Wednesday, December 31, 2014

The Decline Of Medical Neologism

Medicine has always been good at inventing new terms to describe the human condition. Traditionally the words were based on Greek and Latin roots. That's why we get words like "hypokalemia" that can still stump new medical students, National Spelling Bee contestants, and electronic medical record software engineers alike.

Later on, the French made their contributions to the medical dictionary with lyrical terms all their own. Phrases such as peau d'orange (to describe the orange peel looking skin of advanced breast cancer) and cri-du-chat (the crying cat sound a child makes when he or she suffers from chromosome 5p- syndrome) flummoxed our less savoir faire young doctors. However, they do make the speaker seem more sophisticated and worldly if he can easily slip French words into a medical conversation.

American medicine has been in ascendency for the last couple of centuries. Therefore it is appropriate that American English words (not equivalent to British English) would make its way into a doctor's dialogue. Unfortunately we have not been quite as creative at inventing new elegant sounding phrases like the French.

For instance, we have descriptions like "cobblestone" to characterize the look of the intestinal mucosa of a patient suffering from inflammatory bowel disease. Or we get a contribution from the uniquely American melting pot with a term like "schmutz" to represent nonspecific debris on the body. Descriptively accurate? Yes. But decidedly pedestrian.

All of which leads me to a head turning note I saw on a patient in our hospital computer. It would seem that despite millenia of development of medical terminology, some young doctors feel they have to come up with new words to truly chronicle the plight of their modern patients. Thus the appearance of the phrase "stably-sick".

Now some purists would say that doctors should never refer to patients as stable. Stables are where one beds down horses for the night. But since it has been universally used to refer to patients who are neither deteriorating nor improving, I'm not going to quibble with it. But then this doctor can't quite bring himself to say the patient is stable. The patient is also very ill as illustrated by the need for IV pressors to maintain blood pressure. So is the patient progressing or sinking? Hmm. Let's think about this for a minutes. Since we can't make up our minds, let's just mash two words together and broadcast to every doctor and nurse who reads this note that despite our years of medical training we are too indecisive to truly understand this patient's medical condition.

Maybe medical schools should include a semester of French as part of the curriculum. That way if these new doctors are going to start making up words and putting them into legal documents, they can at least sound educated, not like graduates from the generation that gave us "twerking".

Tuesday, December 2, 2014

"Studies Show We Are Just As Good As You." Anesthesiologist Vs. CRNA

It's a rare gloomy and rainy day here in Los Angeles. The patients are all running late because of the horrendous traffic that paralyzes the city every time a few raindrops slicken the roads. So I thought this is a good opportunity to have a few laughs while at work, especially if it is at somebody else's expense. Enjoy.

Monday, December 1, 2014

Evolution Of The Anesthesiologist

I saw this chart on the Facebook page of a British anesthesiologist (anaesthetist if you're speaking the Queen's tongue).There is only one thing wrong with this picture. Can you guess? There were no cavemen in 2,000 B.C. Everything else is about right.

Which Institution Is The First In The Country To Embrace Sedasys?

Though the Food and Drug Administration approved the use of Sedasys in 2013, it has taken a year for the first hospital to accept its use in a clinical setting. Sedasys is a computerized system that administers propofol autonomously without the presence of an anesthesiologist in the room. It was mired in regulatory limbo for years before the FDA, in extraordinary fashion, reversed its own earlier ruling and allowed it to go into the market, thus realizing most GI doctors' propofol fantasies.

The first medical center to embrace Sedasys has turned up in...Seattle, Virginia Mason to be exact. Otto Lin, M.D., the Director of Quality Improvements at Virginia Mason and also a gastroenterologist, proudly states that, "It really allows us to use propofol, which we believe is superior to midazolam and fentanyl, in outpatients without having the added cost of having the anesthesiologist administer the drug."

Quite frankly, unless the anesthesiologists at Virginia Mason are employed by the hospital, Dr. Lin and the other GI's who work there may have trouble finding any anesthesiologist to back them up when, not if, an airway emergency occurs. Any anesthesiologist knows that once he steps into that procedure room, or even if he is within earshot of the impending disaster behind that closed door, the liability for the airway catastrophe instantly shifts to the anesthesiologist and away from the GI doc. Do they expect anesthesiologists to rush into an unknown and unstable situation at any time and just perform an airway resuscitation on a complete stranger out of the charitable goodness of our hearts?

Anesthesia reimbursement for endoscopies have been steadily eroding anyway. Sedasys was approved by the FDA only for ASA 1 or 2 patients. Insurance companies have increasingly denied anesthesia payments for MAC administered to these relatively healthy patients. Therefore it probably isn't going to have a major effect on most anesthesiologists' incomes. Any anesthesiologist whose livelihood depends on giving anesthetics exclusively to ASA 1 or 2 endoscopy patients every single day probably isn't living up to the potential of his hard earned board certification and should probably move on to something more professionally fulfilling in his life.

So let's see what happens now that Sedasys has been unleashed out into the wild. Will the cost savings really justify its exclusion of the potentially life saving presence of a second physician in the room? Will gastroenterologists accept full responsibility for a patient's airway calamity or will they still attempt to push the job to any anesthesiologist that just happens to be walking past the endoscopy suite? Only time, and a few unfortunate complications and possibly deaths, will answer that question.

Sunday, November 30, 2014

Why Surgeons Can't Seem To Show Up On Time

We have been trying to understand the reasons why so many of our cases start late. Cases not starting on time is probably one of the chief complaints of surgeons, anesthesiologists, and patients. If we can solve this thorny issue, half the battles in the place would be taken care of.

Our surgery center has been focusing on the first case of the day since if the first case is delayed then the entire lineup in that room will also likely be late the rest of the day. Therefore, for the last year we have been keeping track of the reasons for the first case not getting into the procedure room on schedule.

After compiling the data, it will come as a surprise to virtually nobody that surgeons are one of the chief causes for delayed starts. The nurses have to clock in by a certain time so they are rarely late. The anesthesiologists have to get there early to set up their rooms. Consequently it is almost always the surgeons who are the source of the bottleneck.

We then wrote some gentle email reminders to the worst offenders to ask them to please show up on time so the whole day isn't ruined by their tardiness. Did we get any mea culpa's from these medical professionals? Were there any acts of contrition and promises to be more responsible in the future? Maybe in your wildest propofol dreams. Here are some examples of the responses we received from these doctors.

"We are not motivated to get there on time b/c it never runs on time.  My 7AM case started on Monday at 7:45 b/c my patient was held up in registration.  Why should I go out of my way to get there on time just to sit await and await."

This is clearly circular logic at its best, or worst. So this surgeon will routinely show up late for cases because his patients are not being properly instructed by his office to show up early so the voluminous paperwork can be completed in a timely manner. Even if the patient did get all the preop work finished on time, the surgeon likely won't be there anyway because in his mind the patient has probably been delayed by the system. So why should he be held accountable for the whole day running late?

"I, not being an IT person, takes me a very long time to get the attestation to get the H&P and all the requirements which I feel have no relevance to patient care and probably other doctors feel the same."

Meanwhile this surgeon is blaming our computer system for causing the cases to be delayed. Never mind that we have been using the system for over a year and almost all the other surgeons have long ago figured out how it works. He goes on to complain about the relevancy of the EMR to patient care which actually has nothing to do with the problem at hand. It's just another form of deflection and not taking responsibility for causing the main source of irritation to his fellow surgeons and their patients.

This is the kind of mentality anesthesiologists have to deal with every single day. We have to work with unreliable and immature egomaniacs who think nothing of meting out the blame to everybody but themselves. It's a wonder that these people ever graduated from elementary school.

Thursday, November 20, 2014

The Most Meaningful Job In Medicine Is...Not Anesthesiology

The website released an interactive chart on the most meaningful jobs in the country. They define meaningful as "Does your job make the world a better place?" Not surprisingly, Clergy came in as the most meaningful occupation one can attain. A full 97% of clergy reported that their work is meaningful, with 88% saying they have high job satisfaction. On the other hand, fast food cooks came in last, with only 22% saying they have a meaningful job and 45% reporting a high satisfaction.

While it's important to have a job that makes the world a better place like Clergy, maybe some of us prefer to have a high income AND a meaningful job--have our cake and eat it too. For that, you need to get your butt into medical school. Healthcare workers report the highest income and the highest meaningful numbers according to Payscale. On their chart, all the little yellow circles that are far to the right on the meaningful scale and trail up towards the top of the income scale are all healthcare providers. They include OB/GYN, Internal Medicine, Psychiatry, and Family Practice.

And ranked at the very top for medical workers are surgeons. Surgeons reported having the highest median income of all doctors. They arrive at a median income of $299,600 by including the salaries of high paying surgical fields like neurosurgery and orthopedics. About 94% of surgeons say their jobs are meaningful and 82% have a high job satisfaction. However, 79% say their jobs also come with high stress levels.

How do anesthesiologists compare on this chart? We come in at a very respectable number two. The reported median income is $291,300. Ninety-one percent of anesthesiologists say their jobs make the world a better place. Seventy-eight percent say they are highly satisfied with their jobs. Like surgeons, 79% of anesthesiologists report having a high level of stress at work.

So if you want to be poor and change the world, get yourself to theology school. If you want to be poor and inconsequential, apply to your local burger joint. If you want to be rich but unfulfilled, get yourself into law school (40% meaningful). If you want to have it all, be a doctor. But your mother already knew that didn't she when she made you apply to med school.

Sunday, November 16, 2014

When The Surgeon Asks For Cash...And Puts It In His Pockets

Here is some pretty contemptible news out of Torrance, CA. A young woman is suing her surgeon because he said her operation at a local hospital was not covered by insurance but if he paid her in cash he would do it at a surgery center that he co-owns. Sounds pretty shady, right?

Liza Lumanlan-Domingo had a fetal demise and needed to have the fetus removed. She is a nurse at Torrance Memorial Medical Center and asked for one of the staff surgeons, Dr. Steven Rosenberg, to do the procedure. Incredibly, Dr. Rosenberg told her that her insurance would not cover her surgery at her own hospital but he could do it at Pacific Coast Surgical Center, a facility in which he is part owner. Liza and her husband met Dr. Rosenberg at the surgery center at 7:00 AM on a Sunday and gave him $800 in cash which he puts into his pocket with no receipt returned.

She had her surgery the next day but started to bleed profusely. The surgeon asked her husband to run to the hospital pharmacy to buy $160 worth of medications that the outpatient facility did not carry. Eventually she needed to be transported by ambulance to Torrance Memorial for treatment where she stayed in the ICU for three days. Only later were they informed that her insurance would have covered her procedure at the hospital.

We hear these kinds of self-serving stories all the time. As more surgeons start building their own outpatient surgery centers, they siphon off the best patients from the very hospitals that they work in. Patients who have good health insurance or can afford cash are quickly whisked off to a posh aromatherapy infused ambulatory center while the Medicare/Medicaid/Uninsured patients are herded to the local hospital. Hospitals start losing money because of poor reimbursements while their staff physicians drive into the doctors parking lots in their Mercedes and Bentleys.

Should the couple have called the insurance company to question the denial of payments for treatment at the hospital that she works at? Perhaps. But maybe they were so emotionally distraught and they felt they had a surgeon whom they thought they could trust that they didn't want to go through the red tape of dealing with the insurance company. They just wanted to expedite the surgery for a quick closure.

One day, when all doctors in this country become government employees, these terrible stories of how avarice infected one of the most respected professions will serve as cautionary tales. We'll look back and wonder how we let the critical need for healthcare become a profit center that made a very few people very, very rich.

Friday, November 14, 2014

News Flash--Expanding Medicaid Enrollment Costs More Money

This story is both comic and tragic. State governments are now realizing that expanding the number of patients eligible for Medicaid is straining their budgets and the healthcare system. Hello! Obamacare allowed the states to expand their Medicaid eligibility rules to cover more people. Twenty seven states have done so. Now Medicaid covers 68 million people in this country while Medicare covers 53 million. In ten years it is projected Medicaid will be used by 93 million citizens. The Wall Street Journal has an article detailing the outcome of expanding Medicaid in New Mexico, the state with the highest proportion of Medicaid patients in the country.

Who will see all these patients? The primary care physicians who are expected to be the gatekeepers are already straining to keep up. Many have capped the number of Medicaid patients they will see in their practice. Dr. Holly Abernethy, a family practitioner in New Mexico, has to keep her Medicaid patients to less than 13% of her practice. Otherwise she will have to work a lot longer to keep her office from closing. As it is, she is making $150,000 per year.

In the meantime patients still need to be seen so they are gravitating to healthcare providers like nurse practioners. Jodi Padgett, an NP in New Mexico, has seen an influx of new Obamacare patients on Medicaid. She will accept up to 40% of her patients being on government insurance. She will be paid the same amount of money seeing a patient from Medicaid as Dr. Abernethy, about $80. Her income this year will be $130,000, almost the same as a medical doctor. But she too will eventually have to turn patients away to keep her business from bankruptcy.

Patients finally turn to the emergency room for their care when they run out of options. At a San Juan Regional Medical Center, ER usage is up about 9%. However, Obamacare cut back compensation to hospitals for uncompensated care, reasoning that more patients will have health insurance. This has decreased the government funding from $12 million to only $2 million. As a result, the local government has had to trim other programs like the local park and raise taxes.

The first hints of the consequences of Obamacare are now starting to trickle in. So far it doesn't look good. More patients have insurance but access to medical doctors may be limited. They may have to settle for being seen by nurse practitioners or physicians assistants. Hospitals are getting flooded by poorly paying patients while their funding gets chopped. Local governments have to raise taxes to make up for the lost revenue. And this is while the federal government is paying for 100% of the extra Medicaid expenses. What will happen in two years when the states will have to start paying for a portion of the Obamacare bill?

It's no wonder nearly half the states' governors have opted out of expanding Medicaid despite the federal government's enticement of 100% reimbursement. The crap is starting to hit the fan. Let these other states get splattered first with the excrement and see how they clean it up.

Thursday, November 13, 2014

When Male Chauvinism Turns Deadly

I've been following this horrible story out of India the last few days. Over a dozen women have died and dozens others become seriously ill after undergoing a tubal ligation, part of the government's attempt to rein in out of control birth rates in that developing nation.

Initially suspicion fell on the surgeon, Dr. R. K. Gupta. He reportedly performed 83 sterilization procedures in a span of six hours, though some witnesses claim it was as little as two hours. For all that work he received $100. That is a short day for him because he reportedly has done as many as 300 procedures in one day. The rules say no more than 30 sterilizations should be done at a time. However his breach of protocol didn't seem to affect his standing as the local government honored him last January for having performed 50,000 tubal ligations.

Patients describe the clinic as an assembly line. Each case was performed in a matter of minutes with only local anesthesia. There was little regard for patient discomfort. With such a fast turnover, there was little time for proper sterilization of the surgical instruments. Dr. Gupta reportedly dipped his equipment into a pool of disinfectant just long enough for one patient to be taken off the procedure table while another one was put on. While that may be the standard of care over there, that would be a "Saw" horror movie here in the U.S.

Now there are reports that other women have fallen sick after receiving sterilization. Fingers are now being pointed at possibly tainted samples of ciprofloxacin and ibuprofen that each woman is given after the surgery.

Regardless of the cause of these women dying after attempting to control their reproduction, it is very sad that so few Indian men will do the same thing. Up to 37% of Indian women have their tubes tied, the highest in the world, versus less than 1% of men with vasectomies. Vasectomy is a safe, outpatient procedure that really can be done in just a few minutes with a much lower risk for major complications like sepsis or organ injury. The Indian government even offers higher cash incentives for men to undergo sterilization. Men receive 2,000 rupees ($33) while women get $1,400 ($23) for going through a much riskier and invasive operation.

A husband of one of the victims was interviewed after receiving $3,300 as compensation from the state. He complained it will do him no good now as he has three children to take care of on his own. Perhaps he should have sucked it up as a man and gotten a vasectomy instead having his poor dead wife suffer because he couldn't bear the thought of having his scrotum cut.

The Most Self Loathing Anesthesiologist In The World

I usually don't like to comment on the opinions of other anesthesiologists, much less dump on them. After all their opinions are their own and why should I try to refute their beliefs. But I just read an opinion piece in the widely seen and respected site KevinMD. Written by Dr. Shirie Leng, it is so outrageous and preposterous that I felt I needed to make a counterpoint.

Titled, "Anesthesiologists have to start to truly care for patients," Dr. Leng, a former nurse, starts off by stating that anesthesiology is for people who don't like to relate with patients. She describes the interaction between a patient and an anesthesiologist as thus, "He reviews the information the surgeon and nurse have compiled in the patient’s chart. “Hi, How are you?  I’m your anesthesiologist.  Anything to eat or drink today?  Any problems with anesthesia in the past?  No? Great!  I’m going to put your IV in and then we’ll get going.”

I don't know about Dr. Leng, but my bedside manners are much friendlier and more refined than what she depicts. If that is how she talks to her patients, I wouldn't want her to be my anesthesiologist either. While my time with patients are constrained by necessity, that doesn't mean I can't have a meaningful exchange with them and their families. As a matter of fact I have patients who ask for me by name whenever they need to come back for another procedure. All good anesthesiologists have been blessed with the appreciation of grateful patients. Maybe Dr. Leng just hasn't had the privilege of being loved by her patients if she thinks that's how patients see us.

Naturally this drivel has generated quite a bit of publicity for herself, the way a bad wedding video can go viral for no other reason than that it was bad.  So she wrote a response post on her blog with a blatantly backhanded compliment of anesthesiologists. I'm not going to bother linking to that nonsense since I don't believe I want to give her any more exposure than she already has. But let's just say she doesn't appear to love any anesthesiologist except maybe herself and her anesthesiologist husband.

For any medical students out there contemplating anesthesiology, obviously don't believe everything you might read about this profession. Talk to an anesthesia attending that you respect and get their perspective. I bet he or she can regale you on how crucial a good anesthesiologist is for patient care. We truly save lives every day. As for me, I feel lucky every day that I work in a job I love. I wouldn't have it any other way.

Tuesday, November 11, 2014

What Really Happened At Yorkville Endoscopy?

The release of the Health Department's inquiry into the death of Joan Rivers has certainly shed some light on the event last August at Yorkville Endoscopy clinic. While the following is merely speculative, and we may never know exactly what occurred in that procedure room, we can certainly use some analysis of published data to try to draw a clearer timeline of what led up to her demise.

For months, most anesthesiologists, including myself, thought for sure that Ms. Rivers went into laryngospasm during the case. This is because most of us have seen it happen during a routine endoscopy. Then word came out that there was an ENT surgeon involved who may have been examining her vocal cords without prior consent to look for a source of her hoarse voice. This really put the laryngospasm theory into overdrive. We all slapped our foreheads with our palms and went "Duh! What do you expect will happen when you touch the cords during a sedation case?"

The official report from the Health Department doesn't paint such a clear cut picture. First of all, as it turns out, an anesthesiologist was present during the procedure. I guess Dr. Cohen will use an anesthesiologist for his VIP patients after all. The report also throws the whole laryngospasm theory in doubt. In the document, it helpfully lists Ms. Rivers' vital signs from preop up to when she went into cardiac arrest at five minute intervals. After looking at the data closely, it seems more likely she did not go into respiratory arrest at all before the cardiac arrest.

We know that she had perfectly normal vital signs in preop at 8:44 AM: BP 118/80, HR 62, O2 sat 100%. The patient went into the operating room at 9:00 AM. Then we get to see the vitals as they occurred during the procedure. 

9:12 AM: BP 117/60, HR 71, O2 sat 92%
9:16 AM: BP 92/54, HR 56, O2 sat 94%
9:21 AM: BP 89/44, HR 54, O2 sat 97%
9:26 AM: BP 84/40, HR 47, O2 sat 92%

The report does not indicate what time the procedure started. However it does say that Dr. Korovin started first with a nasolaryngoscopy before handing the patient over to Dr. Cohen for the EGD. The endoscope was removed from the patient at 9:28 at which time Dr. Korovin attempted to perform a second nasolaryngoscopy. At about 9:30 was when Code Blue was called.

So let's assume that the first VS was the baseline before the patient entered the room. Judging by the drop in blood pressure and oxygen saturation at 9:16, she had probably already started receiving some sedation with propofol. The electronic anesthesia record noted that propofol was given at the following times: 100 mg @ 9:21.45, 100 mg @ 9:21.46, 50 mg @ 9:21.48, and 50 mg @ 9:21.50. This is a total of 300 mg of propofol pushed in five seconds.

The anesthesiologist claims that those quantities are mistakes. The patient had only received 120 mg of propofol for the whole case, which she wrote in an addendum to the record later that day. She told the investigators that she accidentally double clicked the computer for the 100 mg boluses and really meant to click on 20 mg bolus instead of double clicking 50 mg boluses.

One thing about electronic medical records--just because you click on an event doesn't mean it actually happened at that time. You may have been too busy with your responsibilities before realizing you forgot to enter it on the computer. You then finally document it even though it happened a few minutes prior. Even though the anesthesiologist may appear to have first bolused the propofol at 9:21.45, it is conceivable that this was a slow bolus given over several minutes but not charted until that time. If we presume that the hypotension seen at 9:16 was already the beginning of the sedation, then the drug was not entered into the computer for five minutes. At that point the anesthesiologist documented 100 mg at 9:21 even though it may have been given over several prior minutes.

Why was her O2 sat only 92% at 9:12 even though the rest of her vitals were normal? This maybe an instance of bad oximetry data. There are many reasons for a sat monitor to pick up an erroneous reading. Perhaps her fingers were cold. Maybe she was shivering. Or maybe somebody was moving her arm. The computer will record whatever number it sees at a particular time without regard to its accuracy. It is up to the user to write a note explaining the false data in the record.

As the oxygen saturation started to drop during the procedure, the anesthesiologist says she turned up the oxygen flow and applied jaw thrust to open up the airways. The anesthesiologist's statement that she kept the O2 sat greater than 90% is true based on the recorded data. But unfortunately that was not Ms. Rivers' problem.

I've seen many laryngospasms during an endoscopy. On nearly all of them, the O2 saturation drops first because the patient can't pass any air. Then the body starts fighting like mad to open up the airways. This results in a severe tachycardia that doesn't slow down until the cords open up or the O2 sat drops so low that the heart becomes ischemic, leading to bradycardia, a most ominous sign.

But Ms. Rivers' problem doesn't seem to be hypoxia. Her sat never goes below 90. Instead we see hypotension and bradycardia first. This is most likely due to a depressed cardiac output. If the CO drops, the O2 saturation eventually falls too as the heart can't pump enough blood for adequate oxygen exchange in the lungs.

What could have caused her heart to fail? Right at the top of the list is propofol. That is why propofol is such a dangerous drug. If not used judiciously, it can cause severe cardiac depression and hypotension, sometimes fatally. In an elderly patient, the impaired heart function can be quite profound. While I want to give the anesthesiologist the benefit of the doubt and agree that she didn't give 300 mg of propofol to an 81 year old in a span of five seconds, which would no doubt lead to a catastrophic bottoming out of her blood pressure, even 100 mg of propofol if pushed too quickly can cause a severe decreased cardiac output.

Another possibility is a strong vasovagal reaction. This is especially true with something as stimulating as a laryngoscopy. If the patient is not sedated adequately, the stimulation from the procedure can cause the BP and HR to drop in some people. This usually goes away once the stimulant is removed by withdrawing the scope. Respiration again is not impaired but the sat may fall because of the decreased blood flow to the lungs and tissue.

Could she have suffered a pulmonary embolus? A PE can cause acute hypotension and bradycardia as the right heart workload suddenly increases. But a PE also usually causes severe hypoxemia, especially for one that leads to death like a saddle embolus. The medical examiner's report also failed to mention a PE as the cause of her death.

An acute myocardial infarction? Maybe. But it would be awfully coincidental for her to suffer an MI right at the time she was getting a procedure done, though it wouldn't be outside the realm of possibility.

If laryngospasm is no longer the likely cause of Ms. Rivers' death, it also explains why she had a hypoxic brain injury. It is easy enough to treat laryngospasm, especially with an anesthesiologist and an ENT surgeon at the bedside already. If it can't be broken with positive pressure ventilation, then give a muscle relaxant to open up the cords and intubate the patient. None of that should take so long as to cause brain ischemia. However if she had heart failure, the low cardiac output would starve the brain of oxygen leading to its death. She sent into cardiac arrest at 9:30 and was not fully resuscitated until 10:00. That is a full thirty minutes of suboptimal blood flow and oxygen exchange to the delicate brain tissue. Thus the brain dies.

Therefore the most likely reason that Ms. Rivers died that day was her heart failed. Either she went into such a severe vasovagal reaction during the laryngoscopy that they couldn't revive her heart or the anesthesiologist felt she needed to give so much sedation to perform the laryngoscopy (Anesthesia! The patient is moving!) that it irreversibly impaired her heart function.

That's just my two cents.

Joan Rivers. The Health Department Report Shows Major Violations.

New York's Health Department has released its findings on the events leading up to Joan Rivers' death at Yorkville Endoscopy last August. It gives a fascinating reading on how celebrity and unprofessional behavior of physicians can interfere with the best laid plans to protect patient safety.

Basically the report states that Yorkville Endoscopy failed in its responsibilities in these four areas:

1. Have a process in place to assure that only authorized personnel are permitted in the procedure room.
2. Have an effective process in place to assure that only credentialed physicians can perform procedures.
3. Ensure that informed consent is obtained for all procedures that will be performed and
4. Ensure a "Time-Out" (a preprocedure protocol for verification of the correct person, procedure, and site) was called to confirm each procedure to be performed.

Essentially, all these deficiencies point back directly at the ENT surgeon, Dr. Gwen Korovin. The report states that Dr. Lawrence Cohen, the gastroenterologist, wrote that Ms. Rivers needed an EGD to evaluate for gastric reflux and hoarseness in her voice. However, two nasolaryngoscopies were performed by Dr. Korovin, as confirmed by the anesthesiologist. The first one was performed before the endoscopy while the second one was done immediately afterwards. The Interim Medical Director and the Vice President of Clinical Operations both confirmed that Dr. Korovin had no privileges to perform procedures at Yorkville. Ouch.

The endoscopy technician said she had never seen Dr. Korovin before. During the Time Out, there was no mention of a nasolaryngoscopy to be performed on the patient. Dr. Korovin's role in the procedure room was not brought up during the Time Out. There was also no consent for Dr. Korovin to do a procedure or Ms. Rivers to have a laryngoscopy.

The report clearly documents the downward spiral that took place in the room. Ms. Rivers' baseline vital signs were: BP 118/80, HR 62, RR 16 O2 sat 100%. During the course of the procedure, the vitals steadily deteriorated:

9:12 AM: BP 117/60, HR 71, O2 sat 92%
9:16 AM: BP 92/54, HR 56, O2 sat 94%
9:21 AM: BP 89/44, HR 54, O2 sat 97%
9:26 AM: BP 84/40, HR 47, O2 sat 92%

Two minutes later, a Code Blue was called. Even the type of cardiac arrest is in dispute. One note, called the Cardiac Arrest Record, indicated that the patient became pulseless at 9:30. Meanwhile, a different page called the Endoscopy Code Blue Record said that the patient went into ventricular tachycardia with a pulse. In either case, there is no indication that she received the proper resuscitation protocol per ACLS.

Much of the events mentioned came from the GI tech and administration staff, as the physicians in the room have all essentially lawyered up and refused to give any incriminating statements. However the anesthesiologist was cited for two major violations. As part of her routine preop exam, she failed to mention the height and weight of Ms. Rivers. This could easily have led to an overdose of propofol if the correct weight is not used in calculating the rate the drug was given.

A second misstep was in the documentation of the drugs given during the procedure. In the computerized anesthesia record, the anesthesiologist said she gave a total of 300 mg of propofol. Yet in an addendum she said only 120 mg was given. When asked about this discrepancy, she said that she only administered a 100 mg bolus of propofol followed by a 20 mg bolus later. The computerized record showed she gave boluses of 100 mg, 100 mg, 50 mg, 50 mg all within five seconds of each other. Those other boluses, she said, were accidental double clicks on the computer for 100 mg. She couldn't explain how she double clicked 50 mg boluses when she claimed she only gave 20.

There are no statements made to the Health Department from the GI physician, Dr. Cohen, himself. I'm sure the anesthesiologist's statement that Dr. Cohen took a cell phone picture of the patient while she was asleep will not help his case. He probably has some very expensive lawyers right now telling him to just shut the f*** up for now.

What a tragic end to a brilliant comedic career.

Monday, November 10, 2014

Why Is The Doctor Testing Your Grandma For Ecstasy?

You want proof that medical schools are full of smart people? Just follow the money. The Wall Street Journal has a report out on the exploding growth in the number of drug tests being administered on Medicare patients. In 2012, the government healthcare program for the elderly spent $445 million on drug testing, up nearly 1,500% in five years.

Why is this happening? In the past, a doctor could bill Medicare $20 for each class of drug that was tested using a simple urine dipstick exam. Then four years ago, the feds thought they would try to save money by capping the total bill to $20 for each urine specimen. This didn't sit well with some physicians.

Doctors then figured out that Medicare doesn't put a limit on urine drug exams using more high tech equipment like mass spectrometry. Medicare allowed doctors to bill for each individual drug tested using the new machines. This turned into a goldmine for some enterprising physicians.

Dr. Robert Wadley of Raleigh, NC started a urine drug testing firm called AvuTox that used a mass spectrometer. Each drug that is screened is billed over $20 to Medicare. A standard panel that AvuTox offers consists of over 40 different substances tested. The tests included range from standard narcotics to ecstasy to PCP, which are rarely positive in patients over 65 years old. His average payment from Medicare in 2012 was $1,265. AvuTox received $7.3 million from the government, the tenth highest drug testing reimbursement in the country. Dr. Wadley was paid $1.4 million from the program for his own patients. "Urine drug testing is how I pay the bills," he admits.

AvuTox then parlayed it expertise in Medicare billing into a scheme for patients with regular health insurance. It offered its services to other doctors, who pay the company a flat fee. The physicians then bill the patient's insurance company for the tests and they get to keep the balance. On AvuTox's website, they claim doctors can make as much as an extra $96,000 per year. That claim has since been taken down once the media started asking about it.

Dr. Wadley states he is innocent. He says he had no idea he was doing more urine drug testing on the elderly than other doctors. He believes all the drug screens he performs and bills the government for are medically necessary to detect any drug abuse problems that aren't being picked up.

Some doctors even go so far as to cause the problem that they will eventually bill Medicare to detect and treat. Dr. Fathalla Mashali, a Massachusetts pain physician was the single highest recipient of Medicare money for urine drug screening in 2012--$2.8 million. Ironically he was also arrested by the FBI for Medicare fraud for prescribing narcotics to known drug users and not performing physical exams to document their need for pain meds.

Some doctors just get too greedy for their own good. But the government makes it so easy to do so, especially if you're smart enough to get into medical school.

How Much Money Does It Take To Buy Happiness?

Today's Wall Street Journal discusses how much money it takes for one to be happy. There's the usual platitudes about how money can't really buy happiness. However, a couple of charts that accompany the article belies the writer's point. One chart, shown above, correlates happiness levels with income. Not surprisingly the more money you make the happier you are. What's interesting is that at an income of greater than $500,000 per year, 100% of people are very happy with their lives. A second chart in the article that measures life satisfaction with income also shows that at greater than half a million dollars per year, 100% of the survey respondents were very satisfied.

So there you have it. All you need to be absolutely positively sure you'll be happy is to make $500,000 per year. That means all those neurosurgeons, interventional cardiologists, and spine surgeons should be golden. But since we anesthesiologists can see that many of them are not happy, that throws this whole study into the appropriate place where it belongs, in the round outbox sitting under my desk.

Sunday, November 9, 2014

Do Robots Make The Perfect Health Care Provider?

Did Disney animators create the perfect health care provider? In the movie "Big Hero 6", a big huggable robot named Baymax was created by his inventor to help diagnose and treat whatever human ailments he finds.

He has all the qualities that many people say doctors and nurses should have but are usually lacking. He comes running as soon as he hears sounds of distress, like "ouch". He always has his patient's best interests at heart, refusing to leave until the sufferer has acknowledged his improved status. He possesses an infinitely vast wealth of medical knowledge. He is nonjudgemental. He doesn't ask for money. And the best part, with a quick change in programming, Baymax can become a kick ass, karate chopping, villain foiling, flying superhero. Wouldn't it be cool if doctors could do all that?

Some people would say that medical personnel in this country are almost like robots already but not in a good way. We increasingly rely on algorithms to manage our patients instead of using our judgement, or the art of medicine. Who reads textbooks anymore when we simply download the latest medical information on our smartphones from sites like Google and Up-To-Date? And many patients complain that doctors are so harried by their overbooked schedules that they show the same empathy as humanoids.

So perhaps this movie is just a sign of the frustrations that people have with their current providers. This fantasy is what many people wished their doctors should be but aren't. Maybe there is a take home lesson in this film if we are willing to accept our own shortcomings.

By the way, the movie is awesome. Disney did not pay me to shill for them, but I wouldn't mind it if they did. Hello Robert Iger?

Why You Can't Rely On TV Reporters For Medical News

I learned of a new heart rhythm the other day. I had never encountered it in my cardiac physiology classes or subsequent CME courses. A local Los Angeles TV station aired a heart rending story about the death of a 90 year old former nurse due to a pharmacy error. The reporter said she was receiving diltiazem to treat her "atrial fibulation." Hmm. I wonder if there is some sort of connection between the nurse's heart and her lower leg. Also if you watch the video clip, you will hear the reporter pronounce diltiazem as "dil-tee-azem" instead of "dil-tie-azem". So don't be surprised if patients come to your office pronouncing their medication the wrong way.

Saturday, November 8, 2014

The Focus On Patient Safety Pays Off For Anesthesiologists

The ASA Committee on Professional Liability has released its latest finding on malpractice insurance premiums for anesthesiologists. And the news is good. Anesthesiologists have not paid such low premiums for insurance in decades. The survey by the ASA was based on numbers from 25 medical liability companies that collectively cover 16,000 anesthesiologists, or a quarter of the U.S. anesthesia population.

As you can see from the chart, the numbers continue to fall, following the same trend from the past several years. These premiums are for $1 million/$3 million policies. In other words, $1 million payout per claim and up to 3 claims per year. The 2014 average premium is only $17,845 compared to $26,665 ten years ago. These numbers are dwarfed by the confiscatory premium rate of $40,028 thirty years ago, when the specialty was in the midst of a malpractice insurance crisis.

These numbers are just averages. They vary significantly by geographic location, rural/urban divide, and age of the physician. Anesthesiologists who practice in Florida, Illinois, and Washington, D.C. pay the most, averaging over $30,000 per year. Midwestern anesthesiologists in states like Iowa, Minnesota, Nebraska, and Wisconsin pay the least, with average premiums of less than $10,000. That's just another reason why anesthesiologists should move away from the blue coastal states to the more physician friendly Midwest.

If you're a pain management doctor, the news isn't as good. The average premium for pain doctors is $20,130. However that is still down about eight percent compared to last year. Pain physicians have consistently paid about ten percent more than regular anesthesiologists through the years.

Why are anesthesiologists' malpractice premiums falling? My guess is that our specialty's strong emphasis on patient safety has decreased the likelihood that patients will find fault with our work as the basis for a lawsuit. This is unlike the call for expediency and profits practiced in other fields like gastroenterology. The GI docs are paying the price for being so rapacious. Their average malpractice premiums have actually gone up, rising from $17,900 in 2011 to $20,000 in 2012. If I were a GI physician, I would seriously question my society's constant downplay of the role anesthesiologists can play in allowing them to perform a safe endoscopy on their patients. Looks like the insurance numbers are not in their favor.

So keep up the good work, my fellow anesthesiologists. Though patients may not fully comprehend the magnitude of our involvement in guiding them through a safe operation, the green eyeshaded accountants at the nation's malpractice insurance companies do.

Why Is Goldman Sachs Interested In Anesthesia?

Did you know that anesthesia is a growing market? The field currently has about $12 billion dollars in sales. It is projected to grow at a 9.5% annual rate over the next several years, reaching sales of $19.6 billion dollars by 2018. That rate of expansion puts such venerable growth companies like Coca Cola (6.22%) and Proctor & Gamble (8.05%) to shame.

What's driving this enviable growth? Demographics plays a part. As the U.S. population ages, people will need more operations for their various ailments such as cataract and orthopedic surgeries. But another major contribution is the much derided Obamacare. When millions of people gain health insurance, they are suddenly able to afford the procedures they have been putting off, like screening colonoscopies and hernia operations. So more anesthesia providers will be needed to perform these operations.

Herein lies the opportunities that have been keeping major bankers and private equity firms busy. Anesthesia in the U.S. is very fragmented. There are hundreds of different anesthesia groups practicing all over the country. However, they are slowly and inexorably being subsumed into large geographically diverse anesthesia groups in order to compete more effectively against the equally gigantic hospital and insurance companies.

This has led groups like Goldman Sachs (Resolute Anesthesia) and Moelis Capital Partners (North American Partners in Anesthesia) into buying anesthesia practices all over the country. There have been nearly one hundred acquisitions in the last five years worth billions of dollars as these investor spy an enormous opportunity to make money thanks to demographics and healthcare laws.

What do the doctors who sell their practices to these investors get out of the deal? For one, they will finally get a steady paycheck. Their incomes will no longer be at the mercy of stingy insurance companies, underpaying government entities, and unreliable patients. Somebody else will should all the risks of poor reimbursements. The doctors also won't have to deal with the headaches of byzantine government regulations and the escalating costs of maintaining a modern medical office. All the expenses of running a medical group will be borne by somebody else.

But passing the buck to a new employer carries its own costs. By selling out to large corporations, the anesthesiologists trade a higher but unpredictable income for a smaller but steadier salary with hopefully more benefits than what a small anesthesia group can afford. The buyout firms hope to make a profit by having a better position to negotiate favorable reimbursements with hospitals and insurance companies.

So for all you medical students who hope to one day have your own independent practice without anybody looking over your shoulder, I'm afraid it may already be too late. Your medical degree will only entitle you to join one of the thousands of physician minions in the country who toil for millionaire bankers, the true 1% of the nation.

Thursday, November 6, 2014

Celebrity Doctors And Their Celebrity Patients

The New York Times has a lengthy puff piece on the ENT surgeon who was present during Joan Rivers' final and fatal procedure, Gwen Korovin, M.D. Dr. Korovin graduated from Cornell then went to SUNY Syracuse for medical school. Upon graduation she did her residency in Manhattan's Lenox Hill Hospital. There, she was mentored by Dr. William Gould, an ENT physician with many celebrity patients. When Dr. Gould retired, Dr. Korovin assumed his practice, retaining many of his famous clients.

Dr. Korovin was highly recommended among the rich and famous. She appeared to have treated everyone on Broadway for throat and sinus ailments. They all loved her. And she loved them back. She was glamorous in her own right, dressing in chic outfits that rivaled her patients and attending their red carpet premiers. Like a good concierge physician, she apparently could be reached at all times day or night by her patients. She received their loyalty when she confronted show producers and demanded they let the stars rest their voices instead going on. So much for the old show business ethos, "The show must go on."

The writer, who admits he has been Dr. Korovin's patient, name drops the doctor's patients throughout the article. Stars like Cher, Bruce Springsteen, Elvis Costello, Ariana Grande, and many others are mentioned. I wonder if all these people that are named gave the author permission to mention them as being patients of Dr. Korovin. If not, this is a huge HIPAA violation.

Perhaps it was these ongoing relationships with VIP patients that ultimately led to her downfall. She may have been just a bit too cocky as she breezed into Yorkville Endoscopy that fateful day last August to treat her good friend Ms. Rivers. She was so sure of her status that she couldn't even bother identifying herself to the staff at the surgery center, some of whom assumed she was the patient's makeup artist.

The coroner's report ultimately stated that Ms. Rivers died from an anoxic brain injury from a propofol sedation that was "a predictable complication of medical therapy." A doctor who has no credentials for working at a surgery center can just waltz in without any identification is a complication of medical therapy? When a doctor can perform a procedure that the patient may not have consented to is a complication of medical therapy? When a surgeon is so confident of her relationship with her patient that she can commit the atrocious act of taking a selfie with her phone while the patient is asleep under anesthesia is a complication of medical therapy? An ENT surgeon who is actually present in the operating room when a patient suffers laryngospasm but incredibly is unable to establish an emergency airway is a complication of medical therapy? Wow. Who paid off the coroner's office in New York?

Whether the doctor will be sued by Ms. Rivers' daughter for medical malpractice is still to be determined. But that is the life of a VIP doctor. Your mistakes are just as outsized as your patients.

Doctor, There Is A Hair In My Anesthetic

Ewww. A human hair was found stuck in the stopper of a Hospira produced bottle of local anesthetic. The company has voluntarily recalled the drug, which is a single dose, preservative free 1% lidocaine. They were distributed from May 2014 to June 2014 with an expiration date of April 1, 2016. The lot numbers are NDC 0409-4279-02, Lot 40-316-DK.

Says the FDA, "[if] the particulate breaks and pieces are able to pass through the intravenous catheter, injected particulate material may result in local inflammation, phlebitis and/or low-level allergic response to the particulate or microembolic effects." Gee no kidding.

Your Tax Dollars At Work--Free Anesthesia For Screening Colonoscopies.

The Centers For Medicare & Medicaid Services (CMS) finalized its physician fee schedule for 2015 and there was good news for anybody receiving Medicare. The government has decreed that Medicare recipients will not have to pay a dime for anesthesia services while getting a colonoscopy. No deductibles or copays will be charged. You can walk in with nothing but your Medicare card and receive free anesthesia.

You can thank the ASA for this freebie. Due to their vociferous lobbying, they urged the CMS to classify anesthesia services for colonoscopies as an essential benefit. In their strongly worded letter to the department, "Medicare should pay the anesthesia provider for the service; payment should not be conditioned on the presence or other specified diseases, conditions, or other diseases." Who could turn down a mandate like that?

So thank you, oh great ASA for providing us with more taxpayer money. I am curious though why your letter to the CMS uses the term "anesthesia provider" instead of "physician anesthesiologist" like you use for all your public statements. Don't tell me my membership dues are being used for you to lobby for the CRNA's to get their government handouts too.

Wednesday, November 5, 2014

Where Do CRNA's Make More Money Than Anesthesiologists?

In my last post I looked at the Rasmussen College's web tool for comparing the buying power of an anesthesiologist's income across different states. However, since the data is based on the government's Bureau of Labor Statistics, the site can also be used to compare the income of other jobs. Let's just randomly pick one now okay? How about...CRNA's.

Click to enlarge
You might think that the incomes of CRNA's and anesthesiologists would roughly parallel each other in each state. But this is clearly not the case. If we search under CRNA, it's easy to see how the rank of income levels is far different from physicians.

Whereas anesthesiologists' incomes for California, New York, and Illinois are clustered close to the bottom of the country according to the BLS, CRNA's working in those states rank much higher. In fact, California CRNA's make it into the top ten in the country in income for their profession.

If you then rank the incomes based on buying power, again the big blue states fall down the list due to their higher taxes and cost of living.

But if you look at the top of the rankings, Nevada and Wisconsin show substantial income and buying power. The average CRNA salary of $221,000 in Nevada translates to an equivalent of $225,000 when adjusted for cost of living. In Wisconsin, a $200,000 salary becomes $215,000 due to its extremely low cost of living.

How substantial is a cost of living adjusted salary of $215,000? In fact it is greater than the average adjusted income of anesthesiologists living in CT, IL, MD, DC, NJ, MA, CA, NY, and MS. These expensive (not counting Mississippi) coastal states pay their anesthesiologists less than CRNA's who reside in cheaper states like WI and NV. In addition, CRNA's in Nevada make competitive incomes, within $10,000, of anesthesiologists in these other states: MN, VT, WA, VA, DE, NH, CO, AK.

With all the extra liability and reimbursement issues that anesthesiologists face, it makes one wonder why we didn't just become nurse anesthetists. It's pretty clear from the government's own statistics that the income disparity hardly justifies the extra responsibilities of having an M.D. appended to the back of our names.

Where Should Anesthesiologists Live?

Where is the perfect place for anesthesiologists to practice? If all you care about is money, there is a new salary comparison tool to guide you. Using data from the federal government's Bureau of Labor Statistics, Rasmussen College has developed a website to compare the buying power of your salary across all fifty states.

Click to enlarge
I made a screen shot of the Rasmussen result for anesthesiologists. First a couple of quirks. The salaries for anesthesiologists that the BLS uses seem to be a lot lower than the Medscape survey of physician salaries released earlier this year. Medscape reported that anesthesiologists made on average $338,000 last year, while the BLS seem to list anesthesiologists as making only in the mid to low $200's. Because Medscape's survey is based on doctors self reporting their own incomes, there may be a bit of a bias towards high income earners being more eager to participate.

It's surprising that anesthesiologists in the big coastal states of New York and California make among the lowest incomes in the country, ranking only 47 and 48, respectively. Illinois, another big population state, did even worse coming in at 49 while the poorest state in the union, Mississippi, unsurprisingly offered the least amount of money for anesthesia services. In the graph I also highlighted the other populous states of Florida and Texas.

The interesting picture appears when these numbers take cost of living into account. The high tax and high cost states of CA and NY stay stuck at the bottom. IL, due to its lower cost of living, rises slightly in the rankings. TX rises due to its low tax environment while FL drops because of its higher cost of living compared to TX. The high income low tax states like Kansas increase their buying power even more. Is it any wonder doctors tend to skew conservative and Republican? While money is nice though, the Midwestern states don't get to celebrate Christmas like we do out here on the left coast.

Proposition 46 Fails In California! Because Doctors Don't Need No Stinking Oversight.

Hallelujah! The bitterly despised Proposition 46 here in California failed at the polls by a 2-1 margin yesterday. It would have raised the medical malpractice cap for pain and suffering here in the state from $250,000, which has been in effect since 1976, to $1.1 million, which is what the inflation adjusted number would have been. If malpractice lawyers can't make a viable business case from six figure payouts for representing their suffering clients, then they probably don't really care that much about these "victims" and really should go into a different legal field. Many doctors have to make a living with far less reimbursements than that.

Another provision of Prop 46 would have subjected physicians to random drug tests and testing after patient complications. This is patently silly. While drug testing maybe required for professional athletes, airline pilots, bus drivers, and other people, obviously citizens held in as high esteem as doctors would never abuse drugs and alcohol, do we?

So hats off to all the medical societies who spent our annual dues to protect us from urinating into a little cup. I'm glad our money has been put to good use, instead of spending it on hosting another luxurious conference in Hawaii.

Monday, November 3, 2014

Songs To Drive Your Surgeon Crazy

You know that tune you hear on the radio as you're driving in to work that you just can't get out of your head all day? Now somebody has conducted a survey to discover which songs are the catchiest of all time. The Museum of Science and Industry in Manchester, UK asked 12,000 visitors to its website to listen to snippets of the top 1,000 songs over the past seventy years. The participants were then asked how quickly they could identify a song.

Since this survey was done in the UK, it doesn't seem all that surprising that the Spice Girls' "Wannabe" came out on top, able to be identified in about 2.29 seconds. Second place went to Lou Bega's "Mambo No. 5" which was recognized in 2.48 seconds. Third was Survivor's "Eye of the Tiger" in 2.62 seconds. Go here to see the list of the top 20 catchiest songs in the survey.

Most of the survey participants must have been relatively young. I'm not sure many surgeons, especially the ones over 50, would be identify Hanson's "MMMbop" in 2.89 seconds. And I'm sure he would have you turn off your iPod if you tried. There are a couple of Elton John and Elvis Presley songs in the list that the more mature surgeons may be able to identify. But otherwise it looks like mainly the Gen Xers and above took part in the survey.

Frankly I don't think any of these songs are all that catchy. In my opinion, the tune that will stick to your brain and never let go was from the 1957 movie "The Bridge On The River Kwai." I dare you to play the video clip below. You'll be whistling the song until you want to tear your hair out.

Anesthesia Is Safer Than Ever.

Some great news was reported out of the ASA conference in New Orleans. Out of over three million anesthesia cases examined  between 2010 and 2013, which is about a quarter of all anesthesia procedures performed in the country, researchers found that anesthesia complications decreased from 11.8% to 4.8%. The risk of dying dropped to a tiny 0.03%

Forget the fears of having surgery on weekends or evening hours, at least as far as anesthesia risk is concerned. They found no evidence that anesthesia complications were any higher during a hospital's off hours than normal business hours.

Patients over fifty had the highest rate of adverse events. The most common minor complication was post operative nausea and vomiting, 35.53%. The most common major complication was medication error.

This is the kind of data that we anesthesiologists should be trumpeting every day to refute all the scary stories about anesthesia and anesthesiologists that pervade popular media. With the incredible strides our profession is making in patient safety, this information will make it even tougher for the ASA to prove that anesthesiologists provide a safer anesthetic than CRNA's. But at least they aren't declaring war on the nurses this year. Peace.

Is The Growth Of Epidural Steroid Injections A Consequence Of Too Many Pain Doctors?

The November issue of Anesthesiology has a devastating indictment of the common practice of epidural steroid injections for back pain. In a study out of Johns Hopkins, 59 patients with cervical radiculopathy received pain medicine plus physical therapy, 55 patients had epidural steroid injections, and 55 had a combination therapy.

One month after the beginning of the treatments, arm pain was no different between all three groups, suggesting a lack of effect. However, when measured three months out, the combination group appeared to show significant improvement, 56.9% compared to conservative treatment, 26.8%, and epidural injections alone, 36.7%.

In an editorial in the same issue, Dr. James Rathmell, a director for the American Board of Anesthesiology and is involved in the certification for Pain Medicine, notes that epidural steroid injections should never be the first line of treatment for neck and back pain. They should always be part of a combined therapy involving physical therapy, pharmaceuticals, and injections. The patient must also understand that epidural injections don't treat the underlying cause of the pain to begin with. It only potentially speeds up the recovery that would otherwise have taken place with conservative measures. While speeding up recovery sounds good, one must balance that with the potential complications of infection, wet tap, and potentially permanent nerve damage and death when receiving a needle in the back.

It is easy to see how the rise of Pain Medicine as a desirable subspecialty for anesthesiologists has led to an explosive growth in the use of epidural injections. In an accompanying graph, the number of physicians boarded in Pain Medicine has grown steadily every year, reaching about 5,000 in 2012.

At the same time, the number of injections performed have exploded, particularly for lumbar injections. Talk about a growth business, the quantity of lumbar and transforaminal injections have reached one million per year over the last decade. While not as parabolic, cervical injections have also inexorably risen.

Is this another case of too many doctors looking for a lucrative source of income? As we all know by now, insurance companies pay physicians much more for performing procedures than to sit and talk to their patients. If pain doctors followed best guidelines and simply prescribed drugs while coordinating with physical therapists and forgoing procedures, how would that undermine their plump incomes? They would be reduced to, shudder...internists. And NOBODY wants to be one of those nowadays.

Sunday, November 2, 2014

Anesthesia And Eye Injuries. The Latest Statistics

The current issue of the ASA Newsletter has an analysis from the Anesthesia Closed Claims Project database on the problem with eye injuries in anesthesia. The authors of the study focused on the years 1990-2012 in which there were 184 anesthesia claims during eye surgery.

The most common event during eye surgery that led to a malpractice lawsuit was needle injury to the globe in association with a regional block, which occurred in 29% of the claims. Fortunately, the claims rate for needle trauma have been decreasing due to the more widespread use of topical anesthesia, dropping from 37% in the 1990s to 19% in the last decade. Death during eye surgery was the second largest complaint, comprising 27% of claims. Other injuries, including difficult intubation, myocardial infarct, and poor ventilation, have held steady.

Eye surgery claims were more likely to lead to malpractice payments to plaintiffs, 68% compared to 54% for all other surgical anesthesia claims. The average payout was $205,000.

The most common eye injury when regional block is excluded was optic nerve injury which occurred in 38% of claims. Most of these injuries were related to spinal surgery. When it does occur, the effects are devastating, and it reflects in the claims payouts. It has risen from $129,400 twenty years ago to $429,000 recently. Due to this explosive rise in eye injury claims, the ASA issued a Practice Advisory for Perioperative Visual Loss Associated with Spine Surgery in 2006.

By contrast corneal abrasions have decreased in occurrence to only 18% of eye injury claims. Half of the claims resulted in payments to the plaintiff. The median payment was $12,000.

Go to the ASA Newsletter website for a lot more statistical information on this dreaded anesthesia complication.

Friday, October 31, 2014

When Are You Going To Die? There's An App For That.

Have you always wondered when you are going to die? Down to the last second? Now there is an app that will tell you. The Deadline app uses the iPhone's new Health app to collect your daily activities and calculates your life expectancy. It will even display your time left on Earth in the Notification Center. That way every time you pull down the screen to check your text messages you can also see how many days left you have to live. Isn't that information worth 99 cents?

All About That Bass? What About All That Diabetes And Cardiac Disease?

Yeah, my mama she told me don't worry about your size
She says, "Boys like a little more booty to hold at night."
"All About That Bass" by Meghan Trainor

From the Centers for Disease Control:

The Ebola Hysteria. Where Is The Next Ryan White?

The New York Times reports that the medical staff at Bellevue hospital who are treating Dr. Craig Spencer, the physician who contracted the Ebola virus while working in Africa for Doctors Without Borders, have been shunned and discriminated against throughout the city, even within their own hospital. Businesses have asked them to leave when they find out they are employees of Bellevue. Some nurses who moonlight at other facilities have been told their services would no longer be needed.

Unfortunately, this panic among the general population, and even within the medical community, has been promulgated by the clumsy handling of the issue by the government and specifically the Centers for Disease Control. On their very own website, the CDC states the Ebola virus can only be spread by direct contact. It is transmitted through body fluids or a needle puncture with a contaminated needle. It is NOT spread through the air, by water, or with handling of food. Yet this important information has not been aggressively emphasized as the government has pursued people all over the country who may have flown on a plane that on a previous flight had carried an Ebola positive patient with a very low grade fever. Their mandatory 21 day quarantine also reenforces in people's minds that Ebola is so easily transmittable and so deadly that even people who have tested negative for the virus need to be isolated even though they show no evidence of being infected.

If all of this sounds familiar, then you are right. Back in the early 1980's, America was caught up in another viral disease panic. Its name was HIV. Like Ebola, HIV is not spread through the air or drinking out of the same water fountain. It is now well known that HIV is only transmitted by body fluids or contaminated needles. But at that time, the government's mishandling of the situation led to massive discrimination against HIV patients.

HIV remained in the public conscious as a disease of the damned: the homosexuals, IV drug abusers, and the prostitutes. It was not until a young Ryan White from Indiana came along that put a personal face on the disease. Ryan was a boy with hemophilia. He caught the virus through a blood transfusion at a time when blood wasn't tested for HIV. He faced horrible and ignorant intolerance from children and adults alike. He was banned from attending school. Their family car was vandalized. Store clerks would throw change at his mother to avoid coming in contact with her hands.

Back then, HIV was much more prevalent than Ebola is now. People were familiar with the images of skeletonized HIV patients. There were hundreds of HIV patients in the big cities, making them easy fodder for the major TV news operations of the country. Yet it took the courage of one young man to finally make the country understand that a person who has contracted a disease should be treated with compassion, not as a pariah. With the help of the medical community and the government, people got educated on how HIV is really spread, not just basing their fears and rumors and hearsay.

Ebola is currently in that same early stage of awareness as HIV where people are more fearful of the unknown than the reality. Heaven forbid Ebola will one day reach the same prevalence as HIV. But if it does, we will at least have experienced a similar teaching moment to fall back on and not make the same mistakes all over again.

Thursday, October 30, 2014

Why Nurses Have Bigger Cojones Than Doctors

Physicians can be such wimps. You would think that a group of people as smart as doctors would be natural leaders in society when it comes to making medical decisions. Yet we are pushed around by lawyers and politicians with nary a complaint even though we furtively grouse about our predicaments behind the closed doors of doctors lounges. Meanwhile, when nurses feel they have been wronged, they let everybody know about it.

The latest example is Kaci Hickox, the nurse in Maine who had just returned from Sierra Leone after taking care of Ebola infected patients. The state wants her under "voluntary" quarantine for three weeks even though she has tested negative for the virus and exhibits no fever or other signs associated with the disease. Like a good New England rebel, she has defiantly resisted this rule, even riding her bicycle out in public. She claims it is unconstitutional for the state to keep her locked up in her home out of fear and without any evidence.

This follows the defiance of nurses at Brigham and Women's hospital in Boston (must be something about New England that breeds dissenters) who are suing the hospital over forced flu vaccinations. The hospital has called for termination of their jobs if they don't get the shot. The hospital is demanding the vaccinations despite the fact that there is little evidence the vaccine actually prevents the flu or that it is necessary for healthy young people. Besides the lack of efficacy, the vaccine has real potential complications that can lead to a lifetime of disability, like Guillain Barre.

Meanwhile doctors just complain to each other about how difficult our professional lives have become because our decisions are being made by others, usually not even in the medical field.  Instead of doing something about it, we, and our professional societies, continue to kowtow to sharper legal and political minds as we trudge through our daily grind.

Doctors should be leading the charge against mandatory quarantines where there is no evidence of illness. Physicians should be educating the public about why the flu vaccine may not actually prevent the flu and can lead to crippling illnesses. But we don't. How pathetic is that?

What Are The Most Common Anesthesia Complications?

Pardon the profusion of lists on this post but there are some really fascinating data here that every anesthesiologist should read. The Doctors Company, a national medical malpractice insurer, compiled a list of anesthesia claims between 2007 to 2012. A total of 607 cases were identified. Their most common anesthesia complications leading to claims were:

1. Teeth damage-20.8%
2. Death-18.3%
3. Nerve damage-13.5%
4. Organ damage-12.7%
5. Pain-10.9%
6. Cardiac arrest-10.7%

The most common allegations of malpractice against anesthesiologists were:

1. Improper performance of anesthesia procedure-25%
2. Tooth damage related to intubation and extubation-24%
3. Improper management of patient under anesthesia-19%
4. Failure to monitor patient's physiologic status-3%
5. Positioning-related-3%

And what are the improper performance of anesthesia procedures that people are suing for?

1. Injection of anesthesia into the spinal canal-37%
2. Intubation of respiratory tract-35%
3. Injection of anesthesia-peripheral nerve-20%
4. Injection of anesthesia-sympathetic nerve-3%
5. Nasopharyngeal intubation-2%

The average payout for anesthesia related complications was $309,066. That compares poorly with the average for all other physicians, which was only $291,000. However anesthesiologists are right in the middle of the pack in a list of other specialties. Pediatrics had the highest indemnity with well over $1 million while ENT had the least with under $200,000.

There is a lot more information from The Doctors Company study than is presented here.

Our Hospital's First Ebola (Computer) Virus Scare

Our hospital recorded its first ebola scare today. A woman came in for a routine outpatient procedure. She has been coming to us regularly for months so nobody was especially on guard about any potential health hazard with this lady.

When we opened her electronic medical record, a stunning display popped out. Right at the top of the page, in bold red background lettering, the computer had declared she was positive for the ebola virus. A minor panic nearly ensued as everybody started scrambling for protective gear and wondering how we would all get along as roommates for the next 21 days in quarantine.

Then cooler heads prevailed. A quick call to the IT department confirmed that this was an error. In fact, if we had looked up every patient that was in the hospital at the moment, they all had the same ebola warning. The department was inserting new programming into the system for the diagnosis of ebola, which didn't exist before. Somehow it had crossed over into the live system and infected every patient's chart (pun intended).

After that we all gave a big sigh of relief and laughed at the stupidity of IT. Now we can go back to ignoring the big bold warnings about our patients with MRSA, VRE, MDRO, etc...

Wednesday, October 29, 2014

Anesthesiologists Need To Work Out These Muscles

You know that tired feeling you get after a long day of intubating patients? That sore aching sensation in your lanryngoscope lifting arm that has you popping Advils by the mouthful by the afternoon? Well now somebody has gone ahead and determined which muscles are causing you so much grief.

A study in the British Journal of Anaesthesia has determined which muscle groups an anesthesiologist uses the most rigorously during intubations. They used a surface electormyograph to compare the muscle activity of ten anesthesiologists as they intubated a mannequin using either a Glidescope or a regular Macintosh blade.

They found that the Glidescope allowed for less muscle exertion compared to a Macintosh overall. But it was most significant in the anterior deltoid, posterior deltoid, upper trapezius, and brachioradialis.

So before the next time you start having tender and aching left sided upper body pain, you may want to ask your department to invest in a video intubation system. Or risk having an anesthesiologist file a disability claim against the group for not providing adequate equipment to do his job. Or maybe you just need to hit the gym more often you girlie man. Yah.