Saturday, May 30, 2015

Preaching To The Choir

There are some scientific papers out there that are so original and groundbreaking that they change the paradigm of science and medicine as we know it. Think about Watson and Crick's discovery of DNA or Marshall and Warren's description of H. pylori. These are truly revolutionary research that changed the course of medicine and well deserving of their Nobel prizes. This paper presented at the recent Digestive Disease Week, the preeminent GI conference in the country, isn't one of them however.

Presented at DDW by Dr. Otto Lin from the Virginia Mason Medical Center in Seattle, the study compared the effectiveness of the Sedasys system of propofol infusion with moderate sedation that GI docs normally administer. The Sedasys patients were first given 50-100 mcg of fentanyl followed by propofol infusion from the machine. The control group of patients received only midazolam and fentanyl. A total of 1,466 patients participated in the study. Of those, 1,013 underwent a colonoscopy, 285 had EGD's, and the rest had both.

So how did the robots do? According to Dr. Lin, the patients and physicians very much preferred propofol over the simple cocktail of Versed and fentanyl. Patients went to sleep faster, woke up quicker, and had better retention of facts after the procedure. Patients reported less pain during the procedure and less grogginess afterwards. However their overall satisfaction between the two modalities was not statistically different. Nine patients reportedly suffered laryngospasm that required mask ventilation to break. There were also cases of agitation and discomfort attributed to "monitoring" issues. Dr. Lin's team was so confident about Sedasys that they even started using the machine for off label uses such as complex colon polypectomies and endoscopic ultrasounds. However they didn't have enough numbers of those complicated cases to make any recommendations.

The researchers and GI docs present at the meeting hailed this paper as strong proof that propofol given by a machine is as safe and effective as one administered by an anesthesiologist. Naturally the GI audience in attendance would only see the results that were trumpeted by their GI colleagues instead of noticing the obvious and serious flaws in the study.

First of all, the study authors compared the use of propofol against a standard cocktail of Versed and fentanyl. That is hardly original work. There have been numerous papers detailing the superiority of propofol sedation against a combination of benzos and narcotics in GI procedures. It is well known that patients wake up faster, feel less confused afterwards, have superior amnesia of the procedure, and are able to leave the recovery room faster. So none of this paper's results are surprising. What they should have used as a control was propofol when given by an anesthesiologist to see if those criteria are any different when matched up against Sedasys. With this fundamental flaw in the study, the paper is essentially meaningless.

Then there is the question of the nine cases of laryngospasm among their patients. Nine episodes of laryngospasm seems excessive to me. The numbers sound even worse when one considers that the laryngospasms probably occurred within the 285 patients who underwent EGD's, not the 1,013 cases of colonoscopies. So nine patients with airway obstruction severe enough to recover positive mask ventilation is a very high rate of this complication.

I also wonder who provided the mask ventilation to break the laryngospasm. Was it the gastroenterologist? Would he have just dropped his scope in the middle of the case to run to the head of the bed to slap the mask on the patient? Was it the GI nurse who probably hadn't masked a patient since her last ACLS course a couple of years earlier? Or did they have to emergently scream for help from the nearest anesthesia provider to rescue their patient before they died on the procedure room table? My guess is that it was the latter since the GI knows that no anesthesiologist would willingly turn away from a patient whom they have never met or discussed the risks and complications of receiving propofol but is willing to help their fellow human being from dying of a needless complication of incompetent sedation.

So yeah the GI docs love the results of this "study" on the effectiveness of Sedasys. It tells them exactly what they wanted to hear. But with an estimated seven million EGD's performed in the U.S. each year, that translates to nearly 25,000 cases of laryngospasm and airway emergencies that require active intervention to keep the patient from dying if Sedasys is used for all of them. Those alarming numbers about Sedasys should be what concerns gastroenterologists and federal health regulators, not how much money they think they are saving from cutting out the anesthesiologists.

Friday, May 15, 2015

Today I'm Ashamed To Be A Republican

I normally consider myself a conservative Republican. My political sensibilities were informed during my formative years by the administration of great Californian, President Ronald Reagan. So it was with some dismay when I read about the political debate in the California Senate over a vaccine bill.

Because of the measles outbreak that occurred last winter at Disneyland, California is attempting to pass a bill that would eliminate personal and religious exemptions to children getting the MMR vaccine. The only excuse for not getting vaccinated would be if a physician states that the child is immunocompromised and can not tolerate the vaccine.

Thank goodness some sanity is returning to the vaccine debate. As you can imagine, hundreds of parents have been demonstrating in the state capitol over this proposal with their usual lame uninformed excuses of autism, personal choice, etc. So it was with sad disbelief when I saw the Republican members of the Senate side with these parents. Senate Republican leader Robert Huff says, "I don't believe the [measles] crisis we have seen rises to the level to give up the personal freedoms we enjoy in a free country." SB 277 passed through the Senate Committee by a vote of 25 to 10 with most Republicans voting no.

It saddens me as a conservative to see these Republican pander to the antivax crowd. They claim the bill will intrude on a parent's right to choose how to raise a child. Well, you know what a country where anybody can do as he pleases is called? It's called anarchy. A civilized country has to set limits on some personal freedoms in order to function. What if somebody decides they don't want to stop at a red light because it would interfere with how he wants to drive? Is it intruding on his personal driving habits even if it means a safer driving environment for everybody else on the road? Suppose I want to carry a gun on an airplane because I don't trust the government to keep me and my family safe? It's clear that if people feel they want to do something regardless of public safety in the name of personal choice, the country would quickly descend into chaos.

Besides, who do these California Republican Senators think they are trying to curry favors with? They must know that most of these anti vaccine parents are part of the limousine liberal establishment that are prevalent in LA's Westside and the San Francisco Bay area. These abortion loving, gun controlling, climate change evangelists will never side with Republican candidates no matter how many times they vote to allow parents to withhold vaccinations. If California Republican elected officials truly believe that personal choice takes precedence over the welfare of the general public, then maybe I need to renounce my GOP affiliation, as have the vast majority of the state's residents, and look elsewhere for intelligent political representation.

Tuesday, May 12, 2015

Waze Must Be Banned

How can one drive while looking at this screen?
Doctors have always been at the forefront of public health. We have strongly advocated for smoking cessation, low fat and low salt diets, and increased exercise. That's why we should also be more vocal about the scourge of distracted driving, and in this case, the fiendishly addictive nature of the smartphone app Waze.

For those who are unfamiliar with Waze, it is a navigation app that acts as a traffic monitor. Users of the program enter the condition of the traffic they are currently driving in which allows others to see how bad the road congestion is, thereby allowing them to bypass to a less congested path. This information is critical in densely trafficked cities like Los Angeles. Since users can also input various road hazards like police speed traps, it also allows scofflaws to avoid run ins with the law.

It is this active participation of its users that makes Waze dangerous to drivers. Users, myself included, are constantly looking at the phone to look for traffic congestion up ahead and away from the immediate surroundings. But to report the traffic conditions to Waze, the user must also enter the information, thus taking their eyes off the road. No matter how quickly they can press the simple icons in Waze to input the data, it is still taking their minds away from driving.

Waze compounds this problem by enticing its users to become even more diverted. Drivers get points for putting in road information. It becomes a game to see who can add more points to their total. Waze even offers little virtual candy points for consistent users. The more data they enter, the more points they get, and the more distracted driving is involved.

Since it is now a social media world, Waze also allows one to chat with other Waze users on the road. Now how can somebody drive properly if they are constantly seeking chat buddies nearby?

I know Waze tries to mitigate this problem by allowing the use of voice commands. But it has been shown that the imprecise nature of voice commands in noisy cars cause drivers to take their eyes off the road due to frustration with the system.

Many cities and states have banned the practice of texting and driving because it can be even more dangerous than drunken driving. With the increasing use of safety features like antilock brakes and airbags, automobile fatality rates have been trending down for years. Driving apps like Waze may cause an unfortunate reversal in this pattern. I personally vow to minimize the amount of time I spend on Waze, just as soon as I get my 25 candy points up ahead.

Monday, May 11, 2015

People Care More About White Teeth Than Their Grandparents

I received this junk mail in my mailbox the other day. It is an ad for a local dentistry office promoting some of its services. As you can see, dentists do a lot more these days besides root canals and teeth cleaning. What caught my eye is the only price listed on the whole sheet--$399 for one hour of teeth whitening. Wow, that seems like a lot of money for one hour of work. My teeth better look like the freaking surface of Hoth after they're done for that price.

Then I got to thinking about how much my services are worth. Do people value anesthesia as much as they do white teeth? To find out, I downloaded Medicare's physician payment worksheet, this one is for 2012. The worksheet has a list of all the procedures that were billed to Medicare and what the program actually paid out to physicians. Private insurance pay more to doctors than the government's Medicare program. However since each insurance company pays each doctor differently depending how their rates are negotiated, looking at Medicare data provides a more uniform look at how much money physicians are getting for performing certain services.

The results are quite sobering. Out of the thousands of payments Medicare made to anesthesiologists that year, only a little over 500 cases received more than $400. You may bill the feds $6,390 for giving anesthesia for a CABG on pump, but they will only reimburse you $376. Think you're going to get $4,384 for anesthesia on a carotid endarterectomy? Think again. Medicare thinks your time and malpractice risks are worth only $371.69. The list goes on and on. Spinal cord surgery? You: $3,498. Medicare: $357.40. Knee Arthroplasty? You: $3,991. Medicare: $349.82.

There are regional differences in how much Medicare compensates. But the prices between what anesthesiologists are asking for and what the program will pay just seem so out of sync that one has to wonder who determines these numbers to begin with? Are they merely pulled out of thin air? Magical thinking on the part of physicians? Perhaps doctors deliberately set their prices into the stratosphere in the hopes that private insurance will actually pay that much money. But how many anesthesiologists will hit the jackpot and actually receive the reimbursement that they asked for, like the $1,320 for a ten minute colonoscopy?

As the country's population continues to get older, more and more patients will be on Medicare. Don't forget the millions of people who are enrolled under Obamacare's expanded Medicaid program, which pays much less than even Medicare. Add in the stagnant physician wages that has been written into law under the AMA sponsored SGR fix, it's easy to see why doctors are pessimistic about the future of medicine in the U.S. Is it any wonder that the U.S. News and World Report recently ranked dentistry as the best health care job in the country over nurses and physicians? When people are willing to pay $399 out of their own pockets for white teeth but quibble over a $20 copay for life saving medicines, than you know it is time to get out of Dodge.

Sunday, May 10, 2015

What Do CRNA's Really Want?

Recently, a bill came up in the California legislature to allow the use of anesthesiologist assistants to practice in this state. Never heard of AA's? Anesthesiologist assistants have a Master of Science in Anesthesia degree and are licensed to work under the direct supervision of an anesthesiologist. They are currently allowed to work in 17 states and the District of Columbia. An AA graduates from training with a minimum of 2,000 hours of clinical work. There are currently about 1,700 AA's working in the country.

The California bill, AB 890, is sponsored by Democratic Assemblyman Sebastian Ridley-Thomas and the California Society of Anesthesiologists. Why does California, or any state, need AA's? To allow greater access to health care, of course. According to Dr. Paul Yost, president of the CSA, "So many more patients are entering the health system and more baby boomers will be needing care."

So who would oppose granting patients increased access to medical care? Ironically, it's CRNA's. Even though their political mantra has always been that CRNA's are needed because there are not enough anesthesiologists available for all the cases that need to be performed, they are angrily opposing the passage of AB 890. There is even an AA opposition letter that is circulating on the web that is very much a rough draft at the moment.

Why would CRNA's be against having more healthcare providers available to take care of patients? Just follow the money. AA's can do everything that CRNA's do, except they are under the supervision of an anesthesiologist. AA's don't have privileges to work independently and they have no desire to do so. They know they are not doctors and would rather have an MD take the responsibility of making critical decisions in patient care. They are here to help the anesthesiologist, not supplant them.

CRNA's, on the other hand, wish to act and be treated like physicians. They want to work without anesthesiologists looking over their shoulders, even though their level of training is far below what most anesthesiologists would consider adequate for independent practice. If AA's are allowed to work in the biggest state in the country, they will severely hinder the expansionist agenda of CRNA's. If anesthesiologist assistants can work the same cases as CRNA's, but with the built in safety net of an experienced anesthesiologist present, why wouldn't you want to hire more AA's? This is where the nurse anesthetists are going to have to show their true colors. Who are they really advocates for, patients or CRNA's?

What Is Wrong With This Picture?

Let's play a game of "What is wrong with this picture?" You know that game that is usually found in children's magazines where it asks the reader to identify all the things that could not possibly be correct in a drawing or photograph? The subject of our game is the cover of the latest issue of the ASA Newsletter, shown below.

First we have to make a couple of assumptions about this image. Since this is in the ASA Newsletter, we are going to assume that the person examining the patient is in fact a physician and an anesthesiologist. Who else could it be? A CRNA? A second assumption is that the patient is in an operating room or ICU environment, based on all the different pumps that can be seen in the background. Plus that's where you will find anesthesiologists working most of the time. So look at the picture really carefully and I'll give you the answers below.

1. Anesthesiologists don't wear a shirt and tie to examine patients. About 99% of the time we wear operating room scrubs because it is impossible to change in and out of street clothes between each case.

2. The doctor is touching the patient and her bed with his bare hands. Instant Joint Commission violation.

3. Anesthesiologists rarely use stethoscopes.

4. Maybe because of #3, this anesthesiologist obviously doesn't know how to use his stethoscope since he is listening to the patient over her hospital gown.

5. His hair is too perfectly coiffed to be a hard working anesthesiologist. Most anesthesiologists' hair are flattened from being tucked inside a surgical cap. Plus there is no telltale ring around the forehead where the cap rubs up against the scalp.

6. The patient looks much too healthy to be a typical hospital patient. Check out her alert, come hither eyes and pinkish flush of her cheeks. Not the usual ICU or OR gomer.

7. The monitor is not even on. How can the patient be in the ICU or OR with the monitors off?

8. There isn't a spaghetti tangle of wires draped all over the patient's torso from a properly monitored patient.

Did you get all that? Let me know if you spot any other inconsistencies with this badly staged picture of an anesthesiologist and his patient. One thing the cover does get accurately though--pretty young girls are always giving anesthesiologists that cute lovey-dovey stare while we examine them. NOT.

Sunday, May 3, 2015

From Horndog Doc To ISIS Propagandist

The popular image of the foreign members of the terrorist group ISIS is that of the disgruntled poorly educated westerner who is unattached to any family or significant others. Some have half jokingly suggested that if these young men would just find some girlfriends then they wouldn't have the desire to go off to the Middle East desert to wreak havoc.

Maybe that doesn't accurately describe all the ISIS anarchists. Say hello to Dr. Tareq Kamleh. Dr. Kamleh is an Australian pediatrician who trained at the Royal Adelaide Hospital before deciding that terrorism is the life for him. Funny thing though is that prior to seeking a life of depravity, Dr. Kamleh was voted the most sexually promiscuous intern at his hospital during training. For that, he received the Golden Speculum award in 2011.

The Australian Medical Association and the South Australian Salaried Medical Officers Association both consider the Golden Speculum a bit juvenile but not worthy of condemnation. Say Dr. David Pope, former president of the SASMOA, "It's purely done for their own's not a matter for the association. It is a matter for the medical students themselves."

After finishing his residency, Dr. Kamleh first worked at the Adelaide Women and Children's Hospital. As recently as late 2014, he was found working in Perth. He left Australia for Malaysia in March of this year. He then he popped up in an ISIS propaganda video extolling the virtues of the organization. He is seen handling neonates and urging more people to become jihadists. He has also changed his name to Abu Yusuf.

It is illegal under Australian law to join a terrorist organization. Though the Australian Medical Board has so far declined to deregister Dr. Kamleh as a physician, if he ever returns home he could face 25 years in prison.

Saturday, May 2, 2015

Fifty Shades Of Red

Dr. Edwin Perez
Oh wow. I don't even know how to begin this one. I saw this come across my Twitter feed today and it totally blew my mind. Dr. Edwin Perez, an anesthesiologist from Newark NJ, is seen participating in a sadomasochism party involving blood letting.

At an event called the Cirque de Plasir in Manhattan, Dr. Perez, acting as the dominant, is witnessed using what looks like an arterial line catheter to extract blood from his submissive and then spraying the fluid onto a white art canvas.

Dr. Perez tells the reporter that he and his partners don't do blood play only at S&M parties. They also perform the act in their private homes. He says everything is done under mutual consent and the girls even hang their bloody art work in their rooms.

Of course his professional life and private activities are totally separate. He compares his S&M participation to professional wrestling, "Like the don't try this at home. I just want to be treated like every other extreme performer. It just turns out that I have a day job." He says these parties always have "dungeon monitors" to make sure everybody is comfortable submitting to the different forms of masochistic play that are being administered.

When asked, the New Jersey Board of Medical Examiners say that what Dr. Perez does in his private life is not punishable, no matter how unsavory. Unless there is a specific work place complaint, he is free to do as he wishes outside the hospital.

Is it a coincidence that Dr. Perez is listed also as a pain physician? He certainly chose the right medical field to enter. With his extracurricular activities, if I wanted somebody to draw my ABG, he would probably be the first one I'd ask for.