Saturday, March 30, 2019

Anesthesiologists Have One Job

It was late in the afternoon and I was about to relieve another anesthesiologist for the day. I walked into the operating room and met the anesthesiologist, who was talking with another anesthesiologist in the corner. I guess they wanted to chat away from the operating table so that they wouldn't disturb the surgeon while he was busy doing the case. Unfortunately, they were also far away from the anesthesia monitors, which were not visible from where they were standing.

Exchanging pleasantries, we walked back to the patient so that I could be given a report before I took over the case. When we glanced at the monitors, the first thing we both noticed was that the patient's systolic blood pressure was in the 60's. The blood pressure alarm had been muted so nobody noticed the dangerously low hypotension. Reacting quickly, my colleague gave a small bolus of phenylephrine which quickly brought the pressure back up to the 90's.

This incident perfectly illustrates the one job that anesthesiologists have to perform at all times--vigilance. From this single chore flows all our other responsibilities. It doesn't matter if you're the master of neuroanesthesia or an ace in the cardiac room. If you're not constantly watching the patient every second they are under your care, then you're not doing your job to ensure patient safety.

That's why distractions are so dangerous in the OR. Whether it is cellphone internet surfing or gabbing with colleagues, patient monitoring has to take place above all other activities. Nothing else will define an anesthesiologist's career like missing an event leading to patient harm because one is busy reading their Facebook feed.

Luckily the patient suffered no harm. But what if I hadn't walked into the room at that moment? What if the two of them remained in the corner away from the patient for a longer period of time and nobody intervened? How long do you think the patient's heart and brain can tolerate mean arterial pressures in the 40's? It's not the surgeon's job to monitor the patient while performing his meticulous work. You probably wouldn't want them to anyway. So anesthesiologists, don't f*** this up.  You have only one job in the OR. If you can't handle that then you probably need to go into a different line of work.

Tuesday, March 26, 2019

Drinking As Much As You Want Before Surgery Can Decrease PONV.

The American Society of Anesthesiologists has very clear guidelines for deciding when patients should stop any oral intake before surgery. These guidelines were made to prevent patients from aspirating gastric contents upon induction of anesthesia. For years, the rules were no solid foods up until six hours before surgery and no clear liquids two hours before the procedure.

Granted there have always been complaints from patients about how miserable they feel by the time they get to preop from having to fast for such a long period of time. It's especially bad for patients whose procedures take place in the afternoon and were given instructions to be NPO after midnight. Since this is by no means settled science, there is ongoing research to help remedy the situation.

Some have advocated letting patients drink carbohydrate rich fluids to help with the hypoglycemia that makes the patients feel so deprived. However, they still say nothing by mouth for two hours before surgery. Now the British have done something even more bold than Brexit--all you can drink right up to going into the operating room itself.

In a followup to a study first published in the European Journal of Anesthesiology in 2017, researchers in the UK allowed patients to drink as much as they want immediately before surgery. Covering over 30,000 patients, the study showed that the rates of postop nausea was lower for patients who had unrestricted fluid intake, 3.8% compared to 5.2% for patients who could take clear liquids up to two hours before. Postop vomiting was also lower, 2.2% to 2.8%.

The $64,000 questions is what concerns anesthesiologists the most. What are the aspiration risks with unlimited po fluid intake before anesthesia? Surprisingly, they were very good. Only two patients suffered aspiration of gastric contents. Both patients had risk factors including BMI>35 and history of gastric reflux. That compares to a normal aspiration risk of 1 in 8,000 anesthesia patients.

The researchers speculate that patients who were allowed unlimited drinking before surgery had less postop nausea and vomiting because hunger itself can cause nausea. Their conclusion is that the risks of gastric aspiration is low enough that it justifies patients being allowed to drink fluids to prevent the higher likelihood of PONV.

These numbers look very promising on paper. However, in the much more litigious U.S. legal system, I think I will continue to follow the ASA's guidelines instead. People normally go hours during the day without eating or drinking anything. They can certainly do that the day of their operations.

Monday, March 25, 2019

When Did Medicine Become A Branch Of The Democratic Party?

Physicians used to be considered pretty conservative in their political views. They were considered very learned and commanded respect from their patients and communities; the definition of pillars of society. You probably didn't see too many physicians rolling around naked in the mud at Woodstock. Nor did you see them burning their draft cards/bras or march in antinuke rallies.

But times have changed. Medical societies, which are of course composed of physicians, seem to be veering more and more toward leftist ideology. The causes they espouse come right out of the Democratic party playbook.

The latest example is the American Academy of Pediatrics endorsement for a soda tax. They believe that taxing sugary drinks will lower heart disease and diabetes. They naively believe that the extra money from the tax should go towards subsidizing government programs to encourage people to eat healthier foods.

This is despite evidence that these soda tax policies don't work. When it was instituted in Philadelphia, the results showed that most people just bought their soda outside the city limits to avoid the tax. The tax hurt the business owners, many of whom were small businesses and minorities, who lost customers when they decided to buy their soda elsewhere, along with their other grocery needs. Another unforeseen consequence of the soda tax was that alcohol sales went up. If you have to pay extra for your soda, why not just step up to something else?

This soda tax endorsement is just one more piece of evidence that medicine has become a leftist organization. Along with medicine's endorsement of Obamacare and climate change, it's clear that this is no longer your father's or mother's medical practice.

Sunday, March 17, 2019

Doctors Who Cheat

Amid the Hollywood actresses and hedge fund titans who were caught in the college cheating scandal, two healthcare professionals were also charged with using the services of Rick Singer, the mastermind behind this scheme to get children of the wealthy into elite colleges.

The first is Dr. Gregory Colburn, MD. He is a radiation oncologist in San Jose, CA. Graduating from UCLA, he has been in practice for over 20 years. He and his wife allegedly paid nearly $25,000 to have his son take an SAT exam with a corrupt proctor present to boost his score. When news came out, online reviewers quickly gave him one star. He is now being investigated by California's Medical Board and could have his medical license suspended.

The next medical professional's motive is a little more puzzling. Dr. Homayoun Zadeh was the director of periodontology at USC's School of Dentistry. He supposedly paid $55,000 to have his daughter recruited at USC as a lacrosse player, even though she doesn't play the sport. They reportedly had to refinance their house to make the payments. When word of his arrest became public, USC quickly fired him from the dental school.

I just wonder why Dr. Zadeh felt he needed to cheat to get his daughter into USC. She should have a huge advantage over most USC's applicants since her father is a tenured professor at the university. Unless she's a really mediocre student, what made the parents think she needed that extra boost to get her in?

While this episode is truly embarrassing and sad, I can understand the angst these parents are facing to get their children into "elite" schools. My own kids are very shortly going to start applying to college. There is enormous pressure for them to go to top flight schools, mainly as a vanity project for the parents. I personally went to a state university and have done well professionally, but in good school districts with many upper middle class families, the social pressure to one up other parents for bragging rights can become toxic.

I feel worse for the children. Whether they were complicit or not, having their parents' names splashed in headlines across the country must be incredibly traumatizing and stigmatizing. Knowing their parents have lost their jobs and their reputations, it makes you wonder if it was worth it. In hindsight, it obviously isn't.

Saturday, March 16, 2019

What Do Anesthesia Program Directors Want?

Congratulations to all the medical students on another successful Match Day. I want bore you with the details about how anesthesiology did this year. As usual, there were more programs and spots available over last year despite increasing concerns about training too many anesthesiologists. However some of the increase can be attributed to osteopathic programs that are now part of the unified Main Residency Match. As usual, over 98% of positions were taken, though only two-thirds were filled by US senior med students. That compares with over 90% US seniors in highly desirable residencies like ENT or orthopedic surgery.

What I found more newsworthy is the NRMP's survey of program directors. For practically forever, med students have wondered what qualities residency directors look for when seeking applicants for their programs. That is one of the top questions I get asked every year. We now have concrete answers thanks to the NRMP.

The NRMP director survey is done for each specialty. Obviously I'm just going to talk about anesthesia directors. So what are the factors that make a student more desirable?

As you can see, the number one issue that makes a student competitive for an interview is the board scores, particularly Step 1. This is followed by the letters of recommendation, grades in the clerkship, Dean's letter, and class rank. Surprisingly, even though students sweat for weeks working on it, your personal statement isn't really all that important.

When it comes to how programs rank all their interviewees for the Match, the number one factor is interactions with faculty, followed by interpersonal skills, interactions with housestaff, feedback from residents, and board scores. This proves what I've been telling students all along--if you're credentials are strong enough to make it to the interview stage, the rest is all about personality and interactivity. It doesn't matter if you're the most brilliant student this side of Stephen Hawking. If you come across as an arrogant jerk during the interviews or a shrinking wallflower, you will not get ranked highly.

So go check out the rest of the survey by clicking on the link above. You'll find other interesting tidbits like the average anesthesia residency received over 800 applications, but interviewed less than 150. And how Canadian students are really screwed on American Match Day. Again congratulations to all.