Saturday, June 29, 2013

I Told You. No You Didn't.

Gather around boys and girls. It's time for another Morbidity and Mortality discussion courtesy of the California Department of Public Health. Every few months the DPH releases a list of fines meted out to hospitals for egregious acts of incompetence. If you go through the list, you will see that, sadly, retention of foreign bodies, such as lap sponges and Babcock clamps, are still occurring all too frequently during surgeries. However there are a couple of interesting cases here that I would like to highlight. Luckily on this go around there are no anesthesia related incidents.

First up is a sad tale of the perils of not double checking the medications that are given to patients. A patient was admitted to Marin General Hospital in Marin County for sepsis and pneumonia. Antibiotics was ordered. After the nurse hanged what she thought was Ceftriaxone, the patient's heart rate and blood pressure dropped precipitously. The BP bottomed out at 51/30 while the heart rate went from the 90's down to the 50's. He was intubated to support his ventilation. It turned out the nurse had started a Labetalol drip instead of antibiotics. Once the error was realized, the drug was quickly stopped and the BP brought back up.

Unfortunately the patient suffered acute renal failure because of the poor perfusion. He had to go on dialysis. He also developed shock liver and rising LFT's. The hypotension also caused severe ischemia of his extremities. He was in excruciating pain due to gangrene of his lower legs and fingers. He required a Dilaudid drip to placate his pain. At this point the family decided to withdraw life support and he passed away.

During the investigation it was noted that the Labetalol and Ceftriaxone bottles were similar in size though in different colors. In addition, Labetalol came in a liquid while Ceftriaxone was in powder form that required it to be dissolved before giving to a patient. How the nurse got the two medications mixed up may never be known since he or she was not made available to the investigators for an interview. The hospital was fined $75,000.

The second case that I hope you read is a cautionary tale on the increasing prevalence of employee doctors and the shift work mentality that could set in. At Palomar Health Downtown Campus in San Diego County, nurses were having a difficult time caring for an alcoholic patient. The patient repeatedly tried to get out of bed despite warnings that he could fall. While the nurses were giving afternoon report during shift change, a loud thud was heard from the patient's room. When they walked in, they found that he had fallen out of bed onto the floor. A CT scan of the head showed he had a 2 cm subdural hematoma and a 3 mm midline shift of the brain. The on call physician was notified of the results and he ordered hourly neurologic exams only.

During the night the patient became progressively less responsive. He also became tachycardic into the 150's but this information was not forwarded to the doctor. By 5:38 AM, the phlebotomist came into his room and was unable to rouse the patient. She called the nurse to come see him. The nurse couldn't wake him up either and gave him a Glasgow Coma Scale of 3. He saw the doctor sitting at the nurses station and told him about the patient's deteriorating condition. According to the nurse, the doctor told him that he was off duty and to tell the oncoming physician about it. When the morning doctor arrived at 6:00 AM, he immediately called the Rapid Response Team and the patient was transferred to the ICU. When a repeat CT was ordered, it found that the subdural hematoma had increased and he was now bleeding into his brain stem. The neurosurgical team was consulted and declared him inoperable. He was made DNR and died the next day. The hospital was fined $100,000.

When the physician from that morning was asked about his disregard for the patient's condition, he told investigators that he was never notified by a nurse about the patient. He considered it "absurd" that he would brush off the nurse and punt the problem to the next doctor. Now who is more credible, the nurse or the physician? Who's lying? Who knows? As we train new doctors with strict work hour rules, how likely is this attitude to prevail in the future? When doctors increasingly become employees of large medical organizations, will they become like government employees who put a "Next Window Please" sign in your face just when you reach the counter?

Try to take the time to read through these investigations. There is a good reason why the state publishes these mistakes for all to study. They are an incredibly valuable resource for learning about and preventing medical errors. I've just scratched the tip of the iceberg. View what happens when a baby was accidentally injected with methergine instead of the laboring mom. Or how a guidewire from a central line kit was discovered in a patient's heart. If you know about it, hopefully it will never happen to you.

Wednesday, June 26, 2013

The Perils Of A Dirty Mouth

Where is the endotracheal tube?
If there is one thing I can count on in the hospital, it is that inpatients will invariably have the most disgusting oropharynx imaginable. This is particularly true for the elderly, the demented, or the ICU patients. While the nurses are busy checking for decubitus ulcers or IV site infections, the mouth is all too frequently neglected. Whenever I have to intubate an inpatient, I will almost certainly encounter detritus collecting just above the vocal cords. I'm talking about filth like dried phlegm, old blood, or leftover food bits either from poor swallowing ability or regurgitation. And don't ask me about the severe halitosis that comes with all this decaying matter.

It is well known that poor oral hygiene leads to a higher risk of pneumonia. Ventilator associated pneumonia is the second most common nosocomial infection in the ICU. VAP is estimated to occur in 250,000 to 300,000 patients per year in the country. It prolongs a patient's ICU stay and increases the cost of patient care by an estimated $20,000.

The American Association of Critical Care Nurses even has a guideline for how to perform proper oral care in the ICU patient. This includes twice daily brushing of the teeth and oral and lip moisturizers every two to four hours. Yet I have never, EVER, seen an ICU nurse brushing a patient's teeth.

The picture above is of an unfortunate patient that I recently had to intubate. She was elderly, frail, demented, and of course full code. The family wanted everything done thus a trip to the operating room was needed for a minor procedure. After induction I looked into the patient's mouth and saw...nothing. The tongue was so dry that it stuck to the laryngoscope blade. Once I was able to maneuver the scope further back I encountered a wall of debris making it impossible to recognize any normal anatomic landmarks. As I was furiously trying to suction out the trash, her O2 sat dropped perilously, which is all too easy in these kinds of patients. Finally, after I cleared a tunnel through all that organic waste, I caught a glimpse of the vocal cords with the help of some heroic cricoid pressure from the scrub nurse. I shoved the ETT in quickly and breathed a sigh of relief when I got some ETCO2 back on the monitor. Whew. The patient will live to have another operation ravage her body before she finally meets her maker.

As self described leaders in critical care medicine, we anesthesiologists should be advocates for better oral care in our patients. While we are busy in our ivory towers studying the body's inflammatory responses to endotoxins, perhaps we are ignoring the preventive aspects of critical care that will keep sepsis from occurring in the first place. Instead of spending billions of dollars developing new antibiotics for increasingly resistent hospital bacteria, maybe something as simple as brushing a patient's teeth twice a day will do the trick. Instead of being reactive, we should be more proactive. Why wait for an infection to set in when there is a simple, inexpensive, and universal mechanism to keep it from establishing itself and killing our patients? Anybody can intubate a patient. It takes true medical leadership to enforce changes that can actually improve a patient's well being.

Tuesday, June 25, 2013

Of Sunny Beaches And Confiscatory Tax Rates

I've mentioned before how infuriating it is to live in California. For people with even a modicum of success, the state continues to drain you as if you were a maple tree in Vermont. Physicians in the state have it especially bad. We are socked with the highest marginal income tax rates in the nation thanks to an electorate who vote for tax increases out of envy instead of clear logic. The cost of doing business here is outlandish, with high office rents, expensive employee compensation, and onerous work rules. Yet the state is determined to drive down physician compensation by ten percent for its Medi-Cal program. This of course is the service that a million previously uninsured Californians will have to sign up for once ObamaCare kicks in full force in 2014.

While this calamity is happening to the medical community, what is the state doing about it? They are suddenly spending money like a new mega lottery winner, which in a way is what California's government bodies have discovered. Our elected representatives have realized that there is more money in the pot than what they've been used to for the last half decade. So now it's party time like it's 1999. Future busts be damned.

Thanks to the higher tax rates this year California has a small budget surplus. Because more of my income is being taken by the government, the governor and state legislature think they are the smartest kids in class when they can pass a budget that is not marked in red ink. Now they feel they deserve a raise. The state has just granted itself raises along with increased health care benefits. So really through no action of their own, the increased confiscation of my hard earned money has allowed our politicians to give themselves a little gift. In the meantime my reimbursements are being cut even while the same politicians are driving thousands of new patients into my practice. Talk about nice work if you can get it.

The Los Angeles Unified school district also can't wait to get its hands on the new money. They have just decided to give every single student in the school district an iPad. The cost is $678 per tablet. The district serves almost 700,000 students. The pilot cost for this program is $30 million but once all the students have one, along with various support and maintenance expenses, the final bill will be in the hundreds of millions of dollars.

Seriously? For that kind of money, the school district could easily higher more teachers to lessen classroom crowding. Heck they could even build a brand new school with that. That thought of thousands of students traipsing all around Los Angeles carrying expensive electronics is terrifying. New York City is suffering a crime spree thanks to thefts of the iPhone. What's going to happen when vulnerable students are targeted by thiefs as they carry their iPads to and from home? This could be the biggest opportunity of all time for eBay and Craigslist users.

That's not even considering the thousands of tablets that will have to be replaced due to carelessness. Have these school board members never seen what children can do to school property? And who is going to pay to keep these iPads upgraded. Buying desktop computers is easy since they don't need to be upgraded so often. iPads are updated every year. Who wants to own an iPad that is even three years old? Their depreciation are even worse than cars. Is the school going to keep buying new iPads as another model is introduced? Would it be fair for the some kids to get newer models while others are stuck with the older ones? And what ever happened to funding programs that really have shown benefits to children? You know, like music and the arts? Have we all bowed down to the deity of Apple Inc. and offered our children and cash as sacrifice?

Is it any wonder people don't trust government with their tax dollars? As soon as the money is collected, it is spent. The list of needs is endless. But the resources are finite, unless you can convince the proletariat to keep voting against their employers. California better keep showing those promotional commercials of sunny beaches if it hopes to convince people to move here and give up their money.

Sunday, June 16, 2013

Drug Labels Shouldn't Be This Confusing

Our hospital, like most hospitals, shops around for the cheapest vendors for our necessities. That's why generic supplies, everything from oxygen masks to anesthesia circuits to generic drugs, can change from month to month. Most of the time there is little difference in products between the companies, such as endotracheal tubes that are essentially identical yet can save the hospital a few pennies by going to a different vendor.

A couple of weeks ago, the vascular surgeon asked for 5,000 units of heparin to be given to my patient on the O.R. table. I immediately reached for the heparin section of the anesthesia cart. It felt different from the heparin we were using before. It appeared like we had found another vendor to supply our heparin now. When I grabbed the bottle, I stopped and took a second look at the label. Yes it was clearly marked "heparin". But what caught my eyes was the dosage in bold number under the name. At first the only thing I saw was "10,000". Holy crap, did somebody stock my cart with the 10,000 units/mL concentration of heparin? This is not a minor issue as heparin comes in different concentrations. Many doctors here know of the unfortunate incident a few years ago when a Hollywood celebrity's newborn children were accidentally given a massive overdose of heparin in a local hospital because the wrong concentration was supplied in the nurses' drug cart and nobody bothered to read the label when it was given to the patients.

Staying calm, I kept focusing on the drug label. Sure enough, in small lettering under the "10,000" was the actual concentration of heparin inside, 1,000 units/mL. The 10,000 units referred to the entire contents of the bottle, which was 10 mL. But you had to rotate the bottle slightly to get to the part about the 10 mL that was contained within. Assured, I gave the patient his 5,000 units of heparin.

I don't understand why this drug company, ahem Hospira, would put at the top of its label the entire quantity of drug within the bottle. That is not how we work. It's comparable to buying a car advertised as getting 600 miles per tank of gas when what we want to know is it gets 30 miles per gallon. We don't need to know that there are 10,000 units of heparin inside the bottle. We always calculate how much drugs to give based on its concentration per mL.

For instance, these labels on the propofol and atropine bottles got it right. Immediately under the names of the drugs, in large lettering, are the concentrations of the drugs in mg/mL. I don't need to know that there are 8 mg of atropine in the bottle. I'm unlikely to give an entire bottle of atropine to the patient. I just need to know how much is in each mL I inject.

To any drug company presidents out there that may be reading this. Please take a close look at the labels you put on your products. Even though all of us should double check the information before we give it to the patient, it would really help us out if we could get the vital facts as quickly and accurately as possible. We have enough trouble as it is differentiating the myriad of drugs in our carts. Any assistance that can be given to improve patient safety would be greatly appreciated.

Monday, June 10, 2013

When Do We Get Protection From Medical Malpractice Trolls?

Dear President Obama,

It is admirable that you have decided to do something about the proliferation of frivolous patent lawsuits brought on by so called "patent trolls". These suits cost companies billions of dollars to defend each year and stifle technologic innovation. However, if you could be so kind as to extend your generosity, you will find that medical doctors too face similar litigation from trolls. If you replace the word "patent" with "medical malpractice," you will see that these abusers of the courts are just two sides of the same coin.

For instance, one of your proposals is to indemnify users of a disputed patent. Those tricky lawyers have been going after small businesses and individuals who are unknowingly using products where there is a contested patent. The attorneys figure it is easier to get small settlements from multiple individuals than it is to extract a large reward from a well armed Fortune 500 company. The same problems afflict the medical community. Whenever there is a recall of a defective medical device, the lawyers are out in force suing everybody who has ever laid a finger on the product, from the manufacturer to the hospitals to the physicians who innocently implanted the flawed equipment. We did not design the product. We did not make the product. We did not advertise for the product. Yet if there is a problem, we get a subpena delivered to our offices as we are dragged into another malpractice case. And unfortunately all too often the insurance companies will make a settlement rather than go through a protracted lawsuit. The malpractice troll wins again and lives another day to sue more innocent victims. This doesn't seem fair, does it?

Another one of your ideas to discourage patent trolls is to follow the English rule for collecting attorney fees. In other words, loser pays. That's a plan that physicians have been requesting for years. Most of these trolls, I mean ambulance chasers, I mean medical malpractice attorneys work on a contingency basis. They don't have much to lose by litigating knowing that they only have to pay their own expenses if they fail in court but hope to collect so much more from the defendants if they should prevail. Under the English rule, the winning defendants can demand that the plaintiffs pay all legal costs of both sides, thus putting a little more pressure on trolls to bring justifiable cases to court. If the administration can see the logic of protecting the technology business from frivolous lawsuits by imposing the English rule, doesn't it make sense to do the same for the health care industry which makes up 17% of the country's GDP?

So please President Obama, you haven't shown much love to the doctors who are going to be at the vanguard of the millions of new patients you have shoehorned into the Affordable Care Act. Your legacy with the ACA will live or die by how well we treat all those people in our overcrowded and overbooked offices and hospital beds. However, if you expand your protection of innocent victims to include medical malpractice defendants, I think there is a good chance you will be under the good graces of the medical community again.

Yours truly,

Is Direct Laryngoscopy Obsolete?

Anesthesiology is all about safety. Ever since William Morton first publicly demonstrated how anesthesia allowed surgeons to operate safely on a patient, our whole raison d'etre has been about how we can make sure patients survive their operations safely and with minimal discomfort. To that end we've coducted endless research on improving the safety profile of the drugs and equipment we use. The human body's physiologic adaptations to anesthesia have been analyzed down to individual molecular changes. It's the reason the ASA keep statistics on closed claims cases to help understand why cases don't go as planned. The attention to safety is so pervasive in our practices that sometimes I wonder if the ASA should adopt the Trojan condom as our mascot.

As a consequence of our pursuit of the perfect anesthesia, our work has constantly evolved. For decades physicians placed central lines based on anatomic landmarks such as the location of a pulse or the angle of a needle relative to the ipsilateral nipple. Though mostly effective, it was not guaranteed. All sorts of books have been written about the complications of central line placements, from pneumothorax to accidental arterial punctures. Now the standard of care is the ultrasound guided line placement. Even though I've placed hundreds of central lines the old way, our hospital doesn't allow that anymore. These days if you didn't use the ultrasound and you get a complication, you don't have a defense to fall back on.

Regional blocks have also advanced beyond its crude anatomic origins. Some anesthesiologists have made careers out of drawing the perfect intersection of disparate bony prominences to identify where nerves can be most easily and consistently anesthetized. That too is slowly fading into a distant memory as the ultrasound has gained importance. With that visual aid, the chances of a failed block, nerve damage, or arterial injections are much less likely.

Is the direct laryngoscopy the next entity to join ether and the copper kettle into the dustbins of anesthesia history? Some people may scoff at that notion. Many anesthesiologists take great pride in their ability to intubate almost anybody. But let's face it, there will always be a patient where direct laryngoscopy is challenging even for the most skilled physician. Today, whenever one of our colleagues encounters a difficult airway, the first thing that is requested is no longer a different laryngoscope blade or even the fiberoptic; it is the video laryngoscope. Video laryngoscopy has proven itself multiple times at preventing a difficult airway from becoming an emergency airway.

Objections might be raised about the cost of equipping each operating room with a VL machine. But how much does it cost to buy one when compared to the potential catastrophe of a failed airway? American medicine has always advocated the use of equipment that makes patient safety a priority regardless of cost. Examples include the previously mentioned ultrasound or laparoscopic surgery or CT imaging to diagnose appendicitis.

It's true that studies have shown that it takes longer to intubate a patient with a VL. However the VL greatly improves the visualization of the vocal cords and cuts in half the chances of a failed intubation. Isn't that the kind of safety record that all of us would be interested in seeing in our daily work?

I know that I've derided fellow anesthesiologists who have difficulty using a DL and resort to VL or fiberoptic routinely. However if the VL is the must have equipment for an unexpected difficult airway, why not just make it the standard for any airway? Why worry about waiting for somebody to rush to the equipment room to fetch a VL if it is urgently needed when by using a VL all the time the fear is eliminated? The ASA should probably look into the video laryngoscope as the next standard for best practices in anesthesia, the way they advocated the capnography and pulse oximetry as standards. How many emergent cricothyrotomies or anoxic brain injuries can be prevented with VL will be difficult to quantify. But if it prevents even one from occurring, isn't it worth it?

Friday, June 7, 2013

Anesthesiologists Are Not Physicians. My EMR Says So.

The other day I happened to glance at the computer screen of the circulating nurse in the operating room. She was entering information for a case and was on the page that listed the personnel that were in the room. Typically, the EMR asks for the names of the surgeons, the nurses, the surgical tech, etc. I couldn't help but notice that anesthesiologists have their own category.

Hmm. Is the computer implying that anesthesiologists are not physicians? Why do anesthesiologists have a different line at all? The Physician lines make no distinction between attending surgeons, assistant surgeons, or surgical residents. Isn't that just as important to know when it comes to documenting who was working in the OR? Shouldn't there be a separate line for "Attending Surgeon", "Assistant Surgeon", and "Surgical Resident"? If our computer system doesn't really care about categorizing the physicians in the room, then why does it break out anesthesiologists as being separate from other physicians?

Also, why are we placed way down at the bottom of the list? Are we not deserving of a spot higher up on the screen? Instead our names are to be entered after all the nurses and just before the technologists. I say the EMR is dissing the anesthesia profession. I need to talk to our IT guys and give them an earful about the great medical field of anesthesiology. I guess I should just be thankful they used "Anesthesiologist" instead of just "Anesthesia". That would really raise my hackles.

Wednesday, June 5, 2013

The Latest Villain Causing America's Exorbitant Health Care Bill Is The Colonoscopy?

Here we go again with the media, another expose for why medical costs are so high in this country. Earlier this year, Time magazine blamed expensive health care on hospitals and their trumped up, rarely enforced, charge master prices. They detailed a conspiracy theory of hospitals, doctors, and pharmaceutical companies all working in collusion to rip off the Americans and send this country to the poorhouse.

Now the New York Times has written an inflammatory story about the abuse that seem to permeate the health care industry. Under the headline, "The $2.7 Trillion Medical Bill" is the sensational subtitle, "Colonoscopies Explain Why U.S. Leads the World in Health Expenditures." Really? The humble little colonoscopy is the root cause of why the U.S. spends trillions of dollars on medical care? That seems to be quite a stretch.

I'm not going to go into the merits of the article and all its finger pointing. The gist of the story implies that greedy gastroenterologists have built these fabulously lucrative ambulatory surgery centers that can charge patients more for an endoscopic procedure than if it is done in a doctor's office. The newspaper also couldn't help dragging anesthesiologists into this tawdry state of affair by stating anesthesia really isn't necessary at all for a colonoscopy. We are only doing it for the money. Blah blah blah. That discussion has been ongoing since the invention of endoscopies so I'm not going to go into any more details. If you want to read the numerous posts this blog has done about anesthesiologists and endoscopies, just type "GI anesthesia" in the search bar on the right side of this page.

No, what caught my eye about this extensive piece of yellow journalism is one of the subjects who is profiled. In the very first paragraph, the paper talks about Ms. Deirdre Yapalater. She had just had her colonoscopy at a surgery center and was shocked to discover that the procedure cost $6,385. Further down the lengthy article (her story is scatterly randomly throughout) we find out that the cost was broken into $1,075 for the gastroenterologist, $2,400 for the anesthesiologist, and $2,910 for the facility fee. She had no complaints about the facility, calling it, "very fancy, with nurses and ORs. It felt like you were in a hospital."

The story reveals that she never wondered what the cost of the colonscopy was going to be when she scheduled it. She felt that since the insurance company was going to pay for it, why should she bother? It turns out she has quite a comprehensive health insurance plan. Though the newspaper describes her family as frugal, with stacks of water bottles piled up around the house with its dilapidated dining room wall paper and an anecdote about her desire to save on a $130 copayment for a dermatology medication, her family appears to have quite a Cadillac health plan. Their health insurance costs $35,000 per year, of which they have to pay $15,000. That is a huge chunk of change for an insurance plan. It's no wonder she didn't worry about the cost of the procedure beforehand. Her insurance is so comprehensive it pretty much pays everything, sparing her the need to further investigate costs. She paid absolutely nothing for her colonoscopy.

To me that is one of the reasons why we spend trillions of dollars on health care. When somebody else is paying for it, why bother shopping around? Imagine if the government or insurance companies bought everybody cars and all we had to do was contribute a small copay. Of course we would all want the best and most expensive care available, regardless of cost. Heck somebody else is paying for it. Why can't I have the best car in the world? Why can't my 92 year old grandmother have that Rolls Royce? I will sue if she gets a cheaper car and something goes wrong because nobody should be treated less than somebody else.

So now Ms. Yapalater is "stunned" that her procedure costs over $6,000. She laments, "You keep thinking it's free. We call it free, but of course it's not." Hello. why does she think medical care is free? Does she expect her food from the grocery store to be free? The gasoline in her two SUV's? Her summer vacation home on Fire Island? Yet somehow she gets it into her head that health care should be free for all. Now she's upset that her insurance premiums are going up by double digits every year.

No I don't blame the life saving colonoscopy for the entirety of America's health care woes. I do blame people who get it into their skulls that health care should be free for everybody. That nobody wants to pay for it even though everybody wants the best quality care available. And if it is not the best or there is an unanticipated outcome they will call the lawyers. But of course the newspapers can't write stories that might insult their readers. It is so much easier to put the blame on doctors and hospitals who can't truthfully speak their minds about what they think is raising health costs. But I just did.

Tuesday, June 4, 2013

Calls May Suck, But Anesthesiologists Still Come Out Ahead

As I said before, taking calls suck. There is no nicer way of putting it. The lack of sleep, the disruption of your normal circadian rhythm, the randomness of the cases, and the high risks of treating emergency patients all make overnight calls one of the most hated experiences of being a doctor. However, most doctors do get compensated for working at night. According to a survey conducted by the Medical Group Management Association, more and more doctors are now getting paid to carry a pager overnight.

For the first time, over half of primary care doctors now receive compensation for calls, compared to 43% back in 2011. This compares to surgical specialists where over 80% get paid to take calls. The on call pay for PCP's also went up by almost seven percent to $250 per night. The specialists pay decreased during that time to $900 per night.

Doctors used to take calls as part of their work duties. They were rarely compensated. But now most physicians despise doing it. As medical students and residents become accustomed to doing shift work as part of their training, this trend away from calls will likely accelerate. Consequently hospitals have to pay doctors more money to entice them to work off hours. Otherwise they cannot consider themselves twenty four hour full service facilities.

What about anesthesiologists? We've been doing shift work and treating patients at all hours since the dawn of the profession. According to MGMA, anesthesiologists' median on call compensation in 2012 was $2,400. Assuming a 12 hour, 7:00 PM-7:00AM shift, that is $200 per hour. Compare that to PCP's who get $20 per hour and surgeons who pull in less than $80 per hour.

But of course anesthesiologists work much harder on call. While we're at the hospital, we're busy watching OB patients and fetal heart monitors, emergently intubating crashing patients on the floor, and frantically sustaining trauma patients on the OR table. Meanwhile the other doctors are answering the phone calls of emergency physicians from the comfort of their beds. Do they deserve any more money for merely giving verbal orders for admissions to the hospitalist? Even though we make more money than other doctors while on call, I dare say we totally deserve it.