Saturday, November 30, 2013

I Knew The ASA Is Just Another Money Making Enterprise

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

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

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

Thursday, November 21, 2013

The ABA Made Me Do It

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

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

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

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

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

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

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

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

Wednesday, November 20, 2013

Simple Test To Assess Physiologic Age

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

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

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

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

Tuesday, November 19, 2013

Anesthesiologists Are Tethered

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

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

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

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

Monday, November 18, 2013

The Most Important Thing Not Being Taught To Anesthesia Residents

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

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

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

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

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

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

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