas Day, it was nearly eighty degrees outside, perfect weather for going to the park after the kids had opened up all their presents. Hope everybody else had a great Christmas too.

Orthopedic Surgeons Are Dumb. Fact Or Fiction?

We often chide our orthopedic surgeons for their supposedly inferior intellects. After all, it doesn't appear that it would take too many brain cells to wield a hammer or direct a power drill. There are plenty of jokes about the half-witted orthopods: How does an internist keep elevator doors from closing shut--she uses her arm to stop the doors. How does a general surgeon stop the doors--he uses his foot. How does an orthopedic surgeon stop the doors--he uses his head. Then there is the viral video from a couple of years ago, Orthopedics vs. Anesthesia, that pretty much encapsulated our experiences with our orthopedic colleagues.

But how much of this belittling of the orthopods is justified? Surprisingly there is a study that looked into this very topic. An anesthesia colleague of mine passed along this paper that was published in BMJ.com (formerly British Medical Journal) from two years ago. Written by orthopedic surgeons, it attempts to put to rest the notion that orthopods are nothing more than big lumbering steroidal idiots.

Thirty-six orthopedic surgeons at three British hospitals voluntarily subjected themselves to a Mensa intelligence exam along with a hand grip test to measure their physical strengths. Forty male anesthetists (their terminology) volunteered to do the same. Female anesthetists were excluded because the researchers couldn't find enough female orthopedic surgeons for comparison. A formal IQ test was not performed due to its complexity. Therefore the results are not directly comparable to a real IQ test and the numbers do not reflect the test takers' IQ.

The results showed that the surgeons scored slightly higher than the anesthetists on the intelligence test, with a mean of 105.19 vs. 98.38. The orthopod researchers condescendingly expressed astonishment with the test scores by noting that anesthetists were frequently seen working on crossword and Sudoku puzzles. As for physical strength, it's no surprise that the surgeons won easily. It doesn't take a lot of hand strength to hold a pencil to complete my crossword puzzles.

Surprised by the study's conclusions? Perhaps we shouldn't be. Orthopedics is one of the most competitive residencies to attain. No longer is it the last bastion of college jocks who weren't quite good enough to make it onto the varsity football team. It takes a lot of smarts for an orthopedic residency program to even consider a candidate. Having said that, in the paper's scatter gram of test scores, there is one anesthetist who scored only 60 on the exam. I wonder how much this one individual skewed the results since there were so few participants to begin with.

So next time you think about using monosyllabic words to communicate with your orthopedic surgeons, remember that he maybe hiding his brilliant acumen behind a humble facade. Or maybe not.

A New Way To Give Anesthesia For Colonoscopies

Now here is a new way to give anesthesia for a colonoscopy. I didn't know that the brachial plexus reached all the way down to the large intestine. I must have missed that class in residency.

The HP iPAQ. That Is Not A Typo

Recently I was cleaning out my old electronics drawer (every guy has an old electronics drawer full of stuff that he can't bear to discard) and I came across an old device that I hadn't given a second thought to in years, my old HP iPAQ powered by Microsoft's Pocket PC. This was HP's answer to the successful Palm Pilot and a precursor of the iPhone and iPad. I'm surprised HP never sued Apple for trademark infringement.

Out of curiosity I juiced up its removable battery overnight then powered it on. After a couple of minutes when nothing happened and I thought the machine was truly dead, the screan turned on. Oh the memories started flooding back. When I had this thing in the early 2000's, it was the cooliest device around. While others were merely carrying around iPods that could only play music, my iPAQ could play MP3's, surf the internet, send emails, and do pretty much anything a Windows desktop can do. Microsoft even included Pocket PC versions of Excel and Word, a marketing strategy that it continued when it introduced Windows RT tablets last year.

And just like Windows RT, the Pocket PC operating system is a memory hog. The iPAQ comes with less than 64 MB of memory. That's right, MEGABYTES. Only power users using desktop workstations had access to gigabytes of memory at that time. MS was able to squeeze in a minimized version of its desktop OS but only by consuming nearly half of the machine's memory. Luckily, unlike an iPad, the iPAQ has an SD card slot at the top. I tried inserting a 32 GB card but it wasn't recognized. But when I put in a 512 MB card, it read it right away. It seems ludicrous nowadays that a 512 MB memory card can be useful for anything. But that will hold about 100 MP3 songs which was far better than toting around a bunch of CD's and a CD player that some anesthesiologists had to use at that time.

After playing around with it awhile, I remembered why I stopped using the iPAQ. First of all, this version did not include cellular functions so it was basically just a PDA. Other versions of the iPAQ did have cell phone functions though. Then its ability to subsitute for an iPod was severely compromised by a loose headphone port. I have to fiddle with the headphone jack for it to seat properly in the port and then it will only play out of one speaker instead of stereo. Finally the data port on the bottom broke loose, making it impossible to charge and sync information directly. I can exchange information by swapping out the SD card and I can charge the battery with the separate battery charger but it is a pain. Removing the battery to recharge it erases all the previous settings and I have to start all over again when I turn it back on.

So there you go, a report on everything you've always wanted to know about a ten year old HP iPAQ. It was far more functional than the old Palms and Apple Newtons. With its touch enabled color screen and included stylus, internet connection, Bluetooth capability, media player, and functional versions of Word and Excel, it seemed like it was an inspiration for the iPhone which would be introduced in just a few years. The iPAQ was truly ahead of its time.

I Knew The ASA Is Just Another Money Making Enterprise

The American Society of Anesthesiologists bills itself as a standard bearer for anesthesiologists. With its lofty, and oft repeated, statements about patient safety and anesthesia advocacy, the organization comes across as saintly as the Vatican. So it's a shame they will demean themselves by running a stupid Black Friday sale.

I was dismayed when I got an email from the ASA on Black Friday hailing their "hottest sale of the year". Upon viewing the merchandise the group was marking down, it is obvious the selection is full of stuff nobody wants. An eight year old ACE booklet for $30? I guess it is a deal when it used to cost over $100 when new. But how many people really need a CME program from 2005? Medical information has expiration dates. That's why we spend billions of dollars on new research every year. These old CME booklets will not advance an anesthesiologist's knowledge base. More mature and stable information hopefully should have been retained from residency.

In fact, if the ASA really cared about physician advocacy, it should donate these old programs to anesthesia residencies all around the country. Any leftover books more than four years old should be handed out by the ASA for free. This will get the information to individuals who need it the most, our future anesthesiologists. The group should not be hawking its leftovers from the back of their warehouse to make a few extra bucks. But then again I guess they need the money to finish their sparkling new headquarters.

The ABA Made Me Do It

The American Society of Anesthesiologists recently published a list of procedures and practices that they feel have been overly used and abused. Among the items that the organization advises doctors to minimize is the compulsion to draw routine blood tests on young healthy patients, blood transfusions for patients who are young and hemodynamically stable, and the use of cardiac stress tests or pulmonary artery catheterization in low risk patients for procedures that will produce minimal cardiac disturbances.

This all sounds pretty commonsensical. I've had many conversations with our surgeons who insist on getting a full preop workup on young patients prior to a relatively benign operation. Just the other night, I received a young patient from the ER for a laparoscopic appendectomy. He was less than 40 years old. His H+P consisted of "No previous medical history" and "No previous surgical history". Yet the ER had drawn a complete metabolic panel, coag studies, and performed an ECG. Why do surgeons continue to request all these tests when it's so obvious that most are unnecessary and a waste of money?

The simple answer is that surgeons hate to have their cases delayed or cancelled because the anesthesiologist wants one more test before clearing the patient for a procedure. By painful and frustrating experience, almost all surgeons become habituated to overtesting their patients just so they can be sure that the anesthesiologist doesn't have any excuses to cancel a case and ruin everybody's day.

This leads to the question of why some anesthesiologists want so many studies before they will take a patient to the operating room. While I don't have direct knowledge of why some people do what they do, I submit that a fundamental reason for this action is because we were all horribly traumatized by the American Board of Anesthesiology during our oral examinations prior to receiving our board certification. Virtually every anesthesiologist remembers the horror story of that experience. You study for months at a time, spend thousands of dollars on board prep courses, then fly to a city far away to get grilled by four distinguished strangers for nearly one hour straight on esoteric subjects you hope you will never encounter in real life.

As part of this examination, you are asked by the executioners, er I mean examiners, what kind of lab work you want before allowing a patient into the operating room to continue the exam scenario. Almost automatically we all want to have every blood work and cardiac exam possible. It is so much easier to get every lab done before taking the patient to the OR than to discover that you missed a crucial piece of information once the patient goes under the knife. Heaven forbid that the patient starts bleeding out on the OR table because you didn't think the patient needed a PT/PTT and it turned out she has a Factor XI deficiency. Now you're stuck with an unstable patient in the OR with no clue as to why the patient is oozing from every cut surface in the body, and most likely you also didn't bother getting a Type and Cross to the blood bank too. FAIL.

You'll have nobody to blame but yourself if on the physical exam in another hypothetical preop you hear a heart murmur and the patient says he's had mitral valve prolapse for years but is asymptomatic and you don't do anything about it. Then during surgery the patient becomes unstable because in reality he has severe mitral regurgitation and pulmonary hypertension. At that point you are scrambling to save your skin by calling for an emergency TEE instead having an echo done before surgery and hoping you still have a rat's ass of a chance of passing this exam, which you probably don't.

What about all the expenses and potential complications of performing so many tests on patients who most likely don't need them? Well, in these simulations, cost is never a factor. You may have to justify the need for a test based on your examinations, but money is never an excuse. As a matter of fact, if you omit a test because you say the cost doesn't justify the benefits, you will unerringly be led down a path where you absolutely should have performed that preop test but now it's too late and the patient died on the table. And it will be ALL YOUR FAULT, you penny pinching board failing loser.

So it is understandable why some anesthesiologists continue to be haunted by the what ifs in their daily practice. After being scarred for life by the ABA, it just makes sense that most anesthesiologists will want multiple preop tests performed with little regard for necessity. It is simply better to be safe than sorry. If anybody complains about the expense, tell them to take it up with the ABA.

Simple Test To Assess Physiologic Age

As the patients we evaluate for surgery get ever sicker, we are always searching for better ways to assess a patient's health. Of course there are all sorts of expensive tests we can order to give us hard numbers and reassure us of our anesthetic plans. However in this age of cost cutting and insurance oversight, perhaps there are cheaper tests that will give us equivalent results.

A few years ago I wrote about an article in the ASA Newsletter that described a couple of bedside techniques to help decide if a patient is safe to undergo surgery. They both have the advantage of requiring nothing more than a blood pressure and a pulse. Nothing simpler or cheaper than that.

Now there is another simple test that can be performed quickly and cheaply in preop. Written up in the Wells blog of the New York Times, this new test was developed in Norway and rapidly assesses the oxygen delivery capacity of a patient. Oxygen delivery is one way of determining a patient's cardiovascular health and physiologic age. The researchers were able to whittle all the different physiologic measurements of their 5,000 test subjects down to a test with only seven questions that can reliably decide oxygen delivery. Three of the questions ask about the exercise habits of the subject. Other questions include sex of the person, age, waist size, and baseline pulse rate. After trying out this test, it seems that the quantity and quality of exercise made very little difference in my calculated physiologic age. Whether I worked out less than or greater than thirty minutes each time made no change in the final calculation. But varying my waist size or pulse rate made much more meaningful changes. This makes sense since most people can achieve a smaller waist size or slower heart rate by exercising regularly.

So next time you see a patient in preop who you want to delay a case to get one more test prior to clearance, try some of these simple and noninvasive methods. This may save the patient from another expense and prevent your reputation from taking a hit as the anesthesiologist who likes to cancel cases.

Anesthesiologists Are Tethered

Anesthesiology is great. Anesthesiologists make a lot of money and have an envious lifestyle. Isn't that why it is such an aspiring field for medical students? However, one aspect of anesthesiology that students and residents may not be fully aware of is that we are strictly tethered to the hospital. Almost all anesthesiologists, if we don't spend our call nights in the hospital, have to be able to get there from home within thirty minutes. The reason for this is that we may have to come in for a trauma or an emergency obstetric case. In such situations, minutes can mean the difference between life and death. This restriction can severely affect our quality of life and spending choices.

The TV show "House Hunters" illustrate this issue. One episode was about Joey, an anesthesiologist in Wilmington, NC. The doctor's search for his new home were restricted by having to live within a few minutes of his hospital. This may not be a problem if one lives in a small town. I grew up in a rural hamlet in the Midwest. Driving thirty minutes outside of town led to cow tipping territory already.

But if somebody wants to live in a traffic plagued city like Los Angeles, living thirty minutes from the hospital may put one only about five miles away. Thus compromises have to be made--life plans may need to be altered. In LA, anesthesiologists who can afford to live near the nicer hospitals on the Westside, like in Beverly Hills or Santa Monica, may have to squeeze into smaller homes. They may have to pay for their kids to go to expensive private schools. There may not be more than a few square feet of lawn for children to play in. If they want to have a nicer home with a bigger yard and better public schools, they may actually have to transfer to a different hospital to stay within the thirty minute radius.

So yes, anesthesiologists have a nice lifestyle. Just remember that the anesthesia lifestyle may include a view of the hospital from your bedroom window.

The Most Important Thing Not Being Taught To Anesthesia Residents

This month's issue of the ASA Newsletter focuses on a subject that is often overlooked and belittled by academic anesthesiologists as they preside in their ivory towers. The topic of the month is the increasing importance of non O.R. anesthesia in our field. NORA is any anesthesia that is given outside the usual hospital OR's, such as the GI suite, Cath lab, Interventional Radiology, MRI, etc. You name it, somebody wants anesthesia somewhere that doesn't have all the niceties and comforts of a regular operating room.

NORA is now approaching 25% of all anesthetics being given in this country. If you also count anesthetics that are given in ambulatory surgery centers instead of hospital operating rooms, that figure is approaching 50%. In other words, there are thousands of anesthesiologists out there practicing outside the hospital operating rooms and the numbers are likely to increase for years to come. Yet I find that our anesthesiology residents have incredibly little training in how to give anesthesia outside their comfort zones of the environmentally protected OR's.

Yes every anesthesia resident wants to get their hands dirty on the intellectually challenging cases like liver transplants and aortic valve replacements. When there is an awake craniotomy to be performed, everybody wishes he was on the Neuro rotation that day. We all love to be involved in cases that will make for scintillating party conversations. But let's face it, for a large percentage of residents, they will not be doing these kinds of cases ever again once they finish residency. They will be faced with giving anesthetics in a setting where they may not have full control of the airway, where the support system of the facility is minimal or none, and the equipment may be outdated or BYOB (Bring Your Own Blade).

Add to that is the fact that MAC cases in NORA's are perhaps some of the most difficult cases anesthesiologists are likely to face. Sure most anesthesiologists scoff at giving propofol for MAC as being far beneath their abilities. But I submit that MACs will tax the intellects of our most accomplished anesthesiologists. I remember the first day I had to go to the GI suite to give anesthesia after my residency. Frankly, I drew a blank as to what to give. I knew all about how to intubate patients with difficult airways and pass Swans in heart patients, but in my entire residency I never once gave anesthesia in the GI suite.

How hard can giving propofol in the GI be? How about confronting morbidly obese patients with pulmonary hypertension with pressures in the 70's, sleep apnea, diabetes, and severe aortic stenosis who needs an EGD for anemia with a Hct of 23? If this patient was having a prolonged procedure in the OR, it would be a no brainer to intubate the patient, start an arterial line, and maybe have a few drips prepared. But you can't do any of that for an EGD where the procedure could last anywhere from 3 minutes to 30 minutes. You need the ability to give maximal sedation for the endoscopic intubation that will prevent the patient from coughing and bucking without having the patient's BP bottom out or heart rate shoot sky high and it needs to wear off within a few minutes so that the next case can proceed on schedule. An anesthesiologist wouldn't survive long in the GI suite if she intubated every patient who came in with morbid obesity.

Other challenging environments include the Cath lab where the cardiologists demand sedation in patients with ejection fractions of 15% and BP's in the 80's so that they can insert an internal cardiac defibrillator. Will the old standard of propofol sedation really be the best drug to give in this situation? Many anesthesia residents will never know until they are confronted with this scenario in private practice. How about giving sedation to a patient in MRI who is morbidly obese, with severe gastric reflux, orthopnea, sleep apnea, and wants to be asleep for the procedure because she has severe claustrophobia? In my residency, I didn't have any training in any of these locations. We were all so busy learning how to do blocks on shoulder patients and understanding the intricacies of inserting a right sided double lumen endotracheal tube that taking time away to learn how to give MAC sedation felt like a waste of my busy residency hours.

But as more and more procedures are moved to outpatient settings where speedy sedation and recovery are of the essence, anesthesia residents should do themselves a favor and ask for more education on NORA. The fact is that almost all of them will be doing some NORA MAC cases at some point in their careers and many will be doing only NORA MAC cases. They should be familiarizing themselves in sedation techniques while they still are protected by experienced faculty. Don't wait until the first week in practice to realize that you have no idea how to sedate a prone patient for ERCP with a big honking scope in the mouth and is refluxing bile all over the bed. And anesthesia residencies would be wise to prepare our residents for these seemingly simple but extremely demanding anesthetics.

The Most Expensive Jack O'Lantern You'll Ever Buy

Happy Halloween!

The most expensive and fastest jack o'lantern you'll ever buy. A McLaren MP4-12C putting its bright orange paintwork to good use.

"I was all for Obamacare until I found out I was paying for it."

That is the lament of one shocked insurance buyer featured in a page one article in the LA Times today. The Obamacare advocacy newspaper is just now coming around to reporting on the financial penalties imposed on people due to the new insurance plans. As it turns out, President Obama's statement that people can keep their health insurance plans if they like it was not passed on to the insurance companies who actually have to sell their plans.

The ACA has forced insurance companies to cancel plans by the thousands because they don't comply with the requirements of the new law. Things like mammograms, contraceptives, and mental health coverage are suddenly being thrust upon people whether they need it or not. Therefore the companies cancel their old plans and force consumers to buy the new ACA compliant plans that may cost them 50% more than what they pay now. Naturally this comes as quite a sticker shock to gullible consumers who believed everything their government told them.

Another one of the President's lies that has now been exposed is that you can keep your doctor if you want to. In order to prevent the premiums from rising even higher, the health insurance industry has significantly narrowed the networks of hospitals and doctors that patients can use under the new plans.

You say that your company provides health insurance for you so you can't empathize with the poor schlubs who have to buy their own health insurance on the new exchanges? Well guess what--that corporate protection might not last much longer. Major corporations are realizing that it is easier to dump their employees onto the insurance exchanges with a small subsidy than it is to keep providing insurance ad infinitum. Or if fate is particularly frowning upon you this year, they may decide to cut back on your hours to part time status so that they have no obligation to provide you with any insurance at all. That's all perfectly legal according to President Obama.

All these changes should really be called the new Obamacare tax that has been subversively thrust upon the American people. They may not call it a tax, and the Supreme Court tried very hard not to defeat Obamacare based on tax clauses, but if you have to pay more money due to a government mandate, it is a tax. During the Congressional debates prior to its passage, there were impassioned arguments from our representatives that it's just not fair the top 1% are taking all their wealth and leaving the other 99% behind. They have to pay for their financial success, which obviously couldn't come from hard work and sacrifice. So let's just raise their taxes to help pay for health insurance for everybody. Everybody else can get free or subsidized health insurance and it won't cost them one bit. Ha ha! The voters have been fooled again.

Everybody is all for universal health insurance coverage, until they have to pay for it as the LA Times found out. While we haven't raised our taxes to the levels found in Europe that are necessary to provide health coverage for everybody, these forced payments on higher insurance premiums for lesser coverage is just another name for a new government tax. But all these people who voted overwhelmingly for Obama twice knew what they were getting when they elected a tax and spend liberal Democrat to the presidency, right?

Don't Forget To Leave Behind Your Constitutional Rights When You Pick Up Your Medical Degree

Recently, an order was issued from the Los Angeles County Department of Public Health. Written by Dr. Jonathan Fielding, the department's Health Officer, it imposed on all healthcare providers in the county this edict:

Pursuant to my authority under §120175 of the California Health and Safety Code, I hereby order every licensed acute care hospital, skilled nursing facility, and intermediate care facility within the County of Los Angeles public health jurisdiction to implement a program under which healthcare personnel at such facility receive an annual influenza vaccination for the current season or wear a mask for the duration of the influenza season while in contact with patients or working in patient-care areas.
  
In other words, get a flu vaccine or wear the scarlet letter equivalent of a mask over your face. There is no leeway or any sort of objection to get around this new rule in L.A. While I am all for preventing the spread of the flu, this seems to blatantly trample on my rights as a citizen of this great United States. Get a flu vaccine or be ostracized at my place of employment? Something doesn't feel right here. Why is it that while parents can legally refuse to have their children vaccinated against childhood illnesses, and thus potentially start an epidemic at my children's school, I have no say in whether I want to get the flu vaccine or not? Shouldn't children who don't get vaccinated as per government recommendations wear a mask at school to keep them from spreading their diseases to other kids? Why isn't the equal protection clause of the U.S. Constitution being observed?

Besides, the flu vaccine is no panacea in keeping one from getting the flu. Its effectiveness is dependent on the recipient and whether the vaccine actually contains the flu strain that is currently the most widespread. Just because I am forced to get a shot doesn't mean I still won't get the flu.
  
Of course doctors should be used to being brushed aside and taken for granted by the government by now. New laws and regulations are issued all the time regarding how we should practice our profession. The most brazen of course is the EMTALA law, requiring doctors to treat all patients regardless of ability to pay.  While admiral in its purpose, it still places doctors into a professional servitude which the feds wouldn't dare impose on anybody else. Would the government force lawyers to work with a client who couldn't possibly pay their hourly rates? In this litigious society having legal representation is practically a necessity but if you have no money, you are not going to get good representation, or even any representation. 

Somehow physicians have come to accept their plight as the cost of doing business. We just roll over while other people make rules for us. I have not heard anyone at the LA County Medical Association object to this ruling. No word from the California Medical Association either. They're too busy throwing parties for themselves to empathize with how doctors well being are being infringed upon by the government. 

So I will be trudging to my hospital's employee health department and getting my flu vaccine soon. It doesn't appear that I have a choice. Maybe I should bring a tea bag with me as a sign of my conscientious objector to this travesty of justice.

Where The Battle Has Already Been Lost

We recently had some traveling nurses come work at our hospital. Their most recent assignments had been at some East Coast medical center. They remarked with astonishment that we have actual anesthesiologists working inside the operating rooms.

"Why do you sound so surprised?" I asked them. They informed me that at the prior hospital back east that they've worked in, CRNA's were the ONLY ones in the operating rooms administering anesthesia. What were the anesthesiologists doing outside while the operations were going on? Seemed like they were in charge of getting the next patient ready for the case, having the anesthesia consents signed, and writing post op notes on the floor. "Didn't they ever come into the OR to do cases?" I further inquired. No, they said. And the surgeons preferred to have the nurses giving the anesthesia at their institution.

I was dumbfounded. And depressed. Something has gone terribly wrong with the way that anesthesiology group has decided to practice at that hospital. This was coming from a state that had not yet opted out of physician supervision of CRNA's. But for all intents and purposes the CRNA's were running the show in their operating rooms. Imagine that you've spent hundreds of thousands of dollars getting your medical education. Spent years out of your life that you will never get back studying to become an anesthesiologist. Then at the end, you are nothing more than a paper pusher and face greeter. That appears to be the functions of their anesthesiologists. 

The longer this situation continues, the worse it will be for those doctors. As the nurses pointed out, the surgeons actually start preferring to work with the CRNA's. The less exposure the surgeons have to the expertise of their anesthesiologists, the less they can trust them or respect their hard earned anesthesia experience. They won't have gone through the difficult cases together, fought the same battles, or share the same war stories. Instead the anesthesiologists over there are on the outside looking in.

Now maybe the anesthesiologists at that hospital prefer to work in this fashion. Perhaps they like not stressing in the operating rooms. It could be that they like to go get their coffee and bathroom breaks anytime they wanted instead of rushing between cases. Maybe their accountants told them that they can make more money hiring CRNA's to work than to bring in more anesthesiologists. But if anesthesiologists start taking this attitude, then it becomes easier for hospitals, and states, to say they want their CRNA's to work without the oversight of anesthesiologists protecting the patients. If anesthesiologists are reduced to little more than legal secretaries and nurse practitioners, then anesthesiology as a relevant clinical field of medicine will be irretrievably lost.

Anesthesiologists' Last Stand?

Last week, Rep. Andy Harris, M.D., the only anesthesiologist serving in Congress, sent a letter to the California Society of Anesthesiologists apologizing for not being able to attend the ASA conference in San Francisco due to the government shut down at the time. In it, he also addressed the issue of the insidious changes that are occurring at the VA Administration in regards to increasing the scope of practice of CRNA's that are being considered at VA hospitals. I have copied the letter in its entirety below.

To those of you who are attending the ASA meeting in San Francisco - I am sorry I have to remain in Washington this week and won't be able to attend as I had planned.

I did want to update you on a very important issue to anesthesiologists addressed here in Washington last week.

The Department of Veteran Affairs recently developed a new draft of the VA Nursing Handbook which dramatically expands scope of practice for nurses. This change would require nurses to practice independently. Currently, the VA facilities operate under the applicable state scope of practice laws.

Last week, I requested to sit in on a hearing of the Veteran Affairs Committee's Health subcommittee where the VA Principal Deputy Undersecretary for Health Dr. Robert Jesse was testifying. I directly confronted Dr. Jesse about these dramatic changes to the nursing handbook. You can watch the exchange by clicking here (or copy and paste this link http://www.youtube.com/watch?v=mTsgFaz0hp8 into your web browser).

The main focus of the over two hour hearing was on the skyrocketing use of prescription painkillers to treat veterans. Those who testified discussed how the VA is failing to adequately treat the pain our soldiers are returning from battle with and failing to prevent our soldiers from becoming addicted to painkillers. The drafted dramatic scope of practice expansion for nurses would only make this problem worse as those with little to no training in pain management would be in charge of treating these wounded warriors. Those who sacrificed for our country deserve better.

During the questioning, Dr. Jesse committed to me that before any changes to the Nursing Handbook are finalized, the VA will have a comment period and will listen to the concerns of the ASA, AAFP, and AMA. I will continue to make sure our concerns are addressed. In addition, the VA Health subcommittee's chairman, Dr. Benishek, and Democratic ranking member Ms. Brownley have written to the VA and expressed concerns about these changes.

If you have any concerns or need to reach me, please feel free to email me at andy@andyharris.com.

Andy Harris, M.D.
Anesthesiologist
Congressman

The danger here, of course, is that the federal government will lead the charge in allowing CRNA's to practice without the supervision of a physician.  Right now, each VA hospital lets the nurse anesthetist practice according to the laws of the state that it resides in, whether the state has allowed CRNA's to opt out of physician supervision or not. If the federal government decides that all VA hospitals in every state should let CRNA's practice without supervision, then the chances are that this will open the door for more states to opt out.

The threat posed by this seemingly minor rules change in the VA Nursing Handbook should not be underestimated. Don't our veterans, the ones who have sacrificed their lives to protect the interests of our country, deserve to have the best anesthesia providers available to them? Do we really want the heroic men and women of our armed forces to be treated by somebody who is just counting down the clock to their 2:00 PM quitting time so they can hustle to their cars ahead of the secretarial and janitorial staff?

If you understand the grave risks the Veterans Administration is posing to anesthesiologists, don't hesitate to contact your state anesthesiology society and your local congressional representative ASAP. Giving money to the ASAPAC or your state society PAC wouldn't hurt either. Congress shouldn't hear only one side of the story from the politically powerful AANA. We need to do everything in our power to prevent these changes from happening at VA Hospitals. If this isn't stopped, it will be a slippery slope to universal control of operating rooms by CRNA's.

What happens when anesthesiologists abdicate their proper role as the patient's safety advocate in the operating room? Read here to find out.

Colonoscopies With Propofol. A Surprising Endorsement From The LA Times

By now we've all heard about the controversy of paying for anesthesiologists to give propofol during colonoscopies. The usual bias is that the procedure doesn't require the heavy sedation that is achieved with propofol. Colonoscopies in most parts of the world are performed with little if any sedation. If every colonoscopy in America suddenly needed an anesthesiologist to provide sedation, the country will be driven even more quickly into bankruptcy.

Yesterday, the LA Times consumer reporter, David Lazarus, penned a surprisingly accommodating article about using propofol for lower endoscopies. In the story, he criticizes the practice of health insurer Anthem Blue Cross in denying reimbursements to anesthesiologists who administer propofol to patients which the company deems are not medically necessary. Mr. Lazarus quotes one patient named Michael who says, "I can't imagine going through that procedure without anesthesia."

Mr. Lazarus goes on to accuse Anthem and other health insurance companies of being penny wise and pound foolish. He interviews Dr. Eric Esrailian, co-chief of the Division of Digestive Diseases at UCLA who defends the practice. Says Dr. Esrailian, "Colon cancer is a preventable cancer. Screenings are the key. We should do whatever is necessary for society to be screened." He states he would use propofol for all his colonoscopies if it weren't for having to deal with insurance company reimbursement problems.

The reporter goes on to list the potential down sides of using moderate sedation instead of propofol. He quotes a letter from Alister George, medical director of the Digestive Health Center in Thousand Oaks, CA. In the letter that is sent out to patients, Mr. George describes the side effects of moderate sedation, including, "The pain experienced while undergoing conscious sedation may be very unpleasant for some patients. The drugs used for conscious sedation may cause side effects such as prolonged drowsiness, low blood pressure, nausea and vomiting. Compared to propofol, the recovery time for conscious sedation is considerably longer."

Mr. Lazarus chastises the insurance companies for not reimbursing anesthesiologists who provide propofol for colonoscopies as being extremely short sighted. If people understood how propofol can make colonoscopies virtually painless, then more would probably get screened, preventing thousands of colon cancers from forming and saving the insurers billions of dollars. Studies have even shown that colonoscopies performed with propfol sedation yields a higher success rate of detecting colonic polyps vs. ones done under conscious sedation.

This is the kind of reporting that the ASA should be actively seeking from news media all around the country. While doctors may grumble and write letters to insurers defending their practices, nothing gets the companies more defensive than having the the general public, and hopefully politicians, breathing down their necks at their callousness in denying comfort to patients who need and want it.

Winning The War

At the just completed ASA conference in San Francisco, Dr. John B. Neeld, Jr. delivered the prestigious Emery A Rovenstine Memorial Lecture to thousands of anesthesiologists in the audience. Dr. Neeld is a former president of the ASA back in 1999. His talk was titled, "Winning The War." As you might guess, it has nothing to do with the war on poverty, drugs, or Afghanistan. Instead it is a call to arms against the encroachment of CRNA's into our profession.

"We are in a war over the provision of anesthesia for patients," he said. "The safety and survival of millions of patients demand that we win this war. I call upon ASA to appropriate $1 million to fund outcomes research to demonstrate the value of physician-led anesthesia teams." He notes that the nurses are quickly gathering allies in all the right political offices to expand their practices. The Obamacare laws even forbid payment discrimination by federal programs for delivery of medical services no matter whether they are performed by MD's or CRNA's. Continues Dr. Neeld, "Failure to prove that anesthesiologist-led care is the gold standard will submit millions of patients to increased risk. Performing these outcomes studies is all about the patient."

Bravo Dr. Neeld. We do need to prove to everybody, especially the people who are paying our bills, that anesthesiologists deliver a higher quality of anesthesia and increased levels of safety to our patients than CRNA's. However the proof is in the pudding. Just having a gut feeling about our superiority in providing anesthesia due to our longer training period or hearing anecdotal tales of scary nurse anesthetists' misadventures in the operating rooms don't sway anybody's perception that anesthesiologists cost too much money.

As I have mentioned, we have pretty much shot ourselves in the foot with our drive to improve patient safety in the OR. While it is great for patients that anesthesia has now become one of the safest fields in medicine, it has greatly complicated our ability to market ourselves as the better anesthesia providers. With anesthesia complications now running so low, it is nigh impossible to prove one way or another the differences in outcomes between MD's and CRNA's. With the ASA's stated goals of eventually have zero anesthesia complications, this will only exacerbate our high cost image problems. After all, if a procedure is highly risky, patients will want the physician who is the most highly trained and has the most experience. However, if the risk becomes very low, regardless of who is doing it, the urgency to want only the best trained provider becomes less immediate and people start shopping around using other factors besides training, such as cost. For example, nobody is going to cost shop a neurosurgeon for a brain tumor resection because the procedure has a relatively high risk of complications. The patient will want the best surgeon available. However if anesthesia risks are practically zero, regardless of who is administering it, then costs will definitely become a consideration, which it already has for many hospitals and insurance companies.

So Dr. Neeld should be commended for stepping into this minefield. However, any chance that some studies will show the superiority of anesthesiologists over CRNA's will be years away and cost millions of dollars to conduct. And in the end it may just prove that the outcomes are the same regardless of who is pushing the big syringe and little syringe as the ASA's zero anesthesia complications initiatives become widely adopted by all anesthesia providers, whether they be doctors or nurses.

Where is the next great peril to anesthesiologists about to occur? Read about it here. 

Oops. Happy Belated Ether Day

Okay, I'll bite. The friendly representatives of an anesthesia device company sent me a nice email reminding me that October 16 was Ether Day, or now called World Anesthesia Day. Since I was on call yesterday, and I was literally up for 24 straight hours, I had totally forgotten about this historic day and what it means to anesthesiologists.

The medical device company sent this nice graphic of the history of anesthesia. Of course they specifically highlight all the great contributions their equipment has made towards our field. Now this is by no means an endorsement of the company or its products and I am not receiving anything for this. I just think it is interesting and a bit informative.

Young Idealistic Medical Students

A new survey has just been published in Academic Medicine that drew my attention due to its provocative title. It is called, "Primary Care, the ROAD Less Traveled: What First-Year Medical Students Want In A Specialty." Since the paper deliberately used ROAD in its name, it felt like a personal attack on the field of medicine that I love best. I had to investigate this travesty further.

The researchers asked over one thousand first year medical students what they considered to be important factors in the medical specialties they might choose when they graduate medical school. Naturally they asked about the importance of lifestyle. They delineated lifestyle into five different subcategories. The medical students felt that "Enjoying the type of work I am doing" was the most important criteria for a good lifestyle, with 61% of the votes. "Having control of work schedule" received 15% of the votes for a good lifestyle. "Having enough time off work" got 14% and "Enjoying the work environment" got 9%. Rounding out the bottom of the list for a good lifestyle was "Financial compensation" which received a measly 1% of the votes.

Oh you poor, poor, naive med students. Perhaps it's not fair to do a survey like this on first year students since you are still so young and enthusiastic. Many of you are simply regurgitating what you wrote in your med school applications. Sure you want to enjoy the type of work you're doing. But how much enjoyment will you get when you are seeing forty patients a day in your office and working at least 60 hours per week, much of it uncompensated like calling in prescriptions, answering phone calls, and fighting insurance companies. That is what's in store for students who go down the ROAD less traveled, straight into primary care hell.

As for having control of your work schedule and getting time off from work, well good luck with that. Unless you sign up as one of those part time doctors that pisses off everybody else in your group who has to accommodate your precious schedule over their own, you are unlikely to have much of your schedule under your control. This lack of ability to control one's own destiny inevitably leads to loss of enjoyment of the work environment which you can ready about on any primary care doctor's blog.

That financial compensation is listed last in importance to a good lifestyle shows that these students haven't yet confronted the terror of paying back hundreds of thousands of dollars in student loans. Believe me, when the first four criteria eventually fail, especially in PC fields, financial compensation will quickly bubble to the top.

It is ironic in their discussion that the authors claim, "Although time for family and balance between work and personal life were important to all first-year medical students, these specialty characteristics were significantly more important to PC-first students." It is precisely for these reasons that most doctors choose to get out of primary care. Even residents who match into a primary care field eventually realize the heartaches ahead and scamper away into a subspecialty just so they can attain that elusive work/life balance. They can see the handwriting on the wall with the healthcare industry cutting reimbursements while expecting greater productivity (more work for less pay). Something's got to give and it's usually primary care.

Perhaps these students will wise up in the next four years of their studies. In the next phase of their work, the researchers plan on asking these same students again as they graduate from medical school how their responses and actions differ from their initial survey. It will be interesting to see how much cynicism has been pounded into their overstuffed brains by then.

Anesthesiology Is One Of The Safest Fields In Medicine

Diederich Healthcare has put together a summary of all the medical malpractice payments that were made in 2012. The insurance company found that there were over 12,000 judgements against doctors totaling $3.6 billion that year.

New York was the worst state to be a doctor and the best state to be a medical malpractice lawyer. It led the pack with over $763 million of payouts during the year. This was followed by Pennsylvania, California, New Jersey, and Florida. If calculated on a per capita basis, New York again came out on top, with $38.99 worth of payments per person in the state, with second place Pennsylvania only reaching $24.77. California, with its huge population, doesn't even make it into the top ten per capita. If you want to feel secure from lawsuits as a doctor, head on down to Texas. There the ambulance chasers were only able to get $3.03 per person, followed by North Dakota and Wisconsin.

As for the types of injuries that resulted in judgements against doctors, 31% were due to death of the patient. This is followed by significant permanent injury with 19% and major permanent injury with 18%. Interestingly 0.4% of the money went for insignificant injuries. While that may sound like a very small percentage, it still amounted to over $14 million for something that is considered insignificant.

The most common cause for losing a medical malpractice case was due to diagnosis related errors with 34% of all payouts and specifically with failure to diagnose leading to 20% of the payouts. Surgery related errors led to 24% of the payments followed by treatment related errors with 18%. Anesthesia related payouts appear way down at the bottom of the list, with only 3%.

It looks like anesthesiology's pursuit of patient safety is paying off. We are on the forefront of ensuring that the latest technologies and practices will help patients get through their hospitalizations without adverse incidents. No longer will our specialty be defined by exorbitant malpractice insurance premiums as it was back in the 1980's and 1990's. But that doesn't mean we can rest on our laurels. As we continue to research and implement new safety techniques, we will strive to reach the goal of having zero anesthesia related complications in the future.

Liberal Europeans Hijack The American Justice System With Propofol

Last week I received an urgent email from the American Society of Anesthesiologists. In the letter, they warn about the possibility of an acute shortage of propofol in the United States due to the actions of one small state in the country. To be specific, the Missouri Department of Corrections was planning on performing two executions on convicted criminals in the coming weeks using propofol as their drug of choice.

Apparently this has set off a worldwide controversy. The European Union has laws prohibiting the export of products that could be used for capital punishment. Unfortunately for us, nearly 90% of all the propofol used here are manufactured by the German company Fresenius Kabi. Fresenius had delivered the propofol to the American distributor Morris & Dickson which then supplied the drug to Missouri. The EU has demanded that the propofol be returned to Morris & Dickson or they would cut off the export of propofol, thereby depriving us of this essential anesthetic, patient necessity be damned.

Did Missouri stand up for its right to treat its hard core criminals as their laws and juries see fit? Sadly, no. The state government knuckled under the demands of the EU and has returned the propofol back to the distributor. The Missouri DOC says that it has enough American made propofol still in stock that can still be used for the executions. But now Governor Jay Nixon has postponed the executions indefinitely until another method can be worked out.

It is outrageous how the EU has blackmailed America into treating our prisoners to their liking. Their faux compassion is especially galling when one considers that the EU looked the other way when products were shipped to Syria to help make chemical weapons that killed thousands of people. They sell billions of dollars worth of military equipment around the world that will be used to kill thousands, perhaps even millions, more people. Now they have the temerity to dictate to us how we should treat our prisoners who have been convicted of murder by juries of their peers? Hypocrisy doesn't even begin to describe this outrage. Sadly for our justice system, one of the three pillars of the American Constitution, they got away with it.

Have You Read Your Package Inserts Lately?

This is just a quick update on a story I wrote a while back. A couple of years ago I wrote about a medical malpractice case in Connecticut involving the use of an LMA in a morbidly obese patient. It turned out to be not such a great idea as the patient suffered a severe aspiration and was left in a coma for 26 days and suffered long term medical complications. The anesthesia group wound up paying $10.5 million dollars to the plaintiffs for this incident.

Since the wheels of justice grinds ever so slowly, you probably wouldn't be surprised that this case has still been winding its way through the state court system for the past two years. A few weeks ago, the state's Court of Appeals upheld the judgement against the anesthesia group. This article has a lot more detail on the case and what happened during the trial.

What is so surprising is how much credence the courts gave the LMA package insert as evidence of a substandard level of care given by the anesthesia providers. One of the contraindications for using an LMA according to the manufacturer's insert was morbid obesity. This was taken by the plaintiff's lawyer and the court as setting a standard of care. Despite the defendant's expert witness stating that the use of an LMA was appropriate in obese patients when properly used, the jury obviously did not agree and rendered the multimillion dollar judgement against the anesthesia group.

This opens up a whole Pandora's box for doctors everywhere, not just anesthesiologists. As we all know, package inserts of medical devices and pharmaceuticals are written in tiny type with every possible risk and complication that's ever been recorded listed. This is more for preventing legal liability on the part of the manufacturer than as guidelines on how to use the product. However, if the courts start considering this as evidence of standard of care, there may be no complication too small for plaintiffs to consider medical malpractice.

How many anesthesiologists have read through those little pieces of paper and memorized the potential complications of propofol, or succinylcholine, or sevoflurane? What about the package insert of that IV catheter you're about to insert into the patient? Or the possibility of harming the patient with use of the IV pump? The risks are endless since those inserts are written by lawyers to cover their own butts. Should we start practicing medicine based on the legalese of some company lawyer? If the trial lawyers start using them as evidence of medical malpractice because we don't adhere to the letter on a product's proper use, and the judges agree with them, then we might as well just start writing out blank checks.

Anesthesia vs. Patient

How difficult is it to get truthful answers from patients? Watch this funny video to see what anesthesiologists have to go through sometimes to get information from our patients. It's funny because it's true. Is it as funny as the classic Orthopedics vs. Anesthesia? You'll have to judge for yourself.

Blame The Anesthesiologist

Hospital administrators and government officials are always trying to eliminate medical errors. It is a worthy attempt as some estimates put deaths due to errors in the hundreds of thousands per year. Unfortunately, no matter how many rules and backstops are put in place, medical errors will still happen. This is because doctors and nurses are all human and humans make mistakes. You can't sign a law banning human error. But there will always be attempts to point the finger at someone when it happens.

A case in point was published by the California Department of Public Health in its quarterly release of hospitals penalized for gross medical errors. The incident at St. Jude Medical Center in Orange County highlights the limitations of multiple precautionary measures in preventing medical mistakes.

A patient was admitted to the hospital in 2012 for a nephrectomy due to a renal mass suspicious for cancer. The surgeon's H+P documented the mass was in the right kidney. When talking to the patient, he complained of pain in his right flank. The surgeon marked the patient's right side in preop to indicate the correct side for the operation. The operating room nurse even called the surgeon's office before surgery to confirm the proper procedure and side. The anesthesiologist also confirmed a right sided nephrectomy after interviewing the patient. The consent for the operation listed the right side was the correct side. The patient then went into the operating room. A Time Out was called before the operation commenced and everybody agreed that it was the right side that was being removed. The procedure went smoothly.

Shortly afterwards, the pathologist notified the surgeon that the kidney that was sent to the lab was completely normal. Startled, the surgeon reviewed the CT scan, which was left at his office the day of the operation. The CT showed that the cancer was in the LEFT kidney. Since the imaging study was performed at a different hospital, it was not available to be reviewed in the operating hospital's computer system, which one of the nurses attempted to do before the operation. Oops.

During the process of identifying the cause of the wrong sided operation, the state's interviewers asked the anesthesiologist if he should have been more thorough in confirming the correct side of the operation. According to the report, "He looked at labs and general medical health. MD 2 (anesthesiologist) stated he would not meet with the surgeon and review CAT scan results and typically did not review test results (x-rays) as it was not a standard of care."

That sounds about right. I don't know of any anesthesiologist who routinely reviews diagnostic studies before an operation. We just take it as faith that the correct operation is being performed since the surgeon, primary care doctor, nurse, and patient have usually unanimously agreed upon the procedure. Why should the anesthesiologist take the time the review the studies one last time? We would just be blamed for unnecessarily delaying the case.

But that's not how the CA Dept. of Public Health sees it. One of their recommendations after their investigation was completed was this:

Prior to commencing surgery, the person responsible for administering anesthesia, or the surgeon if a general anesthetic is not to be administered, shall verify the patient's identity, the site and side of the body to be operated on, and ascertain that a record of the following appears in the patient's medical record.

What the heck? So now we have to be the mother hen and watch over the surgeons because they might not be doing their jobs properly? We already have enough headaches making sure the proper preop workup has been completed prior to surgery. Anesthesiologists are already considered nags for insisting on a cardiac stress test or requesting a pulmonary function test. Now if we don't review all the diagnostic exams we are possibly liable for the surgeon's mistakes? I better get a pay raise if that is considered one of my duties, and the title Captain of the Ship.

The hospital was fined $100,000 for this infraction.

Proof That Jurors Shouldn't Decide Medical Malpractice Cases

Doctors have long contended that medical malpractice cases shouldn't be decided by juries composed of the general public. These jurors just aren't knowledgeable enough about medicine to make an intelligent decision about proper medical conduct. Instead they are easily swayed by crafty lawyers who prey on their emotions. As an alternative medical cases should be overseen by judges who have been specially trained in handling medical cases.

The just concluded Michael Jackson, or more specifically the Jackson family, trial against his concert promoter AEG offers more proof for this common sense approach. The family sued AEG for at least $1 billion because they contend the company hired Michael's disgraced personal physician, Dr. Conrad Murray, which led to his death by propofol oversedation in the singer's private bedroom. If the company knew that the doctor was incompetent and only hired him to help get Michael on stage to perform for his comeback tour with no regard for his well being, then AEG could be found liable for his death. Since this was only a civil trial, only nine out of twelve jurors had to agree.

As it turned out today, the jury did agree that AEG hired Dr. Murray. However, when it came time to answer the question of whether the doctor was "unfit or incompetent to perform the work for which he was hired," the jurors said that he was competent to work as a doctor. Excuse me? This is the assessment of a doctor whose medical judgement is so poor that he gave a surgical anesthetic to a patient in a private home with no monitoring of any kind? This jury gave the doctor a pass even though the cardiologist didn't even know how to do a proper CPR when his patient needed it?

Says Gregg Barden, the jury foreman, "Conrad Murray had a license; he graduated from an accredited college." Another juror, Kevin Smith, stated, "Murray was fit and competent for the job he was hired for...Michael Jackson thought he was competent enough." So these impartial citizens all thought Dr. Murray's lack of medical skills and the resulting death of his one patient was not enough to deem him an unqualified physician. Maybe we can use this trial as evidence that medical cases need to be moved out of the reach of jurors and into special medical courtrooms. Maybe Mr. Jackson's death won't be in vain after all.

An Anesthesiologist's Guide To Medical History

If you like reading history as much as I do, you have to get yourself a current issue of the Anesthesiology News (registration required) for a fascinating article on the history of anesthesiology. Titled "When Settled Isn't Settled: An Anesthesiologist's Guide to Medical History," it is written by regular commentator Dr. Steven Kron. The piece lists his personal "10 Best Anesthesia Paradigm Shifts." This is the kind of information that is never taught to busy students and residents. It's not until they have the luxury of free time do they finally get around to understanding how anesthesiology has gotten to the preeminence it holds today in patient safety.

Many of you may already know this, but I didn't know that ECG monitoring wasn't even considered a necessity as late as the 1970's. This was eighty years after the invention of the device by Einthoven in 1895. Nowadays I wouldn't even start a case until I have a decent ECG reading on my monitor.

The closed circle system found in all operating rooms was invented in 1924. It was developed by the father and son team of Heinrich and Bernhard Drager. That helps explain the source of the Drager name on anesthesia machines that are ubiquitous in operating rooms these days.

Health insurance wasn't even a purchasable product until well into the 20th century. Before that, there was sickness insurance which insured against lost income during illness but it didn't pay for physicians or treatments. At that time doctors had few remedies for treating patient so there was thought to be no need to pay for our work when it was God who decided who lived and who died. Then in 1929, a group of Dallas teacher worked with Baylor Hospital in Texas to pay $6 for 21 days of hospital care (!). This was the beginning of the current healthcare morass we face today.

There is a lot more fun stuff to be found in the article. Things such as the history of the hollow needle and the invention of the anesthesia record. You'll be astonished how much of our anesthesia practice we now take for granted but were revolutionary when first introduced into the practice of medicine.

The LAUSD's IPad Scandal

A few months ago, I wrote about all the new iPads the LA school district is handing out to its students. Thanks to a voter approved tax increase, there is suddenly money for the politicians to shower on their constituents to buy future votes. Never mind that before the election the new tax dollars were marketed as necessary evils to shore up ancient school buildings and infrastructure. After the election, the school district decided that it was far sexier and crowd pleasing to buy iPads for every student in the school district instead of fixing old plumbing.

Many people, including myself, were wary of handing out expensive electronics to every single student. Improving student education can't be as simple as handing out iPads to all of them then expect their achievement scores to shoot higher. Sure enough, within days of passing out the devices, the district came to the sudden realization the iPads really aren't that great for writing papers. There is no doubt they are wonderful for presenting textbooks with eye catching animation and searching the internet for information, but when it comes to writing, you know, one of the three R's fundamental to education, the iPads really suck. So the schools decided they needed to spend millions of dollars more to buy keyboards for those iPads. So a $700 iPad now needed more money to make it useful when a simple laptop can be had for less than $500. But an ultrabook is certainly not as sexy as an iPad.

The crisis worsened this week when the school district realized that many students had already figured out how to hack into their iPads. The iPads were supposed to be secured so that it will only present the electronic textbooks that the students use in class. They weren't supposed to be able to search outside the school's intranet. Well that firewall lasted all of about a week. The kids, again many from lower economic classes, quickly figured how to break the security system so that they were using their tablets for Facebook, YouTube, and anything else on the internet. The breach was as easy as deleting the student's own profile on his tablet and logging in as a guest. Voila. Free web surfing for all with no restrictions. Now the school district is temporarily putting on hold the distribution of more iPads as it considers spending even more money to beef up the security.

Finally, the school board belatedly realized that iPads posed a safety risk to their students. With every student carrying the tablet home every night to do their homework, hundreds of thousands of iPads are floating through the streets of Los Angeles, all of them potential targets for crime. The school hasn't yet decided how to protect their precious purchases or the lives of the students. While they would like the students to be responsible for their own devices, they also don't want them to resist a robber who could physically harm them trying to steal the tablets. Already over 70 iPads have been reported missing.

The district thought about having the parents sign contracts stating they would be responsible for any lost or damaged iPads but again many of the families are poor so the contracts would be meaningless since they wouldn't be able to pay. The district also can't withhold iPads after one is damaged or stolen because there are no more textbooks. If a student doesn't have one, he can't do his homework and keep up with his peers. So the school has to issue a replacement iPad to any student who lost his.

It's unbelievable that these issues were not addressed before the LAUSD signed a $1 billion contract with Apple to supply iPads to all the students. Can they stop the program and pay a penalty for breach of contract? They probably could but they won't. First, they would need time to bring books back into the classroom. The students and families may also be reluctant to give up their electronic toys now that they've had a chance to use them. The district board members probably wouldn't want to admit defeat and lose potential votes in future elections by affirming voters' suspicions of their spendthrift ways. My feeling is they will probably double down on the money to make sure this program works at least until the next election. Am I cynical? You betcha. With the incompetence of the LAUSD on full display, it looks like everybody should be leery of politicians who promise the moon if only we can give them more money.

Medical Heroics In A Steak Restaurant

The knife that saved a life.

Everybody wants to have a doctor in the family. If that isn't possible, it's always nice if you can be in a room full of them when an emergency occurs. A couple of days ago, a customer by the name of Pauline Larwood was enjoying her dinner at The Mark in Bakersfield, CA when she started choking. Lucky for her she happened to be in a restaurant filled with physicians who were in town for a conference on Valley Fever.

When the Heimlich maneuver failed to dislodge her food bolus, she started turning blue. At that point, Dr. Royce Johnson, professor of medicine at UCLA and chief of infectious disease at Kern Medical Center, took charge. He grabbed a large pocket knife from another patron and proceeded to perform an emergency cricothyrotomy right there at the dinner table. Dr. Paul Krogstad, professor of pediatrics and pharmacology also at UCLA, then broke a pen in half and inserted it into the new airway. Dr. Johnson then started to ventilate Ms. Larwood by blowing through the pen as she was transferred by ambulance to the hospital.

Amazing. Most doctors have a vague understanding of how to make a cricothyrotomy but to actually be in a position where one is required in order to save a life is a scenario no doctor wants to be placed. For Ms. Larwood, she happened to be in the right place at the right time. Congratulations to the doctors for a job well done.

I Paid The ASA $360 For A Web Search. I Want My Money Back!

By now all you readers know about my disdain for the MOCA process for board recertification. But just because I don't like it doesn't mean I can just ignore it. I still have to comply with its rules to make sure I have a practice in ten years. In addition, California requires that I have at least fifty hours of CME every two years to maintain my medical license. Therefore, I use the ASA's Anesthesiology Continuing Education program (ACE) to keep up my CME hours.

I've been using ACE ever since I finished residency. It consists of two sets of question booklets, one issued in the spring, the other in the fall. It helps me reacquaint myself with all the information that I learned during training so many years ago. With it, I can receive sixty hours of credit each year. As a bonus, when I submit my answers back to the ASA, they automatically submit the hours I claimed for education to the ABA so I don't have to enter it manually into my MOCA portal. The price this year is $360 for ASA members ($830 for nonmembers) but has been going up steeply recently.

One good feature about ACE is that at the end of every question and answer, the author of that question lists the sources from which they obtained the information. While most of the sources are from reputable journals, I was disappointed that several questions in the latest booklet listed their sources as the medical wiki site UpToDate. Really? For those who aren't familiar with UpToDate, it is like Wikipedia for medical information. You see many of the medical students and residents using it to brush up on their knowledge of a particular subject before or after rounds. It certainly beats carrying all those pocket books that we used to cram into our lab coats, adding about twenty pounds to our weight.

However, for $360, I expect the ASA to use better references for their answers. Why should I pay that much money when I can do a simple web search myself to get the answers? Perhaps I'm asking for too much. Maybe it costs too much money to pay all those contributors to actually find the source article from which they derived their questions. Maybe the ASA needs to save their money for the new headquarters they are erecting in honor of themselves. Maybe the authors are so used to using UpToDate in their everyday practice that they have forgotten how to actually read a medical journal. Whatever the reason, I am sorely dissatisfied with the quality of this year's ACE. It is probably too late to change the questions for the fall booklet but maybe there is hope for 2014. Otherwise I can buy a lot of CME for that kind of money somewhere else.

Signs The Surgical Patient Isn't Doing Well

Surgeons regularly inquire over the ether screen about how the patient is doing during a case. This is very annoying to the anesthesiologist. It makes us feel like the surgeon is intruding on our turf. As a result, nine out of ten times they'll hear the standard reply, "Fine."

A far more accurate way to ascertain how the patient is faring during an operation is to take a quick glance at the head of the operating table. The anesthesiologist's actions and demeanor will tell the surgeon all he needs to know about the state of the patient.

Here is a list of ten signs the surgeon can use to decipher if the patient is really fine or things are not going as well as planned, starting from the least worrisome to the most. Each line is followed by an explanation for the action.

1. The anesthesiologist is sitting down and reading his Kindle.
The case is going so smoothly that the EMR can do all the work of charting the case.

2. The anesthesiologist is sitting but watching the patient monitor intently.
Vital signs are starting to fluctuate at the outer limits of comfort level for the anesthesiologist.

3. The anesthesiologist is standing and watching the monitor intently.
Because standing to watch fluctuating vital signs makes the anesthesiologist feel better even if it doesn't improve the outcome.

4. The anesthesiologist is looking over the ether screen.
He's wondering how soon the case will wrap up so he can get this patient off the table before something really bad happens.

5. The anesthesiologist is asking the surgeon how the case is going.
He's not trying to hide his desperation to get the patient off the OR table anymore.

6. The anesthesiologist is drawing up and pushing multiple syringes of drugs.
Pressors. Need more pressors.

7. The anesthesiologist is making phone calls and talking with an urgent tone of voice.
Time to call in the cavalry.

8. There are more people working above the ether screen than below.
Can never have enough hands to assemble drips and start lines.

9. The anesthesiologist is calling for the crash cart.
The fat lady is about to sing.

10. The anesthesiologist turns off the anesthesia machine.
Opportunity to document zero anesthesia complications during case.

So if any surgeons are reading this post, please follow its advice. Don't aggravate tensions in the room by constantly asking the anesthesiologist for a status update of the patient. With a keen eye, the anesthesiologist's actions will tell you everything you need to know.