Tuesday, April 30, 2013

How Many Anesthesiologists Work In California?

Here are some fun facts from the latest issue of the Medical Board of California newsletter.

Other than the primary care fields (Family Practice, General Practice, Internal Medicine, OB/GYN, and Pediatrics), what are the top three specialties to hold active licenses to practice in California?

1. Psychiatry (8,556)
2. Anesthesiology (7,657)
3. Radiology (6,695)

Of the 128,071 physicians who are licensed to practice in California, what are the percentages of the top three specialties?

Psychiatry (7%)
Anesthesiology (6%)
Radiology (5%)

In the top three specialties, what percentage self report holding board certification?

Psychiatry (62%)
Anesthesiology (64%)
Radiology (73%)

So let me get this straight. Over a third of anesthesiologists in California are not board certified? What the hell am I doing spending hundreds of hours and thousands of dollars maintaining my board certification when thousands of anesthesiologists are practicing without one? You mean one can be a good anesthesiologist without a phony piece of paper from some pompous and self important organization?  Screw you ABA!

Sunday, April 28, 2013

Government Prosecutes Drug Company For Giving Doctors Meals At Hooters. Who's Getting Ripped Off?

Notice how the wings color coordinates with this blog?

It looks like the U.S. government is trying to earn its keep by going after the dastardly drug companies again. Novartis is in the cross hairs of federal prosecutors for giving junkets and free meals to physicians for questionable educational programs.

The government has filed a civil fraud lawsuit in Manhattan alleging that the so called educational meetings sponsored by Novartis and paid to physician speakers and sales reps amounted to little more than bribery and kickbacks to doctors. They claim that many of the meetings were held in less than ideal learning environments, such as on fishing boats, sports bars, and the all American restaurant Hooters. They contend that there is no way a doctor could possibly receive an educational lecture about Novartis's drugs in such settings.

As part of the evidence, the lawyers present cases such as a Florida doctor who was given $3,750 for giving five lectures in nine months on the same drug to the same four physicians in attendance. Another doctor was paid $3,127 to give a talk to three people at a steak and wine bar in Des Moines, Iowa. One physician received $500 for giving a talk at the scandalously expensive Nobu in New York to one doctor, two friends, a friend's girlfriend, and a Novartis sales rep.

The prosecutors claim that overall Novartis spent $65 million to pay 38,000 speakers over a nine year period. They say that much of this money is in reality bribes to doctors to prescribe their drugs in exchange for fine dining and drinks.

I suggest to the lawyers that they should probably lighten up. Who's getting ripped off, American patients or Novartis? Novartis is a gigantic pharmaceutical company. Last year their revenue was over $56 billion. Do the attorneys really think the company can bribe enough doctors with only $65 million over nine years to make a difference in the corporate bottom line?

If anybody should be mad at the poor quality of physician "educational programs," it should be Novartis. They are wasting millions of dollars on speakers who are giving talks to only a handful of people at a time. We know some doctors love to make as many presentations as possible to supplement their already substantial income. Maybe Novartis should set a minimum requirement for how many doctors actually show up to a meeting before paying out an honorarium. Right now it doesn't seem like they are getting their money's worth.

On the other hand, perhaps the federal government can once again dictate to us what is an acceptable location for an educational meeting. Remember how they sent the Las Vegas economy into a tailspin when it chastised AIG for holding a corporate meeting there? Multiple conferences were cancelled as a result, worsening the already substantial unemployment in the city. Perhaps we should follow the righteous examples of our politicians instead. They couldn't possibly have any ulterior motives for meetings in exotic locations now, could they?

How Much Money Did Anesthesiologists Make In 2012

From the busybodies over at Medscape, here's their latest survey for salaries of anesthesiologists. (Registration required) According to this report, the average anesthesiologist reported an income of $337,000 in 2012. That is pretty darn good. We are ranked 6th out of all medical fields. The only docs who make more money are orthopedists, cardiologists, radiologists, gastroenterologists, and urologists. However, the relative position is trending down from previous years when anesthesiologists were ranked third in 2010 and fourth in 2011. About 11% of all anesthesiologists made over $500,000 while 6% earned less than $100,000.

The study said that 46% of anesthesiologists reported making the same income as the year before while 21% made more and 33% made less. As usual, male physicians made more money, with the guys earning $347,000 while the gals made $300,000. But we've already gone over the reasons why women make less money in medicine than men. And it has nothing to do with discrimination.

Where you live is also a factor in how much money you will make. If you want to make the most money possible, start thinking about living in the north plains states like the Dakotas, Nebraska, and down to Kansas and Missouri. The anesthesiologists there on average make $383,000. It is thought that they make the most money because there are fewer doctors and less managed care in the region. Plus that high income will go much further with their lower cost of living. By contrast, if you want to live in the Golden State of California, you will earn the least income in the entire country, $318,000. And you'll face the highest income taxes, the highest sales taxes, the most expensive real estate, and the worst traffic in the country. But hey, you can always go to the beach and order a few mojitos to drown out your sorrows.

Anesthesiologists in general feel good about their field. Fifty-five percent say they are fairly compensated while only 45% say they are not. If you want to look at a disgruntled group of doctors, just take a peek over the ether screen. Fully 58% of general surgeons feel they are not fairly compensated. But with an average income of "only" $279,000, nearly $60,000 less than anesthesiologists, who could blame them.

One nice perk about being an anesthesiologist is that we don't have too much paperwork to deal with.  We usually need to fill out only three forms on each patient: the preop note and orders, the anesthesia record, and the postop note and orders. We are far less burdened than other specialties. Over a third of all anesthesiologists spend only 1-4 hours per week on paperwork. On the other hand, primary care fields like Family Medicine report only 17% of their colleagues devote 1-4 hours per week. About one third of surgeons spend 10-14 hours per week on papers.

Why do anesthesiologists like their jobs? About 35% report that they like being very good at what they do. Another 20% like the feeling of gratitude from their patients. That is low compared to all other doctors who report feeling the love from patients 31% of the time. Of course since anesthesiologists only meet their patients for about five minutes before a procedure, it's no wonder we don't get some of that recognition.

So there you go, the latest reminder of why anesthesiology is such a great field. We already know what most people suspect, that anesthesiologists lead a great lifestyle. Our income, while dropping relative to a few others, is still great. And if you work in the right location, can be astronomical. There isn't much to complain about this year. May all of you have another prosperous year to report to Medscape when they come soliciting for information again next year.

Monday, April 22, 2013

Making Do With Less. Loss Of The American Work Ethic

The federal budget sequestration cuts are finally kicking in. And as expected, things are starting to look ugly. When Congress sliced $85 billion off the $3.5 trillion budget, there were dire warnings about the consequences for government services.

President Obama took the first step by announcing the cancellation of White House tours. This is a huge problem for tourists who typically have to wait months and go through extensive security screenings before receiving a ticket. Here in L.A., the Jet Propulsion Laboratory, the agency that sends those fantastic spacecrafts throughout the solar system, has cancelled their extremely popular annual Open House. If you've never been there, you should definitely go. It is a hoot walking past all the scientific exhibits and models that you normally only see on TV. Just not this year.

Now the government is furloughing air traffic controllers. They are pulling these critical people out of the airport control towers, inconveniencing thousands of travelers and adding significant costs to businesses. All of these hassles for a mere 2% decrease in the budget.

I fail to understand how such a tiny difference in spending money can wreak such havoc. Whatever happened to working with less? In economic terms it is called increasing your productivity. Normally that is a good thing. But when it comes to government priorities, productivity seems to be something that should be avoided at all costs, even if it means angering the people who are paying the bills.

By contrast, New York Times columnist Pauline Chen, M.D. recently wrote about her experience as a surgical resident when there was a sudden shortage in staff coverage. She and her fellow residents, after losing one third of their colleagues, worked out a plan where each of them would work sixty straight hours one weekend a month to make sure all the patients were seen, the work got done, and each would have one weekend off. Sure the plan failed because that was an impossible schedule for any mortal to complete, and it would be totally illegal today. But at least they tried. And it shows what responsible people do when confronted with fewer resources but no less work.

Let's not forget that as part of the sequester, Medicare has sliced reimbursements to physicians by two percent. Have doctors gone to cable news shows to complain bitterly about the unfair cuts? Have we decided that patients can just sit outside the emergency room doors and wait for a few hours because there are not enough doctors working due to furloughs? Of course not. Important, life saving work still must continue. We increased our productivity by digging a little deeper, sacrificing our personal lives to make sure the necessary tasks were completed as before.

The only federal agency that has acted like grownups has been the military. Despite the fact that half the sequester comes out of the defense budget, we have not heard too much grumbling from the Department of Defense. Sure some projects may get stretched out longer to work within the new budget guidelines. But in general I feel confident the military is ready and able to defend us anywhere in the world. That's called acting responsibly and maturely.

Of course all this turmoil may just be political theater. It's just a game for these people we have elected to run our country. But it's depressing to think how much uproar can been caused by taking only two percent out of a multi trillion dollar budget. Is it any wonder that countries like Greece and Cyprus, where real painful budget cuts have to be enacted, are on the verge of collapse? I guess we'll know when we get there.

Sunday, April 21, 2013

How Long Does It Take To Intubate Somebody?

That is a question that has crossed my mind several times. When we're intubating a patient, it feels like time stands still. I've never held up a stopwatch and timed myself. Usually by the time I've induced the patient, intubated, checked for proper positioning, and secured the tube, a few minutes have passed. But how long it takes for me to actually insert the endotracheal tube is a mystery. Sometimes it can feel like an eternity when there is an unexpected difficult airway.

Now there is a study comparing the time it takes to intubate a difficult airway using a GlideScope video laryngoscope versus direct visualization with a Macintosh blade. Published in Anesthesiology News, the study is from the University of Toronto by Daniel Cordovani, M.D. and was presented as an abstract at the Society for Airway Management. The article also answers the key question of how much time is required to place an endotracheal tube in a normal airway.

The researchers identified difficult airway patients based on a Mallampati class of 3, small mouth opening of less than 3.5 cm, and short neck. They found that the GlideScope required a median time of 30 seconds to intubate their patients. A direct laryngoscope only took 18 seconds. A different study comparing intubation times in normal airways showed that a GlideScope needed 19 seconds versus 14 seconds for a Macintosh blade.

However the GlideScope had fewer patient who needed laryngeal pressure to bring the cords into view, 14% vs. 36%.  VL also afforded a better view of the cords 55% of the time. And VL failed to intubate the patient only 12% of the time vs. 25% for DL.

It may seem surprising that it took longer to intubate a difficult airway when using a video laryngoscope when compared to a direct laryngoscope. As anybody who has ever used a VL knows, it takes a little getting used to. It still takes me just a longer to insert the VL blade into the mouth then adjust the blade while looking at a tiny video monitor to find the laryngeal cords. With DL, most of the time the cords usually pops into view and I can insert the tube quickly.

But regardless of the method, it's good to know that in general only a few seconds are needed to intubate a patient. With so much new research and technology, there may come a day when failure to intubate will no longer be a risk of anesthesia.

Wednesday, April 17, 2013

War and Medicine

The horrible, cowardly, despicable attacks at the Boston Marathon proved that we cannot keep terrorism outside our borders forever. While other countries experience random bombings like this on an almost weekly basis, we have been lucky to have lived carefree for the last twelve years.

One of the factors that undoubtedly saved many lives was the proximity of well trained medical personnel near the finish line. Though they were supposedly there to treat dehydrated and exhausted runners, their tasks turned much grimmer on April 15. As dozens of casualties started streaming into the medical tent, the staff immediately switched into triage mode, directing patients to the appropriate treatment.

What struck me about these courageous doctors and nurses was how many of them had served in the military. Many of them had done tours of duty in Iraq and Afghanistan. Thus they were familiar with the types of blast injuries that had injured so many. They knew instinctively what worked to save lives overseas and could apply those same techniques here.

During the heights of the Iraq war, I had purchased a book titled "War Surgery in Afghanistan and Iraq." You can call me curious or you can call me a voyeur. As a medical professional I wanted to know the state of the art in trauma care in the 21st century. And this book doesn't disappoint.

It is authored by three surgeons who were stationed in the Middle East. They go through fifty case studies of war injuries that were inflicted on our soldiers and the general population. The pictures printed inside would never pass through the sensibilities of the censors of any lay periodical. The damage to the human body can be truly gruesome. There are large, extremely graphic and bloody pictures of exposed bones and organs throughout. In the first chapter alone, there are sections that seem quite appropriate for the types of treatments the Boston victims will need: "To Shunt, Repair, or Amputate?" and "Devastating Burn, Blast, and Penetrating Injury."

Later there are entire chapters on craniofacial trauma, soft tissue trauma, burns, and of course orthopedic trauma. There is even a section for pediatric trauma. As we all know now, a bomb makes no distinction between an adult and a child. One of the more interesting chapters is on the removal of unexploded ordnances (UXO). In other words, missiles that penetrate the body but didn't explode. I love the authors' recommendation for how to treat a patient with an UXO, "the UXO (should) be removed in the most efficient and expedient manner possible, with minimal physical disturbance to the ordnance." It is so clinical and sterile, typical of a medical professional.

So if you are the least bit curious about how modern warfare has viciously and indiscriminately targeted its victims, go find a copy of this book. You will see how real life battles are not as clean as that game of Call of Duty that you've been playing on your TV in the comfort of your living room. You never know if you will ever get that dreaded call to come into the hospital to treat mass casualties. I'm sure the doctors and nurses in Boston were not expecting it either on that bright beautiful April day.

Saturday, April 13, 2013

Death In The Dental Chair

Oops. Not a dental chair
Here's another horrifying story of a needless tragedy involving a victim of a poorly supervised anesthetized patient. Marek Lapinski, a 25 year old San Diego resident and former college football player was getting his wisdom teeth removed by Dr. Steven Paul in the dental office. During the course of the procedure he received multiple drugs for sedation. After about 30 minutes, when the patient continued to move and cough, Dr. Paul administered the favorite drug of incompetent anesthetists, propofol.

Predictably Mr. Lapinski stopped breathing. Unfortunately for him, nobody in the office knew how to resuscitate an apneic patient. When the paramedics finally arrived, they started CPR and attempted to intubate Mr. Lapinski. To their surprise, there were still two surgical gauze packed into the oropharynx causing obvious airway obstruction. The patient was taken to the hospital where he died three days later of anoxic brain injury. His medical records indicate that, in addition to the fateful injection of propofol, he had been given fentanyl, midazolam, ketamine, and methohexital. Wow! That is a witch's brew of anesthetics that no well trained anesthesia provider will ever give all at one time to the same patient. 

It's insane how many doctors and dentists think anesthetizing a patient is as simple as pushing a drug into an IV. There is frequently inadequate emergency resuscitation equipment available. The doctor who is doing the procedure is also the one giving the drug. Nobody is focusing one hundred percent of his attention on the most important person in the room, the patient. Dr. Paul may have a pulse ox on Mr. Lapinski, but when the shit hit the fan and the oximetry reading dropped to zero, what does he do? Nothing. Because he didn't know how to properly ventilate an apneic person.

Until more doctors are instilled with the fear of medical malpractice for giving anesthetics that they don't understand or know how to counteract, these unfortunate events will continue. They will have to realize that the price of hiring an anesthesiologist is much cheaper than killing their patients and losing their license and livelihood.

Friday, April 12, 2013

Why Taking Calls Suck

I hate taking overnight calls. It is one of the most vile responsibilities of being a doctor. In our group an anesthesiologist can volunteer to take calls for a guaranteed stipend plus income from any cases he may do during that time. So far there have been no takers.

Having to do calls is so heinous that colleagues have come up with all sorts of reasons to palm it off somebody else. There is always the suspicious excuse of calling in sick on your call day. Other people have used marital strife as an alibi. Then there is the creative use of some murky medical excuse that prevents one from working nights and weekends but doesn't prevent them from working all day on weekdays with any obvious ailments.

Why do doctors hate calls so much? While I can't speak for others, here are my reasons for loathing calls with a passion.

1. Your caseload is unpredictable. With elective surgeries I have the luxury of evaluating a patient the night before the procedure and devise an anesthetic plan. When I'm on call anything could roll into the OR with little time for preparation. It could be as simple as an appendectomy or as exhausting as a multiple gunshot wound to the chest and abdomen. This randomness creates severe anxiety and stress.

2. My income is adversely affected when I take calls. Elective surgeries are scheduled so that there is as little wasted time as possible between cases all to maximize OR utilization and profits. Some anesthesiologists are employees of their facilities and get paid by the hour. For them, a lot of sitting around time between cases doesn't doesn't affect them at all. Alas I'm not one of them. When I'm on call I am on standby for anything that might roll in through the ER that needs urgent surgical intervention. I could be on standby all night which means I can't go out to a movie, go get a drink with friends, or travel more than thirty minutes away from the hospital. But since I work fee for service I don't get paid if I'm not giving anesthesia to a patient.

3. The opposite problem of having too much downtime while on call is being overly busy. Sometimes being on call means running around nonstop all night trying to get cases going with surgeons breathing down my neck. Thus there can be little freedom to go to the bathroom or get something to eat. And since this is the middle of the night there isn't anybody around to give me a break for even a few minutes.

4. Call days feel endless. With a regular day I have an approximation of when I'll be able to go home. When I'm on call I may not make it home until 6:00 PM or 6:00 AM. It is a very demoralizing feeling not to know what time I'll be able to make it back. It's like indentured servitude for twenty-four days.

5. I don't sleep well when I'm on call. My sleep becomes very light. Even if I'm home in my own bed my body is tensed and ready to jump the moment my pager goes off. I get so sensitive that just rolling in bed will wake me up. As I get older it takes me longer to recover from a poor night's sleep. So I'm tired and grumpy for a few days after a bad call day. This does a disservice to my patients and my family.

6. I don't get to write as much as I'd like. Observant readers may notice that my blog entries are somewhat lumpy. Sometimes I'll have new posts virtually every day while other times I'll go AWOL for days at a time. That's usually because I'm too exhausted from a close set of call days to do any creative work. So if you're missing your favorite anesthesia blogger you can blame my call schedule.

Is there a solution for this dreaded practice? I believe it is already happening. In the near future I think fee for service will become a medical relic, like an open appendectomy. Doctors will eventually all be employees of either the government or giant hospital organizations. At that point shift work will be the norm. We'll all work hours like ER doctors. The inhumane practice of working twenty-four hours straight will no longer be tolerated under federal labor laws that protect employee work conditions. Then at that point we can listen to the grumpy old doctors complain about how good the new doctors have it compared to when they were young.

The Yacker Tracker Yanked

Somehow this didn't really come as a surprise at all. Our recovery room recently purchased a Yacker Tracker to monitor the noise levels that were drawing complaints from patients and families. The device is supposed to alarm if the room reached a certain loudness so that everybody would know when to pipe down.

Predictably, like other ill advised medical purchases designed to improve patient care, this one didn't really pan out. As you can see, the Yacker Tracker has now been ignominiously relegated to the closet, piled up with the discarded chairs and other furniture that nobody wants or needs.

This is so typical of the waste that we see all the time in medicine. Somebody will get the bright idea to buy a new piece of equipment because they went to a conference that extolled the virtues of the latest and greatest technology. Or there will be some issue that can only be solved by acquiring more costly paraphernalia. After spending scarce dollars on this stuff, people realize it is no better than what we had before. In this case, my high school librarian could have done a better job of keeping a room quiet. The money has been spent but the problem has not been resolved. If this is typical of how medical dollars are wasted around the country are we surprised how little the trillions of dollars we spend on healthcare get us?

Thursday, April 11, 2013

Drinking Before Surgery

It is one of the cardinal rules of surgical preparation; NOTHING by mouth after midnight, or NPO after MN. That is one of the easiest and most clear cut ways for an anesthesiologist to cancel a case. The surgeon will rarely argue with an anesthesiologist on this point. Some anesthesiologists adhere to this rule so strictly that they will cancel a procedure if the patient is even found chewing gum before surgery.

The reason we discourage patients from eating or drinking anything before receiving anesthesia is that we don't want any contents in the stomach during the procedure. If the stomach is full of food or liquids, there is a risk that the patient will vomit the half digested gastric bolus while under sedation and aspirate it into the lungs. This could lead to severe aspiration pneumonia and possibly death. The doctors and the hospital frown upon unexpected operating room deaths.

But now NPO after MN maybe getting a closer scrutiny. The American Society of Anesthesiologists has for years recommended that cases can proceed if the patient has only clear liquids up to two hours before surgery. Clears means anything that one can see through. Water is obviously considered clears. So is apple juice, grape juice, and, surprisingly, black coffee. Milk, orange juice, and coffee with cream are not clear liquids.

Now a study has been released that may actually encourage doctors to recommend patients have a drink before an operation. As Anesthesiology News reported, researchers at Texas Tech University Health Sciences Center had one group of patients drink a carbohydrate rich clear drink two hours before surgery and another group remain fasting after midnight. Not surprisingly, the group who got to drink before surgery felt less thirsty before their operation. But they also felt significantly less anxiety and greater comfort overall. The researchers concluded that perhaps patients should be allowed to drink clear liquids before they have their surgeries.

First of all I think that is a fine idea that should be further explored. While I would hesitate to let a patient drink as much as these study patients did, 360 mL of fluid which is a little more than one can of soda, I think a couple of gulps wouldn't hurt. We frequently ask our patients to take their medications with small sips of water before coming to the hospital and I don't know of anybody who has aspirated because of that.

Instead of using some specialized "carbohydrate rich beverage" that the researchers used (Clearfast and BevMD) which sounds very expensive, how about just letting patients get a small bottle of Gatorade or other sports drink? It is cheap and readily available. They also contain the electrolytes that are missing from plain drinking water.

Let's face it, NPO after MN is rather barbaric. No elective surgery starts at 2:00 AM. It is especially cruel if the patient's operation isn't scheduled until the early afternoon like 1:00 PM. Is the patient supposed to go without food or water for that long? They can do it but it is not comfortable. Plus by the time the patients comes to preop, they are so dehydrated that it makes starting an IV more difficult. The only reason we tell patients not to eat or drink anything after midnight, even for late starting procedures, is that just in case an early procedure gets cancelled, we can move another patient up without worrying about whether he had just drank something. The last thing the hospital wants is for an expensive operating room to sit empty while we wait for the two hour window to pass.

So let's do patients a favor and consider letting them drink a refreshment up to two hours before surgery. They will feel better when they come to preop. If they are happy, they will make your life better too.

Wednesday, April 10, 2013

Better Late Than Never

I finally did it. After writing this blog for nearly four years at last I have started a Facebook page. You can find it here or search under Great Z's and it should be the first choice that pops up. Right now there is literally nothing yet on the FB page other than a quick introduction. I eventually hope to mirror the content of the blog and the FB site so that readers can find me no matter which social media they prefer to use.

Why haven't I done this earlier? The quick answer is that I just never had time. It is hard enough to write steadily to make a blog worthwhile to read in the little amount of spare time that I have. I didn't feel like I wanted to burden myself by having a second site that required even more of my time. However, I realized that some writings are more appropriate for a long blog post and some are better as quick FB comments. I hope this dual format will make it more liberating for me to write on various topics.

As they say, I hope you like me on Facebook. And please share it with all your 5,158 friends.

Monday, April 8, 2013

I Knew You Were In Trouble When You Rolled In

To the music of  "Trouble" by Taylor Swift

Once upon a time many years ago.
I was in the lounge watching "24".
Trauma called me, trauma called me, trauma called me.
They're bringing a patient up with gunshot to the chest.
Bring all the blood as much as you can.
Set up room 3! Set up room 3! Set up room 3!

You looked long gone when you came to me.
And I realized your life depended on me.

Cause I knew you were in trouble when you rolled in.
Your skin was ashen
Blood poured out your mouth and down your chin.
Gonna lose my lunch, ugh.
I knew you were in trouble when you rolled in.
Your pulse was racing.
Blood poured out your chest and down the bed.
Now you're lying in a pool of clots.

Oh! Oh! Trouble! Trouble! Trouble!
Oh! Oh! Trouble! Trouble! Trouble!

I untangled all your lines. Hooked up the Level One.
I hung up all the O's and the FFP's.
You're fading. You're fading. You're fading.
Now I hear the surgeon shout.
He's cracking wide the chest.
The aortic clamp reaches in. You have gone brady.
And now I see. Now I see. Asystole!

You were nearly gone when you came in.
Now I realize your savior's not me.

I knew you were in trouble when you rolled in.
You're now pulseless.
Crash cart rolls in and we're pounding epi.
Get some bicarb.
I knew you were in trouble when you rolled in.
Squeeze the heart more.
This bloody battle we cannot win.
Now you're lying in the cold hard ground.

Oh! Oh! Trouble! Trouble! Trouble!
Oh! Oh! Trouble! Trouble! Trouble!

Apologies to all the Taylor Swift fans out there.

Sterility In The Operating Room. Hey It's All Relative.

I don't often reply to a comment that people make after reading one of my posts. And I have never before written a whole page to counter what people thought about my writing. But I think this one deserves an exception. An irate reader took me to task for making recommendations for what types of food would be acceptable for consuming in the operating room.

The author of the comment only signed himself or herself as "Anonymous". But he, for simplicity sake, starts off by berating me, and my readers, by writing, "Shame on all of you." He goes on to claim that surgeons and nurses sometimes work for 8 to 12 hours at a time without a break. Therefore anesthesiologist should just tough it out and do the same thing or talk to the administration to hire more anesthesiologists to give us breaks. He chastises us for bringing food into the operating room and possibly jeopardizing the sterility of the surgical field.

Okay, I don't know if Anonymous is a surgeon, a hospital administrator, or a Joint Commission lacky, but his statement that nurses work without a break for half a day is clearly ignorant. I don't know of any operating room nurse who works that long without being given some time out of the room. As a matter of fact, during a single four hour case there may be as many as three or more shifts of nurses moving in and out of the room. Most states have pretty strong rules about how often nurses are supposed to be given relief. And if a hospital is found in violations of overworking their nurses, major lawsuits can ensue.

As for the surgeons not getting breaks, well that is their choice. They can operate twelve hours straight if they wanted to but the truth is that they have options. In a long case, there is always some point where the surgeon can scrub out and take a quick five to ten minute break to go to the bathroom or get something to drink. Rarely is a procedure so intense for the entire period that the surgeon cannot leave for even a few minutes. In addition, the surgeon usually has an assistant in the room that can continue working or at least watch the patient until he comes back.

By contrast the anesthesiologist is almost always working alone. By moral and legal grounds he can never leave the operating room with the anesthetized patient unmonitored. While the surgeon is making a quick run to the restroom, the anesthesiologist is watching the patient diligently to make sure every is going well. It doesn't work the other way around.

Now let's get to the crux of the matter, the reason food is banned from the operating room. Like I said in the original post, food is never, ever, ever permitted in the OR. And the reason for this is the fear that it would somehow contaminate the sterility of the operating field. But is that really the case?

Not a hospital operating room
People have to know that the OR is considered sterile, but the sterility is not as strictly enforced as you might believe. Sure the surgeon and the scrub nurse gown and glove up with the utmost care to ensure absolute cleanliness but it is still far from the true sterility that you might find in say a computer chip manufacturing facility. There, particles measuring micrometers in diameter are efficiently whisked out of the factory to prevent damage to the impossibly tiny tolerances required of modern technology.

By contrast, really the only sterile part of the operating room is the few inches surrounding the patient's open wound and the instruments and hands that reach in. The surgeons gown up mainly to protect their own clothing. Nobody wants to get splattered with disease ridden blood and body fluids. If you wanted to you could operate in your street clothes and I bet the infection rate would not change as long as you wear sterile gloves. As for the mask, think of it as more of a sneeze guard than a true protector of sterility.

For the same reason I find it hard to believe that me eating a little grape under my mask behind the ether screen will somehow contaminate the operating field. I'm usually at least six feet away and frequently BELOW the level of the the open wound while being behind a sterile drape. The surgeons' bushy eyebrows, which are obviously uncovered, are within inches and above the patient's wound. Same goes for the caps they wear on their heads. Those caps are definitely not sterile, nor are the tendrils of hair that often peek out from under the edges of the caps. Should all surgeons shave their heads to prevent dandruff and stray hair from falling out and infecting the patient?

Now I'm not advocating that anesthesiologists should be allowed to bring in gourmet lunches into the operating room. And again pretty much all hospitals frown upon any food or drinks in the OR's. But most see the practicality of allowing some sustenance for the anesthesiologist. As long as one practices common sense and and discretion, a few snacks are usually tolerated. Otherwise cases will just have to be delayed so that the anesthesiologist can go to the cafeteria and eat to prevent his blood glucose levels from collapsing. Which wouldn't really matter to the surgeon or the hospital but it might endanger patient safety, which you know, might not look so good on the local evening news.

Sunday, April 7, 2013

Astroturf On A $2.8 million House. Insane L.A. Real Estate Market Is Back

Just a couple of years ago people were predicting doom and gloom in real estate, particularly in large bubble markets like Los Angeles. Comparisons were being made to the real estate depression that has plagued Japan for over twenty years. Many cried out to the government for relief, which promptly acquiesced and introduced near zero percent interest rates they claim they will maintain as long as necessary.

And you know what, it worked. The housing market has come roaring back. Here in L.A., real estate dropped about 40% from its peak in 2008. But now people who waited for an even bigger decline may be too late. In fact, professional house flippers are already starting to return.

A recent home listing near my neighborhood took me aback for its audacity and bad taste. According to its listing page, this $2.79 million 4,000 square foot monstrosity is a, "Newly custom built home situated at the top of the hill." Yes it certainly looks new, and it does have a killer view out the back yard, but this house is McMansion personified . Though you can't tell from its listing, it is located in the middle of a neighborhood filled with 1950's era ranch style homes that are half its size and price. If your neighbor wanted to borrow a cup of sugar, you could almost reach from your kitchen window directly into their kitchen window.

What made me do a double take was the tackiness of the Astroturf around the house. The owners tried to make this a virtue by describing it as "low maintenance". I think they would have been more successful in selling this fake grass if they had claimed it to be environmentally friendly or even drought resistant. Either way, it is quite jarring to see a multimillion dollar house with a plastic lawn for a yard.

Inside it is all granite tiles and marble columns. There seem to be arches and oversized crown moldings everywhere. The overwrought decorations are meant to justify its extreme price. But the owners better hope they get lucky and find a buy who has the same gaudy tastes in interior design. Anybody who has almost $3 million to spend on a house can buy virtually any house they want. They will not want to spend that much money only to have invest even more dough to rip out all the interior touches that they find objectionable.

So if you were hoping to buy a house in L.A. and was waiting for the market to hit bottom, you may already be too late. Home prices are again reaching levels where even doctors can barely afford to buy one in a decent neighborhood. Though I went through my own personal hell in buying our house a couple of years ago, it looks like I was prescient and got our dream house just in time.

Online Shopping At Work, The Great Benefit Of Having An EMR

When our hospital went to all electronic medical records recently, we had to buy tons of new computers. This ensured that no impatient doctor or nurse ever had to wait for somebody to finish before they can log on and complete their patient charting. We now have multiple computer workstations in every conceivable location short of the bathroom.

But along with this new advance in patient care has come increased temptation. For you see, it is all too simple to start surfing and shopping on our powerful gigabit high speed internet connection. And many staffers do exactly that. You can see it on every ward and in every room. It's easy to find somebody who is logged into their Facebook account updating their status. Or they're shopping for new shoes and bags. Or they're checking out the cheapest tickets to Cancun.

Has all this new technology actually distracted us from our duty to diligently look after our patients?  While the goal of implementing EMR's is to improve patient care and prevent mistakes, I sometimes wonder if  the exact opposite is happening. People seem ever more distracted as they constantly seek out the nearest computer to sate their internet needs which in actuality is insatiable. Whether to check their emails that they last looked up five minutes ago or to find the best deal of the day for a refurbished iPad, non medical use of our computer system is rampant.

The hospital has put in some blocking software to prevent introducing viruses into the system. These mainly affect the foreign country and porn sites, not that I had ever looked of course. But if there were no blocking software I don't think most people would surf there anyway, mainly out of embarrassment of doing so in a public setting. I would think that they could easily block shopping and social media sites. But they don't. Maybe there are just too many for them to try to block in an ever evolving world wide web? Or maybe they are afraid that keeping the staff from misusing the computers will bring down morale? Perhaps they fear that people will just switch to their smart phones instead and start walking into walls since they are staring down at a four inch screen held at chest level.

Whatever the case our EMR is here to stay. And the shopping spree will not be denied.

Saturday, April 6, 2013

The Myth About Anesthesia Sitting Around Time

Surgeons hate delays between operating room cases. They frequently attribute this to the anesthesiologist. They even have a term for this: Anesthesia Sitting Around Time, or ASAT. Some of the less charitable surgeons refer to this as AFAT. I'll let you figure out what the "F" stands for. But they only see half the picture. Let me tell you what really goes on after the surgeon finishes the last stitch and leaves the room.

Once the surgeon finally walks away from the OR table, the scrub tech can then put the dressing on the wound. By now I have already started waking the patient up. If I'm really good, I can extubate the patient almost immediately. However every patient is different, and every anesthesia is different so sometimes it can take a few minutes before the patient is awake enough to have his endotracheal tube removed. Once I have determined that the patient is safely alert and able to protect his airway we can then move him onto a gurney to be transported to the recovery room.

When we are in recovery, I have to give a report to the receiving nurse, including all the relevant patient history, pertinent events during the operation, and his fluid status. Vital signs also are done to ensure the patient is stable before I hand him off. Then I have to write a postop note to document the patient's well being. I then rush back to the operating room to set up my next case. But the janitorial crew hasn't finished cleaning the room yet. And I can't really complete my preparation until they are done. So I do as much as I can before I head over to preop to see my next patient.

If I'm lucky, the next case is on an ASA 1 patient with no complicated medical, surgical, or anesthetic history. The patient will already have an IV in or will have giant garden hose veins. Somebody will hopefully have already put all the important history into the EMR so that I can finish my preop assessment note in twenty seconds. That's the ideal. Often I'll have to prepare an IV bag, start the IV, interview and examine the patient, and write the note, all under five minutes if possible.

Once that is done I head back to the operating room. It is now cleaned and the scrub tech is opening up the surgical instruments. I attach a fresh anesthesia circuit on the machine and put in a clean suction cannister. I announce to the circulating nurse that I'm ready to bring the patient in. I have achieved my goal of getting the patient ready in less than thirty minutes. The nurse says she and the tech have not finished counting the instruments yet so they're not ready.

Okay, fine. I told her I'll meet her in preop when she's done. As I sit in preop waiting for her arrival, another nurse comes to interview the patient. I ask her what happened to the first nurse. Oh, she is giving her a lunch break. This new nurse then notices that the surgeon had not properly filled out the consent form and had not marked the operating site on the patient. Now we need to call the surgeon back to complete those essential prerequisites. In the meantime she needs to go back to the OR to count instruments because she wasn't there when the original nurse counted instruments the first time.

It is now going on forty five minutes since I left the operating room with the last patient. I can see that this is still going to take some time. Therefore I walk down the hallway to the operating room lounge and grab some water and answer nature's call. Suddenly my pager goes off. Preop is calling me. I head back to the room and the surgeon and the nurse are standing there waiting for me. The surgeon mutters something about typical anesthesia delay and stomps back to the OR. Sigh. Sometimes you just can't win for trying.

So you can see, ASAT is really a myth. There is hardly any sitting at all on my part between cases. For people who think anesthesiologist just sit around all day and collect easy paychecks, they obviously have never talked with one.

Thursday, April 4, 2013

Remind Yourself Again Why You Went Into Medicine

Remember how happy you made your parents when you decided to become a doctor? Your mom couldn't wait to tell all her friends that her special offspring was smarter than all their kids because you were going to do something more meaningful, and lucrative, by applying to medical school. She could finally be the queen bee at her tennis club because her child will be an M.D. All the other moms can just go cry in their metropolitans and rue the day their children didn't want to be a medical professional and became a mundane software engineer with a four year degree instead.

Well now who has the last laugh? Business Insider has listed the companies that pay the highest salaries to software engineers. Let me tell you, the money ain't bad. It's fairly comparable to many primary care physicians' incomes. Companies like Juniper Networks, Google, Apple, and Facebook all start their base salaries for software engineers at over $100,000. And that's just the base salaries. It doesn't include stock options, the manna of tech company employees. They are particularly valuable for employees who work at companies that haven't gone public yet like Twitter. Facebook's IPO was estimated to have generated 1,000 new millionaires alone.

Besides the money, tech companies are infamous for lavishing outlandish perks on their employees. Google's workplace is known for giving employees free gourmet food night and day, free gyms, free dry cleaning, even free healthcare with an onsite doctor available to employees. How much of that generosity is enjoyed by the workers who don't have to pay a dime of income tax on those benefits? In the meantime laws have been passed that keep physicians from accepting even stupid gratuities like a box of doughnuts and free pens.

Plus there's just an aura around people who work at one of these corporate leaders. As one Apple employee wrote, "...everyone says 'wow' when you tell them where you work." I know a few people who work at these places and the reaction is always one of admiration and envy. You can't help but wonder how smart they must be in order to be hired by Google or Facebook. When was the last time you had that reaction when you met a doctor?

Well Dr. Z, all that may be true, but as an anesthesiologist you probably make two or three times that much money every year. Yes, the average salary of an anesthesiologist, or gastroenterologist, or orthopedic surgeon is several times that of the software engineer. But the real question is how much income is your peace of mind and free time worth to you? How much money would you place on your anxiety of knowing that any patient who walks through your door is a potential medical malpractice case? How much money would you pay to not have to sit through a deposition because your patient decided to sue you for a broken tooth during intubation. How much money would you give back if you could work an eight or nine hour shift and enjoy every night and weekend with family and friends without worrying about some sick patient in the hospital? Any doctor who has ever been sued will tell you that all those sleepless nights and constant fear and paranoia after getting subpoenaed is not worth the satisfaction of practicing medicine. They would gladly give back all their money if they didn't have to face a malpractice suit ever again.

Remind yourself again why you decided to go into medicine.

Tuesday, April 2, 2013

Those Godless Burned Out Money Loving Anesthesiologists

Here comes another physician survey from the good folks at Medscape. These are the same people who previously found that anesthesiologists as a group are among the happiest physicians in all of medicine. This time they conducted another study to explore the darker underside of medical practice: how much burnout exists within the medical field. The survey is based on responses from over 24,000 doctors that Medscape emailed. For full disclosure, I too participated in this survey but I didn't win that iPad mini they had promised to give to three lucky recipients who returned their email, dammit.

So how did anesthesiologists fare when it comes to feeling stressed? Not so good. While we may be happy, we also feel high levels of stress. In fact, anesthesiologists tied for fourth place as being the most stressed out, along with internists, general surgeons, and OB/GYN. Maybe it's those other burned out doctors that are giving us our stress ulcers. Emergency medicine and critical care came in as the most difficult fields while pediatricians were the most satisfied with their work.

According to this survey, 42% of anesthesiologists feel stressed out, which was defined as, "Loss of enthusiasm for work, feelings of cynicism, and a low sense of personal accomplishment." More women were burned out than men, which may be due to more domestic obligations than their male counterparts. The life stage when anesthesiologists felt the worst are between the ages of 46-55 when 40% of us feel stressed. The younger doctors haven't practiced long enough to be burned out yet and the older ones have probably cut back hours and are looking forward to retirement. As somebody close to that middle cohort I totally agree with this one. This is the period when one has car payments, house payments, childcare and school expenses. It's easy to understand why the middle bracket will feel the most stress.

Maybe exercise will take the sting out of difficulties at work. Yes, but not by much. Fifty-seven percent of the stressed out anesthesiologists exercise at least twice a week as compared to 66% of their happier peers. About 35% of the overburdened doctors work out only once a week compared to 28% of the unstressed docs. So exercise does make some but not a big difference in feelings of work satisfaction. However even if one doesn't exercise much, one should try to watch his weight. Fifty percent of overweight anesthesiologists reported being burned out compared to 39%.

If exercise doesn't take your mind off how crummy your work is, maybe some spirituality might help. In this survey, that didn't pan out either. There were no differences in religious activities between the two groups. Just as many stressed out anesthesiologists participate in religious endeavors as their satisfied peers. However anesthesiologists in general are not that religious. While 88% of Americans report having a religious affiliation, about 30% of anesthesiologists say they have no religion at all.

So here comes the $64,000 question. Does money make you happier? Of course it does. Whoever said money can't buy happiness has never had enough money. Of those anesthesiologists reporting that they feel burned out, 35% said they had minimal savings in their bank accounts. That is nearly twice as many as those who are happy at work. Sixty percent of burned out doctors say they have an adequate amount of money to fall back on while 76% of non stressed doctors say they have adequate savings. Somehow that isn't terribly surprising.

So there you have it. The key to not stressing out at work as an anesthesiologist is to 1) be a man, 2) stay thin, and 3) have lots of money. Easy. Oh, and try to stay away from the nasty stressed out surgeons.