Sunday, December 31, 2017

Happy New Year!

Happy New Year Everybody!

May your 2018 be as joyful and prosperous as this past year!

Wednesday, December 20, 2017

Anesthesiologists Are The Most Unappreciated Physicians

Ever feel like anesthesiologists are not appreciated by patients or other hospital staff? At this time of year, the lack of recognition is particularly acute. While surgeons and internists receive gifts by the truckload, the anesthesiologist almost always receives nothing. Hell, even the nurses usually get some sort of card acknowledging their care while the patient was in the hospital. We just go on doing our routine and try to suppress our urge to scream at the top of our lungs, "I'm mad as hell and I'm not going to take it anymore!"

If you think this is an isolated feeling, now there is a book that recognizes this ingratitude. In, author David Zweig has written, "Invisibles: The Power of Anonymous Work In An Age of Relentless Self-Promotion." People with these kinds of under-appreciated jobs share three character traits: ambivalence toward recognition," "meticulousness," and "savoring of responsibility." He mentions several professions that work in the background but are essential for the ultimate success of the endeavor.

For instance, cinematographers of movies are frequently overshadowed by their more flamboyant directors. Structural engineers are essential in making sure buildings will remain intact under adverse conditions. Yet it is the architect who gains the most publicity for a building design. I'm sure you can name at least one famous architect, from Frank Lloyd Wright to I.M. Pei, but can you name their structural engineers?

Then there is the anesthesiologist. Always in the shadow of the surgeon, the anesthesiologist is never the doctor spotlighted in TV and movies. And if they are, it's usually as some drug addled addict endangering the patient until the surgeon comes to the rescue. As Dr. Alberto Scarmato told the author, "It's funny how on TV the surgeon is the leader of the OR, but in reality, during an emergency they're often the ones freaking out, looking to me for assurance."

So if you're the kind of person who always wants the limelight and accolades for your work, anesthesiology is not for you. We anesthesiologists are satisfied knowing we do our jobs well every day and our patients leave the operating room safely without any drama. Instead of seeking all the attention, we just console ourselves with the fact that we make more money than our general surgeons

Should Doctors Switch To A C Corporation?

The great tax reform bill has now passed Congress and is on its way to the White House for President Trump's signature. While it lowers taxes for nearly everybody, it left a lump of coal for so called pass through businesses who use an S corporation tax structure. Specifically it doesn't allow professionals like doctors, lawyers, and accountants to benefit from the lower corporate tax rates given to other businesses. This was a deliberate act by Congress since their feeling was that we're not really aiding the economy like a widget manufacturer does. Screw you Congressional Republicans.

However, the bill lowers the tax rate of C corporations down to 21%, same as other businesses that got the lower corporate tax rate. Since many physicians have structured themselves as S corporations, should they now switch to a C corp instead to capture the lower rate?

I find the nuances between an S corp and a C corp very confusing. I am no tax expert at all. I've never even tried to do my own taxes on TurboTax. Therefore I went to Google CPA and looked up several articles on this issue. I found the most helpful article in Accounting Today. The desktop website requires a free registration to read but surprisingly the mobile site is open. This is what I've learned.

An S corp pays its taxes on the owner's individual tax rate, which in high income professions is currently 39.6%. A C corp pays taxes using the corporate tax rate, which is 35%. When it pays dividends to its shareholders, the shareholder has to pay taxes on that, which is 20% plus Medicare taxes, another 3.8%. Now that we have the basics down, let's compare the tax implications for both structures.

If your S corp earns a profit of $1,000,000, the taxes on it is based on the owner's 39.6% rate which would leave a net income of $604,000. If it's a C corp, the $1,000,000 will pay a corporate tax of $350,000. The remaining profit of $650,000 is then paid out as a dividend to its shareholders, who pay a 23.8% tax, leaving $495,300. Clearly an S corporation is more advantageous prior to the tax changes.

Let's see what happens now with the new tax law going into effect. In the S corp, that $1,000,000 profit will pay the owner's individual tax rate of 37%, leaving them with a net profit of $630,000. So yes the law helps your income just a teeny little bit as Congress promised. If the physician decides to switch to a C corp, the $1,000,000 profit will pay a corporate tax of 21%, or $210,000, leaving $790,000 to distribute as dividends. The dividend is then taxed at the same 23.8% as before since Congress didn't change those laws. That will leave a net income of $602,000.

So if you were a C corp before, the new tax laws will give you a tremendous boost in your net income, over $100,000 per year in this hypothetical situation. However if you're currently an S corporation, the decrease in the top individual tax bracket helps offset the decreased corporate tax rate the C corp enjoys. The S corp still winds up with a higher net income.

One also has to consider any potential new changes in the tax laws in the future. As it stands now, these individual tax rates are set to expire in ten years, reverting back to the old brackets. Who knows what a future Congress will do to the corporate tax rates too even though it's written to be permanent. Congressional Democrats are already threatening to changes the tax laws again next year if they win Congressional majorities. You don't want to be writing new corporate books every year at the whim of Congress.

Now this is just the most basic calculation I gleaned from the internet. I'm sure there are hundreds of tax minutia that I haven't taken into account. That's why it's still important to consult your accountant or tax attorney before making any leap in your business structure. Good luck.

Tuesday, December 19, 2017

Star Wars: The Last Jedi Explained

Spoiler alert! Do not read any further if you haven't seen The Last Jedi and don't want to have any surprises revealed. If you don't really give a crap about Star Wars then there's no point in continuing this article either.

After watching The Last Jedi, were you confused by some of the plot turns? Was General Leia's ability to fly through space without any protective gear too much Guardians of the Galaxy for you? How did Luke send an avatar across lightyears of space to battle Kylo Ren? Was it really necessary to see Kylo without a shirt, the first time there was semi nudity in a Star Wars film? (Princess Leia's metal bikini in Return of the Jedi doesn't count.) I was certainly confounded by some of the scenes that I had just witnessed this past weekend at the movie theater. Well now the movie director explains some of his thinking in putting together this latest episode of the space saga.

The LA Times has a conversation with Rian Johnson, the director of the movie. In it, he reveals that there is a keeper of the Force lore at Lucas Films by the name of Pablo Hidalgo. Anytime the director needed one of the characters to stretch the capabilities of the Force, Hidalgo would be consulted. If he agreed that, yes Snoke can make a mental connection between two other people across space-time, then it could be added to the movie. Johnson also explains why Snoke, thought to be the new Emperor of the Dark Side, can be so easily and quickly killed off with barely a fight. And yes he talks about why it was necessary to see Kylo beefcake in the movie.

Check it out. Lots of questions are answered in the article.

Surgeon Attacks Nurse. Guess Who Is Fired?

A charge nurse in a Beverly Hills surgery center has sued her former employer for abuse suffered at the hands of a surgeon at the facility. Paula Rickey, a nurse at the 90210 Surgery Center in Beverly Hills, has sued Dr. Kerry Assil, an ophthalmologist at the ASC, and Cedars-Sinai Health Systems, the center's corporate affiliate, with battery, sexual harassment, and discrimination in LA County Superior Court.

The alleged incident took place July 17, 2017. On video surveillance, Dr. Assil can be seen walking behind Ms. Rickey and hitting her on the back of her head. He reported grabbed her arm and told her, "I know I can do this because I know you like the abuse."

When she complained to her supervisors, the incident was reviewed by the hospital's board of directors and she was moved to a different floor. Eventually she had her hours reduced and was soon let go. She claims that despite Dr. Assil's reputation for arrogance and philandering with female employees, he was the ASC's medical director and brought a lot of business to the office. Thus he barely received a wrist slap for his behavior. The fact that other people are seen in the video just walking by the two of them as if nothing has happened shows how chronic this behavior must have been in the operating rooms.

Dr. Assil is one of those celebrity physicians frequently found in Beverly Hills. They can be seen on daytime talk shows espousing their knowledge to a national audience while drumming up more business for themselves. They are unlikely to be sanctioned by a hospital board as long as they keep bringing in well paying patients. Sometimes even having cameras in the OR's are not enough to bring justice to those abused.

Monday, December 18, 2017

Image Makeover At The ASA

Ever wonder what they do over at the American Society of Anesthesiologists headquarters besides counting money from membership fees and organizing office staff birthday parties? Apparently they have been busy with a new project at rebranding the society's image. If you are an ASA member, you should have received an email from Dr. James Grant, the society's president, explaining their new project.

Dr. Grant explains that the previous logo for the ASA, an ECG rhythm that shows a normal QRS complex fading into asystole superimposed over an igloo like image, didn't really represent all the work that anesthesiologists do to improve safety. Plus the logo looked ugly on computer and phone screens.

Therefore they have designed four new logos and asked the membership to help them choose. The email has a link to the survey. Here are the choices in case you haven't had a chance to fill out the survey.
Right off the bat, personally I would eliminate the lighthouse logo. If you google "lighthouse logo," you will see dozens of companies with logos that look very similar to that image. Nothing about it says anesthesiologists other than anesthesiologists like to go out sailing on weekends in their yachts and know how to navigate around lighthouses.

The red molecular structure looks like the ASA is some sort of molecular chemistry organization. I'm not sure how it pertains to our goals for patient safety and advocacy. If the ASA wants people to think we are just a bunch of nerds, this would be it. Otherwise I'll pass.

The last two are a bit more difficult for me to decide because they're both more abstract. The two triangles pointing at each other looks like some sort of point-counterpoint forces butting up against each other. Surgeons vs anesthesiologist? Anesthesiologist vs CRNA? I see tension and conflict there, not cooperation for a common goal to protect patient health.

The last one is the most abstract. The first thing I thought of when I saw it was the movie "The Matrix". You know the scenes with the waterfall of green digital data? Yeah that's what those random lines and dots remind me of. There is nothing wrong with the ASA trying to associate itself with one of the coolest sci fi movies in the last twenty years. But the severity of the abstraction may leave many people scratching their heads.

That's my two cents on our choices for a new ASA logo. Take part in this great democracy of ours and fill out the survey. I'm curious what the final choice will turn out to be, or if they even stick with these four designs.

Sunday, December 17, 2017

Remembering To Count Our Blessings

At this time of the year, it's easy to forget how lucky we are to live in a developed Western country with all of its luxuries and amenities. We don't think twice about attending yet another office Christmas party or private dinner party and dumping the leftover food into the trash can. We vow we will control ourselves in the new year and make another feeble attempt to lose weight.

Yes it's easy to forget that there are millions, even billions, of people around the world who are not as fortunate as us. The New York Times has a heartbreaking front page story about the horror facing the population of Venezuela. Over there, children by the thousands are dying of malnutrition.

In a country that has one of the largest oil reserves in the world, gross mismanagement and neglect by their government has caused massive food shortages and hyperinflation. Prices are expected to rise over 2,000% next year. Soldiers are stationed outside food stores to prevent looting. Dumpster diving takes on a whole new meaning when a restaurant closes for the night and crowds of people scramble for food that are thrown away.

The government blames economic sanctions by the United States and other Western countries for their suffering. They have stopped releasing health statistics to mask the real trauma facing its citizens. The doctors are overwhelmed by the epidemic of malnutrition. Most hospitals have run out of basics like infant formula that might alleviate the hunger of the babies that are brought to their emergency rooms every day.

So as the holiday festivities continue, just remember that we in the U.S. and other First World countries are the luckiest people to have ever lived in the history of the human population. Though we get bombarded daily by the latest outrage emanating from politicians and celebrities, the situation can always get drastically worse far faster than anyone can imagine. Millions of people in the world are living that nightmare at this very moment.

Friday, December 15, 2017

My Mummified Hand

This is what happens to you when you're sitting in a cold operating room all day long. My hand looks like it's about 200 years old. The skin is all dry and cracked, occasionally bleeding through the cracks. Not only is the room extremely cold, causing vasoconstriction and poor perfusion of the skin, I'm also very dehydrated. When they made the rules about no food or beverages in the OR's, they didn't take into consideration the people who have to suffer under those rules. But what else is new? We're just here to work and do what we're told.

Besides the OR environment, other factors contributing to my advanced skin aging include the constant washing of our hands. The natural skin oils get washed away every time I clean them. Even when I put on skin lotion, it is gone after the next visit to the sink.

Then there is the Joint Commission requirement that we have to Purell our hands after every single encounter with a patient. This often leads to Purelling several times an hour. Since Purell is mainly alcohol based, it feels like rubbing ice on my hands each time.

Add in the really dry winter air in Los Angeles, which is currently contributing to our epidemic wildfires this season, and what you have is a perfect storm for drying out and mummifying my hands.

Would it really be so detrimental for the OR's to raise the room temperatures? Would patients really suffer massive infection complications if we brought a water bottle into the room? Can we ease off on the epidemiology gestapo who surreptitiously monitor our hand washing techniques? Show me proof that all these maneuvers actually contribute to decreasing patient infections and complications. Somehow I suspect there is no such data available. We just keep on doing what we're doing because that's what we were told. I went through years of college and medical school for this?

Anesthesiologists Are In Great Demand. Not!

Merritt Hawkins, a national physician recruiting and staffing firm, has a ringside seat to the physician jobs market. Their ability to recognize the need for doctors and capability of fulfilling those needs allows them to judge the market place better than most. The company has just published a white paper on what they see are the doctors who are most in demand at the moment.

Ranked by the percent of job openings relative to the total number of physicians in the field, MH has ranked Pulmonology as the most sought after medical field in the country. That is followed by Psychiatry, Dermatology, Family Medicine, and Neurology. What do those specialties have in common? They are either in primary care, which is always in demand, or in specialties with very low number of training programs, thus keeping their skills highly prized.

Where is Anesthesiology in this list? You'll have to look way, way, way down at the bottom of the graph.  According to Merritt Hawkins, compared to the total number of practicing anesthesiologists, the number of job openings is only 0.11%. So for every 1,000 anesthesiologists working, there is only one job opening. Just one. Anesthesiology have the fewest job openings relative to the number of practicing specialists of all medical doctors. We are ranked just above Physician Assistant and Nurse Practitioner.

Now these numbers sound a bit suspect. It's not plausible that out of 50,000 anesthesiologists that are in the ASA, there are only 50 job openings. Or is it? The anesthesia residency programs keep adding more new anesthesiologists every year, currently well over 1,000 each Match Day. And the numbers are still rising. By comparison there are a little over 500 Pulmonary fellowships offered each year. With the population rapidly aging and their complicated pulmonary issues, it's no wonder pulmonologists are being eagerly recruited. The only way for that many new anesthesiologists to find jobs is if nearly the same number of anesthesiologists start retiring each year.

Even if the absolute numbers are not entirely accurate, anesthesiology's ranking relative to other physicians should make any anesthesiologist pause. There are only so many surgery sites for anesthesiologists to work. With the constant encroachment of CRNA's, pretty soon we'll have to start competing with them directly for job openings. Will employers care that we have thousands of hours more training than the nurses or will they only look at the bottom line and lower the salary offered? In a true market economy, you already know the answer.

Thursday, December 14, 2017

Beverly Hills Anesthesiologist Charged With Murder

Shocking news. An anesthesiologist working at a plastic surgery center in Beverly Hills, CA has been charged with murder of his patient. Dr. Stephen Kyosung Kim was arrested for murder following the death of his patient, Dr. Mark Greenspan. Dr. Greenspan was undergoing surgery when the anesthesiologist reportedly gave him an overdose of Demerol. The patient suffered a cardiac arrest and died. What's even worse is that Dr. Kim was found to be injecting himself with narcotics during the procedure. Thus he was under the influence of drugs while he should have been watching over his patient.

News of physicians being charged with murder for their patients' deaths are extremely rare. They are usually accused of malpractice or negligence. For example, the anesthesiologist present when Joan Rivers died in New York was sued for malpractice, not murder.

Overdosing a patient and causing him to die is a pretty serious complication to begin with. But to also be under the influence of drugs at the same time makes this case almost indefensible. Dr. Kim has pleaded not guilty to his murder charge. We'll see if more details come out later at his trial.

Who Knew? Plants Are Affected By Anesthesia.

Testing anesthetics have always involved subjecting animals to the different compounds and watching its effects. Either using cute little dogs or helpless tiny rodents, animal experimentation have brought a bad reputation to medical science. Now scientists have discovered that plants may be a substitute test subject for new anesthetics.

In the Annals of Botany, European and Japanese scientists used anesthesia to alter the growth and motion of various plants. Some plants were placed in a sealed chamber with a flask of ether. Others had their roots soaked in lidocaine. What they found was quite amazing.

Venus flytraps no longer clamped shut when their trigger hairs were stimulated. Pea plants maintained their curls and wouldn't grow straight until after the anesthetics were removed. Mimosa plants lost their ability to shut their leaves when physically touched.

They were able to measure a decrease in the action potential in the venus flytraps with exposure to anesthesia. After the ether was removed, the action potentials returned within a few hours. The researchers found other abnormalities in the cellular components when the plants were exposed to anesthesia.

Since we still have no clear idea how anesthesia works, this discovery could open up more pathways to understanding how these chemicals affect us without actually subjecting us to experimentation.

Wednesday, December 13, 2017

#MeToo In Medicine

The proliferation of sexual assault and harassment stories that are pouring out of the news media is head spinning. Seems like half the front page of the New York Times is devoted to another sordid story about women being dehumanized by a male superior.

Though these headlines are just now making news because famous and powerful people are being named, unfortunately sexual assault is old news in the medical field. While doctors who are accused of sexual improprieties may not make national news, they are chronicled in the disciplinary actions of their state medical boards, which is public information.

The Medical Board of California publishes a quarterly newsletter of actions they've taken against physicians who have made questionable life choices or had severe run ins with the law. Here you'll find tales of drug abuse, fast money schemes, drunk driving, spousal abuse, and every other vice suffered by the rest of humanity.

Recently a plastic surgeon by the name of Gordon Roget, MD in Lodi, CA was brought to the Board's attention for sexual assault in 2015. This was a particularly sordid story of a vulnerable patient being helplessly assaulted by her doctor. Dr. Roget had a young woman who came to him for a labiaplasty. He kept asking her if she would like the procedure done under sedation. The patient said she wanted to be awake for it. Finally he relented and agreed to use local anesthetic only.

Without any female chaperones present, he placed her in stirrups and began the procedure. After he gave her the anesthetic, he put his fingers into her vagina with his face inches from her perineum. When she asked him if his fingers are supposed to be there, he asked, "You didn't like it?" He then stormed angrily out of the room and the patient heard noises like he was masturbating. She felt trapped in the room with an open wound and feet placed in a vulnerable position in the stirrups. When he came back, he hastily finished the procedure and told her to come back for a second procedure the following week. When she asked him to finish it all in one visit, he called her an "ungrateful bitch." She then got dressed and went to a local emergency room to have her wound properly treated. Dr. Roget lost his medical license in June 2017.

It is pathetic that doctors feel they can abuse their patients' trust just because they are in a supposed position of power. Who knows how many other female patients this plastic surgeon has abused. His words and actions suggest a pattern of behavior that has been well rehearsed. Let us clean up our own acts before the #MeToo movement focuses its unforgiving gaze on the house of medicine.

How Bad Is Your Anesthesia Residency?

You think your anesthesia residency is bad? Just remember that you're not the only one suffering through these tortured years of relentless training. In the UK, the Royal College of Anaesthetists conducted a survey of their country's anesthesia (anaesthesia?) residents. Based on over 2000 responses, this was their finding:

Over three fourths of British anesthesia residents say that their work has had a detrimental effect on their physical health. A majority also say it's had a negative effect on their well being and mental health too. That could be because almost two thirds have missed a meal while at work and three quarters run around feeling dehydrated all day.

When they do finally have a chance to go home, over half of the residents have experienced a car accident or a near miss. A vast majority have felt so exhausted after a night call that they couldn't drive home. Maybe that's because only a third of them have call rooms to sleep in when they're at the hospital and only 18% get more than 30 minutes of rest at night. Consequently the Royal College of Anaesthetists fear up to 85% of their residents have a high risk for burnout.

How does this compare to American residents? Medscape had a survey of residents on this side of the pond and the results are similar. While the Medscape poll is for all residents, not just anesthesia, they found that over 80% felt they didn't have enough time to maintain their health and well being and nearly half have depression some or almost all of the time.

It doesn't look like there is much difference in attitudes in residents all over the world. Just remember that this is only a short temporary phase in one's career and you've got to keep your eyes on the prize. At the end of the road is one of the best jobs in America.

Monday, December 11, 2017

Medical School Is For Chumps

This story makes you realize your parents are so 20th century when they advised you on going to medical school. A 6 year old boy makes an estimated $11 million from his YouTube videos. That's right. Eleven freaking million dollars. What does he do on these videos? Nothing more than toy and children's food reviews. He has ten million subscribers to his channel and has been successfully doing this for only two years. That's less time than it takes to finish med school.

So next time you finish that 36 hour shift and drag yourself home to finish more charting, remember that the future belongs to bitcoin and YouTube advertising revenue. Old fashioned hard work and education are for suckers.

Many Doctors Could Face A 100% Marginal Tax Rate

This is a truly terrifying finding in the Senate tax reform bill. Though this is only the Senate version and the final tax bill after reconciliation with the House plan could turn out to be very different, it's worth reading the fine print now.

According to analysis of the Senate bill, small business owners and people who make good money but are not the super rich could be on the hook for a marginal tax rate of greater than 100% on their income. What does that mean? It means that for every dollar you make over a certain tax threshold, you will owe more than one dollar to the government. That is literally the definition of a confiscatory tax rate.

How does something like that happen? It's rather complex and I haven't quite wrapped my head around it yet. That's why I have a CPA doing my taxes. First you have to be in a business that uses a pass through structure, like an S corporation, the way many small companies and physicians have their corporations set up. The special 23% rate for these corporations currently in the Senate bill slowly phases out after reaching an income of $624,000. Thus the corporation will face the full force of the top personal income tax bracket of 39%. Then if you live in a high tax state like the blue states on both coasts, the deduction for state and local taxes are going to be eliminated. Here in California the top tax bracket is 13.3%. After that various tax credits like the $2000 per child tax credits also phase out for high income earners. And don't forget to add the payroll tax such as Medicare. Voila. Pretty soon the most productive members of our profession are getting hit with taxes close to or greater than 100%.

While the majority of physicians don't make more than $625,000 per year, thousands of them do. The Senate bill is similar to the House version, which is biased against doctors with its refusal to grant a pass through tax cut for physicians. The House-Senate Joint Committee will be meeting this week to bring the two separate bills into agreement. They're hoping the final bill will be signed by President Trump before Christmas. It may be a very unmerry Christmas for many MDs this year.
I want pay more taxes.

Saturday, December 9, 2017

The Meandering Path To Anesthesiology

When I wrote about why I chose anesthesiology as a career a few years ago, I received a few criticisms from readers complaining that I didn't actually choose anesthesiology. Instead I had settled on the field after eliminating all the other possibilities. Did I really become an anesthesiologist because I liked it or was it because I didn't like anything else?

In this month's issue of the ASA Monitor, the editor, Dr. N. Martin Giesecke writes about how he became an anesthesiologist (membership required). His path to his career epiphany was very similar to mine. However he had a little head start down that path since his father was also an anesthesiologist. Yet as a medical student he experienced different medical fields that made him think about other possibilities but ultimately led him to his current profession.

Dr. Giesecke related his admiration for pediatrics. However he didn't have the stomach for taking care of so many small helpless patients. Then he did a rotation in surgery, his first choice in medical school. Though he contemplated going into plastic surgery, the environment he encountered was off putting. He was disgusted by the hostile work environment and mental and physical abuse of the trainees, students and residents alike. That story sounds very familiar.

As part of his surgery rotation, he also did a few weeks in anesthesiology. That's when he realized how awful the surgeons are to their underlings and to each other. Anesthesiology by comparison was pleasant and collegial yet still academic and patient oriented. It was easy to make a decision at that point.

So as you can see, there is not one track to becoming an anesthesiologist. Everybody has a different story on how they made their career choice. Very few people actually decide from day one they're going to become anesthesiologists and not alter their plans. And that's okay. It's like serial dating. You Tinder a few specialties and finally settle on the right one for you.

Friday, December 8, 2017

The Mystery Of Anesthesia

Modern medicine has allowed the humane treatment of patients for over a century now. Yet we still know very little about how it works inside the body. Just recently there was a new proposal on the mechanisms for propofol's remarkable ability to induce sleep. Now there is a new theory on how the volatile anesthetics work to induce anesthesia.

Anesthesiology News details a new study on the mysterious mechanism of gas anesthesia in the body. Though volatile anesthetics have been in use for over 150 years, we know very little about how it actually works. The current theory is that the molecules of gas become absorbed by the bilipid cell membrane of neurons which alters its ability to propagate electrical signals, thus inducing sleep. Now this new paper puts a question mark to that long standing premise.

Published in the Proceedings of the National Academy of Sciences, Dr. Karl Herold, chair of anesthesiology at New York Presbyterian/Weill Cornell Medicine, discovered that it may actually be cell membrane proteins such as ion channels altered by anesthesia that inhibit cell function instead of changes in the bilipid cell membrane. The researchers developed an artificial cell membrane with ion channels in place. Any change in the membrane would alter the flow of ions through the channels. When they immersed the model with therapeutic levels of volatile anesthetics, they discovered that there was not enough reshaping of the bilipid layer to cause inhibition of cell depolarization and signal propagation. Only at super therapeutic levels of anesthesia did they find a change in the cell membrane. Thus they theorize that it is unlikely that cell membrane changes are the source of anesthesia's effects on the human brain.

Though this study did not pinpoint an exact location for the mechanism of action of anesthetics, it at least disproved an old theory, which will allow researchers to move forward to find the real reason why we anesthesiologists can put patients to sleep, and perhaps someday develop even better anesthetics.

Is Anesthesiology Better Served By Having More Women?

The University of Wisconsin, Madison's Department of Anesthesiology has one of the most storied programs in American medical history. They were pioneers in the field during its infancy and invented practices that were eventually adopted by anesthesiologists all over the country and the world. Yet it is being brought low by accusations of bias against women.

The Wisconsin State Journal details the problems in the department that were brought up during a "climate review" after Dr. Robert Pearce, the former department chair, resigned last July. The report noted multiple grievances among the female staff. They described the atmosphere within the department as a "good-old boy network."

The male staff significantly outnumber the women who mostly work part time. The women felt belittled when the men told them they are less committed to their profession because they take more time off to take care of family. Many of the female anesthesiologists who work at the American Family Children's Hospital felt insulted when their workplace was described as "the crying hospital" or "candyland." Female residents were told not to "rock the boat." CRNA's felt they were not valued in the department.

Oy! These are a lot of complaints that really don't seem justified in this male blogger's point of view. First of all, so what if the men outnumber the women by two to one? Must every single job have an equal distribution of the sexes to make it free from discrimination and bias? The truth is one can be harassed whether one is in the majority or minority in a group. Plenty of men have felt they were treated unfairly in their jobs by their male colleagues or superiors.

Let's face the facts here about women who work part time yet expect the same respect at work as men. Yes it's admirable that they want to go home and take care of our children so that we can continue to work hard for the family. But don't expect to get equal pay or get invited to departmental committees if one has to leave by 3:00 PM every day to pick up the kids. It wouldn't be fair to the men who toil away 12 hours a day at their jobs. No disrespect but you can't expect to get the same appreciation from your colleagues if you're only working half the time as others. In fact many of the female anesthesiologists in our department want to work part time. Some even leave our group to work at other hospitals that allow even greater time flexibility. That is no stigma against their dedication to their jobs when they are at work.

The other complaints just seem silly. Calling a children's hospital a crying hospital or candyland doesn't sound insulting, it sounds appropriately descriptive. Describing it as such doesn't demean the people who work there. Stop being so sensitive. Female residents shouldn't rock the boat? Why would you want to? As a resident all I wanted to do was finish my training and get the hell out so I can start my practice. Why would I want to make my life more difficult than it already was as a resident? CRNA's who don't feel valued by the doctors in the department? If they want to feel valued then they need to go get a medical degree.

The department is rectifying the situation by appointing a new female interim chair, Dr. Aimee Becker. While I'm sure Dr. Becker is a fantastic anesthesiologist, I can't help but feel that this was a very political choice to deflect the uproar over the report. When can we get past the sexual politics and just hire the best people for the job without counting how many X chromosomes are in one's DNA?

Thursday, December 7, 2017

Seeing A Permanent Solar Eclipse

This past summer I got to witness one of the great natural wonders of the world, a total eclipse of the sun. It was one of those events that I have dreamed about my entire life. Though my view wasn't perfect due to heavy cloud cover that rolled in over our Midwestern location just as the eclipse took place, we got just enough clearing to see the corona. And to me that was a win. I will never forget the phenomenon and I hope my young son, who I brought along with me, will too.

Now there is an unfortunate woman in New York who may being seeing the solar eclipse forever, not just in her mind's eye, but permanently in her vision. An article in JAMA Ophthalmology written by solar retinopathy specialist Avnish Deobhakta (there really is such a sub subspecialty in ophtho?!), details the cautionary tale of this patient who was too eager to watch the eclipse without first getting the proper equipment.

The patient is a young woman in her 20's who decided she wanted to watch the eclipse at the last second. She stared at the blinding sun for about six seconds before she had to turn away. Then she decided to borrow a stranger's regular sunglasses and continued to stare at the partial eclipse for another 15-20 seconds. Within hours she was having visual difficulties.

When ophthalmologists examined her eyes with a special instrument that can see individual retinal cells, they found a perfectly shaped burn that corresponded to the partial eclipse she witnessed, including the crescent cutout made by the moon partially obstructing the sun. Six weeks later, she still has a hole in her vision where the retinal cells remain damaged.

Again this shows that one should pay heed to doctors' warnings. Physicians for weeks cautioned people to wear eclipse glasses or they could suffer permanent eye damage. Apparently some people just didn't get the message.

Wisconsin Anesthesiologist Retires After Inappropriate Behavior

Think physicians are all well educated and unlikely to conduct obviously inappropriate behavior in the operating room? Not a chance. This blog has documented several cases of anesthesiologists behaving badly in the OR, including here and here. I'm not even going to talk about the deranged anesthesiologist who attacked Senator Rand Paul a few weeks ago. In this atmosphere of heightened awareness of sexual harassment and unacceptable conduct, every person should know by now that witnesses are more willing than ever to report any actions that they deem improper.

However this didn't stop a University of Wisconsin anesthesiologist from being forced to resign for his conduct. Dr. Mark Schroeder, a senior anesthesiologist at UW, was reported by the staff for frequently positioning himself where he isn't supposed to be. A staff member since 1984, it was reported by nurses and other staff that he "likes to be at the 'bottom of the bed' and 'see parts of a patient that he does not need to see.'"

Dr. Schroeder was reprimanded by the hospital for "inappropriate interactions with employees and patients." When his case was brought to the Wisconsin Medical Examining Board, he offered to turn in his medical license and retire.

What an ignominious ending to a long career. The Wisconsin State Journal doesn't mention whether he stood at the foot of the bed only for female patients or male or both. But regardless, anybody who has ever worked in the operating room knows that anesthesiologists rarely make a trip below the shoulder. Other than for putting in arterial lines or a regional block, we rarely venture past the waistline of patients. So if this doctor was regularly wandering his way down there while all the patient's monitors are up at the head of the bed, people know immediately this is not normal behavior. In light of all the sexual accusations that populate headlines daily, any suspicious activity can be construed as deviant. So keep that ether screen up and stay on your side of the blood-brain barrier if you want to maintain your good reputation with the staff.

Wednesday, December 6, 2017

My Patients Have A Good Excuse For Being Late Today

This is what it's like to live in Los Angeles today. A major wildfire broke out early this morning next to the always busy 405 freeway, snarling traffic all over the Westside. It's unfortunate location was made worse by the fact it occurred at a particularly narrow portion of the freeway with steep cliffs on either side and no way to get off. Therefore the road was closed for miles before and after the fire. 

Since this is in the popular and tony Westside, many of our patients and hospital staff live in the area. Consequently doctors are late for their procedures, patients are cancelling cases because they're evacuating their homes, and generally the traffic in this entire area has come to a standstill. Isn't LA grand?

The Most Amazing Library I've Ever Seen

Ok, there are some pretty impressive libraries in the world. The Library of Congress and the New York Public Library are definitely iconic. But this new library in China is almost out of this world futuristic. The Tianjin Binhai library east of Beijing has a unique architecture that needs to be seen in pictures to be appreciated.

The undulating walls can hold 1.2 million books. Right now the shelves are not nearly that full. Many of the "books" on the walls are just images placed there on aluminum plates until real books are eventually stacked there. Still, it is a very awe inspiring design. Maybe if my alma mater can show me something like this when they ask me for donations I would give more money to their library fund.

Tuesday, December 5, 2017

Young Doctors Get More Patient Complaints

We could probably have deduced this one from experience. In a study published in JAMA Ophthalmology, researchers at Vanderbilt University have found that young physicians are much more likely to get complaints from patients than their older colleagues.

The retrospective paper looked at the experiences of 1342 ophthalmologists who practiced at Vanderbilt affiliated medical facilities. The ophthalmologists were grouped in cohorts of ten years of age, from 31-40 years old up to greater than 70 years old. Their records were reviewed from January 1, 2002 to December 31, 2015. The median age of the doctors was 47 years old.

The results showed that the two youngest cohorts were statistically more likely to hear complaints from their patients. The youngest group were 2.36 times more likely to get a complaint while the next youngest cohort had 1.73 times higher risk relative to their older physicians. The younger doctors also had patients who complained more quickly about their problems than the older ones.

The researchers conclude that their findings are consistent with the medical malpractice environment where physicians with less than 10 years of practice are more likely to get sued than their older partners. Their malpractice insurance cost the most until it tapers off when they hit their mid career years. The physicians halfway through their careers may feel social, professional, and family pressure to work harder and see more patients. This leads to greater risk of getting patient complaints. The late career physicians are the ones who survived the burnout and legal difficulties of their earlier years. These doctors have demonstrated the skills and composure to to survive in the medical field and thus should have the fewest patient complaints and lowest malpractice liability.

So for all you medical students and residents out there who see nothing but bleakness and despair for the foreseeable future. Yes it does get better, eventually. You'll just have to survive the first 20-30 years of medical practice then you're golden. Don't you feel better now?

A $500 Million Golden Parachute

The general public often complains that doctors make too much money. But we know who are actually raking in the dough in medicine. And they usually don't take care of any actual patients. A report in the Wall Street Journal discloses that the chief executive of health insurance company Aetna may walk away with $500 million if his company gets bought by pharmacy company CVS.

The money will come in the form of stock options and personal stock holdings. CEO Mark Bertolini will receive $85 million in exit pay for selling the company. If the deal settles for the reported $207 per share, he will also get $230 million in stock options and his Aetna stake would be worth another $190 million.

Think about that for a minute or ten. While doctors are getting vilified for earning a decent living after decades of education and toil, insurance executives are being given nine figure incomes and bonuses for maximizing shareholder profits by denying insurance coverage to patients and reducing reimbursements for physicians. If healthcare reform is to succeed in this country, the insurance company gatekeepers need to be removed so that all those billions of profits will be properly distributed to the patients and their caretakers. It's immoral that insurance companies stand in the way of doctors properly treating their patients while they keep most of the healthcare industry profits.

Monday, December 4, 2017

Remember When Masturbation Was Considered Shameful?

Why are so many men masturbating in front of unwilling participants? The act of masturbation used to be considered shameful. It has been used to great comic effect in movies and TV, in everything from "American Pie" to "Seinfeld." Who wouldn't want to be the master of his domain?

But now it seems that a remarkably large number of well to do men have been forcing their self love onto others as a form of harassment and abuse. Every day another high powered man is accused of or confesses to touching themselves in full view of reluctant colleagues. The latest ones to be charged with this act include the great music maestro James Levine and California Assemblyman Matt Dababneh. This follows the infamous actions of Louis C.K. and the man now synonymous with sexual harassment, Harvey Weinstein.

I know that doctors have been trying for years to reeducate people to make masturbation a less shameful act. It is a natural activity that should not cause embarrassment of its practitioners, which is virtually everybody. However, after all these revelations, I'm inclined to side with our less enlightened ancestors and punish people who can't keep their hands off themselves in front of others. Can you imagine if the victim was allowed to flog the perpetrator for their abusive acts as in the olden days? It would put a real quick end to all these disgusting displays of power and toxic masculinity. Keep it in your pants or take them out only when you have a consenting partner present. Nobody else cares to see how little you respect yourself or others.

Wednesday, November 29, 2017

Can You Be Too Old To Practice Medicine? There's An Answer For That.

Isn't this easier than paper charting?

New Hampshire physician Anna Konopka, MD  has had her state medical license revoked. After practicing for 55 years, the 84 year old doctor says she is not able to maintain electronic medical records as required by the medical board. She still writes out by hand her patient charts and keep them in file cabinets. Even her typewriter is broken. The state requires that doctors use a prescription drug monitoring program on patients to cut down on opioid abuse and deaths.

However Dr. Konopka says she doesn't have any problems with writing out pain prescriptions by hand to her patients who need pain relief, "Bureaucrats who don't know medicine--they are getting this kind of idea that they can handle this type of pain without narcotics. I prescribe a small amount of OxyContin and they are doing beautifully."

She adamantly refuses to be drawn into the electronic age, "Even if I knew how to use the electronic system, I would be unwilling. I cannot compromise the patient's health or life for a system. I refuse to."

On the other hand the medical board says they are revoking her medical license because of poor medical judgement. A young girl with asthma came to see her with tachycardia. The state maintains she did not perform any follow up tests or refer her to a specialist. Her reaction was, "I'm not sending sending my patients to this doctor and this doctor. I treat everything. I have enough experience and can treat any disease."

So who is telling the truth? Is the state taking away Dr. Konopka's license because as she believes she can't or won't start using electronic medical records? Or is her medical judgement so poor that she is a danger to her patients? There's an easy way to answer that. Why not have her take a Maintenance of Certification exam to see if she is still retaining a minimal level of competency to treat patients? After all, isn't that what the ABMS designed the MOC to do, ensure physicians have a certain level of knowledge so that they're not a danger to their patients?

Oh but wait, Dr. Konopka has probably had her board certification grandfathered in. She has not taken a medical exam in fifty years. The ABMS in their infinite wisdom say that the young and most recently trained physicians are subject to their extortion while the older doctors who haven't cracked a medical text in decades get a pass. This again shows the inadequacy of the entire MOC process and how it is just a revenue raising means for the medical boards to sustain their lavish expenses. Any wonder most doctors think the MOC is the biggest scam in medicine?

Racist Nurse Says White Boys Should Be Thrown To The Wolves

Racism much? A nurse at Indiana University Health Methodist Hospital was found tweeting extremely offensive and racist remarks. The recently hired nurse, Taiyesha Baker, was posting under the account "Night Nurse." She wrote, "Every white woman raises a detriment to society when they raise a son. Someone with the HIGHEST propensity to be a terrorist, rapist, racist, killer, and domestic violence all star. Historically every son you had should be sacrificed to the wolves Bitch." Needless to say the nurse was fired from her job shortly after her tweet was discovered.

Funny how somebody with such extreme racist thoughts can categorize an entire demographic as being racist even though they may only be innocent children. I could say this is the pot calling the kettle black but I don't want to be accused of racism and get sacrificed to the wolves.

Tuesday, November 28, 2017

Are Doctors Paid Too Much?

This is the perennial question that comes up every time there's a discussion about healthcare costs in the U.S. People look at the statistics of physician income and can't help but verbalize their envy by asking if they are being paid too much money for their work. It's nearly impossible to answer this question as a doctor without sounding defensive.

Therefore, at your next holiday party some wise guy brings up this subject to your face, point them to this article in Forbes magazine. It is written by a retired pediatrician from Georgia and gives a wide ranging, fact based argument for why American doctors make as much as we do.

It goes through everything from the high debt load carried by American medical students, which aren't shared by many of our foreign trained doctors who get their medical education free, to the huge expenses of running a medical practice starting with the litigious nature of our society. It also brings up a couple of points that you may not have thought about before.

Talking heads often complain that the U.S. has the highest per capita costs for healthcare in the world. The writer's retort is, so what? The U.S. is the richest country in the world. We have the highest expenditures of everything from national defense to leisure activity to charity giving. Should we cut back on all those other costs to match other countries?

They also note that American doctors are drawn from the best and brightest students our school system has to offer. These students could literally choose anything else to become yet they decided they wanted to go heavily into debt to help other people while facing the peril of a malpractice lawsuit with every single customer (patient) they encounter. These kids could have gone into a field that pays even more money with less risk of being dragged into court such as a Wall Street trading desk. Instead they chose the longer and harder road of becoming doctors. Wall Street applicants aren't as likely to make it into medical school even if they wanted to.

The article finishes with a quote from the legendary Chicago columnist Mike Royko, "Let us talk about medical care and one of the biggest problems we have. That problem is you, my fellow Americans." If it wasn't for all the bad habits carried on by Americans, there wouldn't be so much need for expensive healthcare to keep us alive.

So don't argue with your detractors with raised voices and poor me hardship stories. There are plenty of cold hard facts to refute the ignorance of critics who only look at doctors as the source of the high costs of American medicine rather than looking into a mirror.

Monday, November 27, 2017

Bitcoin Envy Hits The Nurses' Break Room

By now you've probably heard about bitcoin and its road to instant riches. The cryptocurrency has risen from practically nothing a couple of years ago to over $9000 per coin today. Its value has increased nearly 900% this year alone. I won't go into detail about what bitcoin is or how it was invented by one man out of practically thin air. You can read about its origins here. Needless to say I'm kind of an old fart and have not jumped on the bitcoin bandwagon which is probably just as well as that train left the station months ago. I'm perfectly satisfied with the unfashionable way of wealth accumulation such as real estate and stocks.

But that doesn't mean that plenty of other people aren't willing to jump on for that heady ride. Today in the nurses' break room, I saw plenty of envious eyes as one young tech savvy nurse held court. He was extolling the virtues of his bitcoin investment made a few months ago when it was less than $2000. He was throwing out terms like Mt. Gox and ethereum as the other nurses hung on his every word. He was already talking about cashing out and retiring on his newfound bitcoin wealth.

I could see the sad resignation in the other nurses as they realized they had missed the investment of a lifetime. They all talked dreamily about how wonderful it would be if they could retire right now. How smart that young nurse was to invest in something that could allow him to stop working at such a tender age. Soon somebody piped up and said, "It's not too late!" Sure it is currently about $10,000. But who's to say that it won't double again in the next few months.

As their breaks finished, they headed back to work, shoulders slumped, as they had to face the reality that they missed their chance at stupendous bitcoin riches. They'll just have to retire the old fashioned way, with hard work and diligent savings. As the religious writer Nathan Whitley says, "The pain of regret is far worse than the pain of discipline."

Good News--American Students Just Don't Give A F**k

Remember all the angst that were expressed when American high school students did poorly on standardized tests compared to their international peers? There was much debate about the quality of our educational system, our culture that prized jocks while demeaning nerds, and our high income inequality that lead to underperformance in economically disadvantaged students. Now another study seems to show that maybe it's the American students themselves who are responsible for their low test scores. They just don't give a damn.

In a paper released by the National Bureau of Economic Research, scientists conducted a study comparing two groups of 10th graders in Massachusetts against similar high school students in Shanghai, China taking the same standardized tests. In a twist, half the students in each country were given a financial incentive to do well. One group of American students were told they would receive $1 for every correct answer while the control group got no money for taking the exam. The Chinese students were given the same deal.

And guess what, the American students who were given money did better than their classmates who received no money. However the Chinese students didn't show any improvement when money was offered. What did the scientists conclude? American students are raised like true capitalists. They are incentivized by cold hard cash. If in the previous international testing the Americans had achieved the same results as the paid students, the U.S. standing would have risen from 36th to 19th. Not top ten but still a huge jump. Americans just don't seem to care when taking a test that has no personal consequences.

By contrast, the Chinese students seemed to have had the test taking mentality drilled into them from early on. In a culture where a single test in high school can determine one's fate for the rest of their lives, testing is an all consuming event and takes precedence over every other daily activity. So yeah you can say that testing is very important to Chinese students. Not so much for American students.

So perhaps we shouldn't be so defeatist when we look at our education system relative to other countries. Our students are pretty smart. They're not going to give their best effort without some sort of reward for doing so. They're not test taking robots that other nations have trained their children to become. They just need to be bribed to do their very best, just like the rest of us. USA! USA!

Friday, November 24, 2017

The Day Everybody Is A Full Stomach

NPO after MN is not going to help after this meal.
Let's not even pretend that on the day after Thanksgiving people can truly achieve an empty stomach before surgery. Unless the patient had a bowel prep for colon surgery or skipped Thanksgiving dinner completely, there is no way the stomach can have emptied in time by first case of the morning.

Our family changed our holiday meal tradition this year by having a big lunch at a restaurant instead of a homemade dinner. It really is a nice alternative as it frees up the rest of the day to watch football, play outdoors when there is hardly anybody outside which is a rare event in a big city like Los Angeles, or prepare for shopping. Plus the house is not a total disaster afterwards. After over 18 hours since our meal, my stomach still feels full and I have a persistent heartburn that just won't quit.

Now imagine your patient who decided to eat their Thanksgiving dinner and then followed the preop instructions by staying NPO after midnight. With all the meats and fats in the food, there is no way that their stomachs will not still have food inside. If the patient is having a general anesthetic with intubation then it shouldn't be a problem as long as they're done under rapid sequence induction. But for cases where the airway is not protected, such as interventional radiology or cath lab, then I'd be concerned about a high potential for a full stomach.

This raises the question of why surgeons would schedule cases for the day after Thanksgiving. And why would patients want to have surgery on this day? Unless it's an emergency, there doesn't seem to be a good reason to skip a holiday tradition to have an elective operation. It can always wait until next week so patients and their families can enjoy their time together over a long weekend. Why would anybody want to schedule a spine or even a major vascular case for today?

I suppose everybody has different priorities. Some patients just want to get better sooner instead of agonizing over their operations over a holiday weekend while some surgeons need the extra cash for their holiday shopping. Whatever the reason the operating rooms are full today as if this is just another usual Friday. Except on this day most of the patients will have food retained in their stomachs so be careful out there.

Thursday, November 23, 2017

Thanksgiving In Los Angeles

We achieved record high heat this Thanksgiving day. Temperature was in the 90's all throughout LA. I'm glad we decided to eat out rather than slaving away in a hot kitchen. Doesn't feel like late fall weather but that's just the price we have to pay for living in Southern California. Yes it's just another day of sun.

Wednesday, November 22, 2017

On This Thanksgiving, Let's Be Thankful For...Anesthesia

We often take modern medicine for granted. People just assume that if they get sick they can go to their nearest hospital and expect to be treated and released within a reasonable amount of time. We forget how primitive medicine has been for most of human history.

Anesthesia is frequently not even the main concern of patients when they come for surgery. They have zillions of questions for the surgeons but the only thing they want to know from the anesthesiologist is if they will be completely asleep for the procedure. If it wasn't for Michael Jackson's notorious death from propofol, most people would have no inkling of what anesthesia is.

However, there is a reason that anesthesia was voted the most important advancement in the history of medicine by the readers of the New England Journal of Medicine, which means just about every significant physician in the world. We forget how agonizing, harrowing, horrifying, horrific, was the suffering of patients who had been through surgery. People would prefer to die than to go under the knife.

Anesthesiology News has a story of the written accounts of people who had to suffer through surgery without anesthesia (membership required). Reading them will give one the chills and make you thank your preferred deity that you live in an age where anesthesia is readily available.

George Wilson, a chemistry lecturer at the Royal College of Surgeons in Edinburgh, Scotland had to undergo a Syme foot amputation in 1843 by Dr. Syme himself. He described the agony as, "Suffering so great as I underwent cannot be expressed in words, and thus fortunately cannot be recalled. The particular pangs are now forgotten, but the black whirlwind of emotion, the horror of great darkness, and the sense of desertion by God and man, bordering close on despair...I can never forget..."

The great evolutionist Charles Darwin attended medical school at the University of Edinburgh in 1825. He was present at two surgeries, including one of a child. But he was too traumatized by the experience and had to leave before they were finished. He said he was "haunted" by the experience for a long time.

Michael Furnell, who trained at London's St. Bartholomew Hospital in 1846 described the case of a young girl who suffered severe burn injuries resulting in contractures of her neck, making it difficult for her to eat. After she consented to surgery, she was tied down to the operating table, "but before many minutes of the operation had elapsed, her cries and entreaties to be untied and allowed to remain as she was were the most frightful that can be imagined. As the operation, which was necessarily a lengthy and slow one, proceeded, her cries became more terrible; first one then another student fainted."

These and other first person tales would probably deter most students today from going into medicine if they had to witness them in person. The suffering that patients had to endure for the slimmest chance of survival is unimaginable in today's world. So as we give thanks this holiday season for all we have, let's not forget the advancement that has allowed medicine to move beyond the Victorian age, the modern miracle of anesthesia.

iPhone X Face ID Doesn't Work In The Operating Room

Well this is one way to discourage anesthesiologists from looking at their smartphones all the time. As you probably already know, the new iPhone X dispenses with the old reliable home button with its fingerprint sensor and instead uses Face ID. Now instead of using your trusty fingertips to conveniently unlock your phone, the phone recognizes your face to unlock itself. Apple claims it is orders of magnitude more secure than the old Touch ID.

After using my iPhone X for a few days, I find that Face ID is usually reliable and incredibly fast when it works. However there are two locations where the technology has difficulty functioning properly. They are also unfortunately two areas that I use my phone pretty regularly. One is in my car. The dashboard mount on my car has to be pointed exactly at my face for the phone to unlock. Even then it doesn't always work. Since the phone is in the center of the dash and slightly below eye level, and not directly in front of my face which would obviously be a driving hazard, it regularly doesn't recognize me. I wind up having to pick up the phone to type in the passcode since it is difficult to type in a string of characters on a glass screen in a moving car that is off to the side of your visual field. The worse alternative is if I awkwardly hold the phone directly in front of my face to unlock it while driving which is illegal here in California. Apple is making a criminal of me while I'm using their product.

The second more serious issue is in the operating room. This really should come as no surprise but it is still incredibly annoying. When you wear a mask in the OR, your brand new, very expensive, iPhone X doesn't recognize you at all. I can't really blame the phone for not being able to tell who I am under the mask while wearing a surgical cap. Sometimes even I have trouble recognizing people when they're wearing masks. Every time I punch in my passcode to unlock my iPhone I wish the X had the ability to unlock with either Face ID or Touch ID. How difficult would it have been to put in a fingerprint sensor somewhere on the phone like what Samsung Galaxy S8 has?

So now when I have the phone sitting flat on the anesthesia machine writing desk, I have to pick it up to either type a passcode or look into the Face ID if I'm not wearing a mask for a procedure. This is much more cumbersome than just pressing my finger on the home button with my old phone to instantly check messages and notifications.

Every new technology comes with adjustments and growing pains. The Face ID advancement seemed like a panacea for convenience and security. Unfortunately it will take some getting used to as I have to readjust my routine just to unlock my phone.

Tuesday, November 21, 2017

The Hopelessly Ambiguous ASA Classification

I've ranted before about how ineffective the ASA classifications can be to evaluate patient morbidity. The American Society of Anesthesiologists is well aware of how ambiguous the different levels of the system can be to categorize patients. They have even published examples of patients in each level to help physicians understand how to organize different scenarios. Despite that, there is still much confusion among physicians, even anesthesiologists who should know this system better than anyone else.

A wonderfully illuminating study was published in "Anesthesia & Analgesia" that looked at how different patients would be categorized by physicians. Just in case you don't know what the different ASA scores are, there are six levels, ranging from one in a perfectly healthy patient to a six, who is considered brain dead. You may want to read the link to the ASA first if you don't understand it.

In the study, 235 anesthesiologists and 101 trauma surgeons were queried about eight different scenarios. They are:

1. Previously healthy patient with hemorrhagic shock.
2. Morbid obesity with non life-threatening injury
3. Brain dead organ procurement
4. Massive trauma
5. Healthy elderly patient with minor injury
6. Hemorrhagic shock in a Jehovah's witness who refuses blood transfusion
7. Previously stable patient with septic shock
8. Intracranial hemorrhage with mass effect

In none of the eight stories was there a consensus where everybody agreed on a single ASA score. In fact, #3, which might obviously belong to ASA 6 was classified by physicians from ASA 1 all the way to ASA 6.

One of the problems is that there is no clear instructions from the ASA about whether the ASA classes relate to the preinjury condition of the patient or postinjury. They found that 72% of the physicians think the ASA scores refers to postinjury status of the patient while 27% think it is preinjury. Over three quarters of anesthesiologists use the ASA scores to indicate postinjury status while 62% of surgeons did. Therefore it is conceivable that a perfectly healthy young person who suffers a brain death injury, an ideal organ donor, could be classified as ASA 1. But for the smattering of respondents who called #4 or #8 an ASA 6, they really need to go back and review the definition of brain death.

At least the anesthesiologists were more in agreement in how to use the ASA scores. They were more in consensus than the trauma surgeons or the combined anesthesiologists and surgeons. However that didn't prevent one anesthesiologist from scoring #8, an obvious life threatening condition, as ASA 1.

So it looks like the ASA has a lot more work to do to educate physicians, and the members of the society, how to properly use the ASA classification. However, attempts at education may be futile since getting anesthesiologists to agree on anything is like herding cats.

Green Potatoes And Other Dangerous Foods

Just in time for Thanksgiving. Medscape has published a list of the eleven most dangerous foods to eat. Naturally some are pretty exotic like the puffer fish that you might find at high end sushi restaurants. Who hasn't heard stories about the poor soul who ate an improperly cleaned puffer fish and developed muscle paralysis and died. That is the whole thrill and reason for eating it, the ability to cheat death.

But you may not have heard that more common foods found in nearly every American pantry can also cause devastating illnesses and death. The homely nutmeg contains myristicin, a toxin that can cause hallucinations and seizures with as little as one nut. Apparently some teens use it as a readily found mind altering drug to induce "nutmeg psychosis."

Remember when you were a kid and you opened a bag of potato chips? There always seemed to be a few chips that had a greenish discoloration to them. You worried whether they were okay to eat or if they were poisonous. You wound up eating them anyway but now we know potatoes that have turned green can be dangerous. Green potatoes contain high levels of glycoalkaloids. Consuming too much can lead to vomiting, diarrhea, and even death with as little as 3-6 mg/kg of body weight.

So peruse through the list if you don't want to accidentally poison your families and guests during Thanksgiving. And I'd be careful about serving any tropical fruit salad.