Thursday, October 31, 2013

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.

Sunday, October 27, 2013

"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?

Saturday, October 26, 2013

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.

Monday, October 21, 2013

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.

Sunday, October 20, 2013

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 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 Harris, M.D.

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.

Friday, October 18, 2013

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

Thursday, October 17, 2013

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.

Sunday, October 13, 2013

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.

Saturday, October 12, 2013

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.

Friday, October 11, 2013

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.

Monday, October 7, 2013

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.

Thursday, October 3, 2013

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.

Wednesday, October 2, 2013

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.