Sunday, August 28, 2022

Anesthesiologist's Second Calling, A Lifeguard

Eric Greensmith, MD (from WSJ)

I love this story. It gives me great hope as I transition into the second half of my career. As reported by the Wall Street Journal, Eric Greensmith, MD (I believe his full name is James Eric Greensmith), an anesthesiologist at Milton Hershey Medical Center at Penn State Health, was starting to stare into the face of retirement and found it lacking. Sixty-seven years old at the time, he decided he wanted to try becoming a lifeguard again, just like he was fifty years prior.

Except his physical conditioning was quite removed from five decades earlier. He was five-foot eight and weighed 210 pounds. For a year he had to train to conquer the physical fitness tests: run half a mile in three minutes and forty-five seconds and swim 500 meters in ten minutes. At first he couldn't even run 100 meters. A year later, he was down to a muscular 175 pounds and passed the lifeguard tests with flying colors. 

Now he bikes routinely to his lifeguarding duties from his home, an eighteen mile round trip. He is at the Jersey Shore five days a week during this summer, two days per week after Labor Day. He still lifts weights and swims regularly to keep up his new job requirements. The other, much younger, lifeguards have all been very supportive of their new comrade. 

Kudos to Dr. Greensmith for discovering the fountain of youth. As many of us look forward to slowing down after a hectic demanding career, it's refreshing to see that there are alternatives to just playing golf or traveling to overpriced resorts once we lay our laryngoscopes down.

Tuesday, June 7, 2022

Facebook Has Kicked Me Out.

At least until FB lets me back in.

Last week, Facebook disabled my account. There was no warning and no explanation. Just one day I couldn't log in and I received an error message that said my account has been disabled and to go to the Help Center for assistance. Down the rabbit hole I went as I waded through pages and pages of advice on how to retrieve my blog's account. All this was presciently described in a recent Wall Street Journal article about the travails of Facebook users who lost access to their accounts.

The newspaper noted that Facebook does not have a phone number to talk to a human being to get support. With three billion users I guess they can't afford to hire that many help staff, even if they hired the entire call support industries in India and the Philippines. The article said one person had success by calling the support line for his Oculus virtual reality goggles that is owned by Facebook. He bought the device just to get access to the phone number. I looked it up and there is no Oculus support number anymore. 

So now I'm stuck with no access to get to my ZMD account page. I go to the Help Center every day and give them the same information they ask for with no resolution in sight. I've never received a single email acknowledging my emails or my or account issues. So if you follow and like me on Facebook, you may not see any new entries for awhile, or even ever. I may have to move to Twitter, which I haven't been very active in, or maybe even Tik Tok, where all the cool kids gather. And if you see a blog entry you really enjoy reading, please let all your friends and colleagues know about it because I can't spread the word on Facebook anymore. 

Monday, June 6, 2022

A Devious Lawyer Can Be A Doctor's Best Friend

We all know that lawyers can be lying, cheating scumbags that destroy all that is good in the world. (Obviously just being hyperbolic here.) Here is the story of a lawyer in Orange County, California that helped a physician get out of a malpractice suit by basically lying to the jury.

The patient, Enrique Garcia Sanchez, was admitted into South Coast Global Medical Center in Santa Ana, CA in 2017 with alcoholic pancreatitis. He was unable to eat for over a month. His gastroenterologist, Dr. Essam Quiraishi elected to put in a PEG tube to facilitate his nutritional intake. He unfortunately perforated the colon while doing the procedure. This mistake was not caught until Mr. Sanchez developed peritonitis and died from septic shock at the University of California, Irvine Medical Center a month later. The family sued Dr. Quiraishi for $10 million.

This is where Dr. Quiraishi's lawyer comes in. His name is Robert L. McKenna III, a founding partner at Kjar, McKenna & Stockalper. He was able to convince the jury that Mr. Sanchez died from catastrophic pancreatitis, not septic shock despite the coroner's death certificate stating the death was due to sepsis and peritonitis from a colon perforation. Mr. McKenna also blamed the hospital staff for not notifying Dr. Quiraishi about the X-ray findings in a timely manner. Not to leave any stone unturned, he also blamed the plaintiff's lawyers for "extortion" of the doctor and being part of a "personal-injury industrial complex." Mr. McKenna sowed enough doubt into the jury that they found the physician innocent of malpractice in a unanimous vote.

Normally this would be the end of another malpractice suit that happens every day across the country. But what makes this extraordinary is that Mr. McKenna was caught on video celebrating his legal victory at his office and it was posted on the internet. It was quickly taken down later but not before other people saw it and reposted it all over the web

In the video, Mr. McKenna is seen at an office party discussing the case and how he deceived the jury into accepting his alternative facts. He described the case as "a guy that was probably negligently killed, but we kind of made it look like other people did it. And we actually had a death certificate that said he died the very way the plaintiff said he died and we had to say, 'No, you really shouldn't believe what the death certificate says, or the coroner from the Orange County coroner's office.'" He said it was the fastest defense verdict he had ever gotten and even had a colleague ring a victory bell in the office.

Naturally the internet mob is now calling for Mr. McKenna to be disbarred. His manipulation of the jury personifies the qualities that people expect and hate about lawyers. However, others have stated that lawyers lie all the time to juries to get their clients free from charges like murder, assault, and other felonies because that is their job. Mr. McKenna is just very good at it. His only mistake was getting filmed bragging about his legal abilities and belittling the jury. 

As a physician, I certainly would want somebody like Mr. McKenna on my side, no matter what he has to do to get me off the hook. This story also illustrates that most people want to believe that doctors are doing the best they can to help people. Almost 90% of medical malpractice cases are found for the defendant even when the evidence is strong for conviction. So should Mr. McKenna be brought before the Bar or should he be lauded for his success? This is a tough one legally and ethically.

Saturday, April 23, 2022

How To Become An Anesthesiologist

You've heard about the great incomes that anesthesiologists make. You long for the legendary lifestyle of working with propofol and volatile anesthetics. So now you're wondering what it takes to become an anesthesiologist. 

You could search through the history of this blog to get all the scintillating details of anesthesiology as a career. Or you can read through this nice little article from Forbes on the process of becoming an anesthesiologist. 

It details the long education process necessary to earn the title, at least a decade of schooling and training after high school. First you have to earn a Bachelor's Degree, which takes at least four years. Then there is another four years of medical school to become a physician. That doesn't include the extra time some students take get another degree like an MPH, PhD, or JD. After that, with any luck you will match into an anesthesiology residency, which is getting harder all the time. There you will spend four more years of anesthesia training to just qualify for taking the anesthesia boards. But that's not the end of the line. Most anesthesia residents now take another year for a fellowship like cardiac, pediatric, or pain medicine. Add it all up and it's a minimum of twelve years to become become board eligible to sit for your certification exams.

Phew. It's not an easy road to earn the moniker of anesthesiologist. If that path is too daunting, Forbes has some alternative choices which involves some anesthesia work. You could become an anesthesia technician, which only takes two years. Or you could be an anesthesia assistant, which requires a bachelor's degree and needs about six years total. Or you could become a CRNA, which takes about seven to ten years. 

While the article in general is fairly accurate, I have a quibble with their assertion that board certification is optional to be an anesthesiologist. That may have been true fifty years ago, but nowadays, no hospital will hire you if you are not at least board eligible working towards certification. I know anesthesiologists a generation older than me who were grandfathered into their positions despite not ever having been board certified, but that generation is quickly retiring or dying off so now almost every anesthesiologist is BE/BC. That is not the same thing as having limited vs lifetime board certification, which is a whole other discussion.

If you're curious about how well trained anesthesiologist are, and why we're not just frustrated surgeon wannabes, take a careful read of Forbes. You'll realize that anesthesiologists are some of the best trained physicians in the country.

Saturday, April 16, 2022

Anesthesiology Compensation In 2022

Medscape has released its annual Physician Compensation Report for 2022. The report polled over 13,000 doctors about their salaries and other details about their work. It looks like the pandemic induced reduction in physicians' incomes are over. For the first time in Medscape's survey history, all medical specialties saw increases in compensation during the past year. ENT topped the list with a 13% increase in average annual income.

Anesthesiologists fared well, as usual. This year, anesthesiologists reported an average income of $405,000. That is up significantly from last year when they disclosed an average of $378,000. That is a seven percent improvement over 2021 which was down five percent from 2020 due to Covid shutdowns.

Since 2015, physician salaries have increased an average of 29%. By comparison, inflation in the U.S. over the last five years has been 14.7%. Anesthesiologists didn't fare as well. In 2015, Medscape said anesthesiologists made an average of $358,000. So In the past seven years, anesthesiologists salaries have flatlined, not even keeping up with inflation. Perhaps that's why our specialty doesn't rank in the top ten anymore of the highest paid physicians. And the ASA wants to keep opening more anesthesia residency spots at the same time.

The top five states with the highest physician incomes are: Kentucky, Tennessee, Alabama, Missouri, and Oregon. If you think you would never live in a rural state even if they have very low cost of living and high salaries, then you're stuck in a bicoastal elitist mentality. Though these states may seem rural, they have very cosmopolitan urban centers too, such as Nashville, Louisville, and St. Louis. Alabama even has nice beaches also. So if you're looking for the biggest bang for your buck, don't overlook this list. 

There's a lot more information in Medscape's survey than what I have listed here, including one nice aspect of working in anesthesiology that tops all other specialties. Check it out.

Friday, April 15, 2022

Wordle For Doctors

Think Wordle, the word guessing game, is too easy? You think five letter words are boring? Peeved that middle school kids are better at this game than you? MedPage Today has a new distraction for you. They call it Wordosis. First of all, the words in this game require SIX letters. So there's that challenge. Next the words are medically related so not just anyone can play it since medical terminology is an actual class in medical school. That adds a bit of exclusivity to this puzzle. Just don't play while you're supposed to be vigilantly monitoring your patient in the operating room. Good luck.

Tuesday, April 12, 2022

Medical Schools With The Best Anesthesiology Programs

The recently completed Match Day once again demonstrated how hard it is to get into an anesthesiology residency. Of all the PGY1 spots for anesthesiology, 99.9% of them were filled on Match Day. Out of 1,509 open positions, 1,508 were taken. It's an incredible statistic and shows how extremely competitive it is to get accepted into anesthesiology.

To gain an edge in the residency match, one should attend a medical school that is highly ranked in anesthesiology training. Luckily for us, U.S. News & World Reports made a list for 2022 of the best programs in the country. Get into one of these med schools and graduates will have a leg up in receiving one of the coveted anesthesiology positions.

This list is based on a nebulous combination of factors including quality assessment, student selectivity, undergraduate GPA, MCAT scores, etc. If you're talented enough to ace all these different components, you're on the ROAD to one of the best jobs in America. 

So here are the top medical schools with the best anesthesiology programs as ranked by U.S. News:

1. Harvard University

2. Johns Hopkins University

3. Duke University

4. University of California, San Francisco

5. Columbia University

6. Stanford University

7. University of Michigan, Ann Arbor

7. University of Pennsylvania

9. University of California, Los Angeles

9. Washington University in St. Louis

11. Mayo Clinic School of Medicine

12. Vanderbilt University

Other schools that made the list but U.S. News demands money to see their rankings include:

Baylor College of Medicine

Cornell University

Emory University

New York University

Northwestern University

University of Washington

Yale University

While getting into one of these schools is nice, remember that a vast majority of anesthesiologists did not graduate from these elite programs. So if you are not a student in one of these schools, don't fret. Most medical students aren't either but that doesn't mean you can't score a treasured spot in an anesthesiology residency in the future.

Sunday, April 10, 2022

"Ailee Was Massively Poisoned By The Anesthesiologists"

Ailee Jong, from SF Chronicle

In a 9,200 word article in the San Francisco Chronicle (behind a paywall or free if you have Apple News), the newspaper details the tragic death of two year old Ailee Jong at John Muir Medical Center in Walnut Creek, CA. 

In 2019, Ailee started complaining of abdominal pain. Her parents, Tom and Truc-Co Jong quickly took her to a hospital emergency room. The CT scan results were devastating. The little girl had a 12 cm hepatoblastoma in her liver and probable lung mets. 

When they heard the diagnosis, the parents quickly searched for the best possible care for their daughter. Since they live near San Francisco, they naturally gravitated toward Stanford University and University of California, San Francisco. As they looked through the list of doctors that could treat their daughter, they noticed one pediatric oncologist who was affiliated with Stanford Children's Health and also worked at John Muir Health in Walnut Creek, which is only 15 miles from their house in Danville. This would make commuting to the hospital easier than driving 40 miles to Stanford. 

But little did the Jongs know that John Muir had little experience taking care of complex pediatric liver disease. Their pediatric ICU had only been in operation for about a decade and they'd never had a liver resection like Ailee's before. According to Tom Jong, "They did say, in these words: 'We can treat her. She can be cured.'"

When Dr. Alicia Kalamas, medical director of perioperative medicine and an anesthesiologist, found out about this upcoming hepatectomy, she immediately questioned whether the hospital was capable of successfully doing the operation on such a small child. However, Dr. Jeffrey Poage, medical director of pediatric surgical services and a pediatric anesthesiologist, countered that the surgeons were up to the task. When Dr. Kalamas brought her concerns to Dr. Thomas Greely, the vice president of clinical affairs at JMH, she was told that Stanford physicians who had been consulted about the case had assured them the small hospital could handle the operation. She brought the case to Dr. Moussa Yazbeck, the chief of staff at JMH who did not question the procedure. Dr. Kalamas's contract was not renewed in 2021.

Dr. Poage was originally supposed to be Ailee's anesthesiologist for the procedure. Less than a week before the operation, he reported a scheduling conflict and two other anesthesiologists were brought in: Drs. Wayne Lee and Romerson Dimla. Dr. Lee finished his fellowship in pediatric anesthesiology at Johns Hopkins in 2017 while Dr. Dimla completed his fellowship at Children's Hospital of Los Angeles in 2019.

On November 12, 2019, Ailee entered the operating room at 7:30 am. By 9:30 am, the anesthesiologists documented that the estimated blood loss was 345 ml, significant for a 24 pound patient with a total blood volume of 800 ml. They noted that they had already transfused four units (1,261 mL) of PRBC and one unit (222 mL) of FFP. 

Ailee's body temperature started to drop, going below 95 F. With all the blood products her potassium level went from 4 in preop to 5.6. At 12:10 pm, she went into severe bradycardia then asystole. They were able to resuscitate Ailee by 12:30 pm. Echocardiogram showed no PE or air embolism. Instead of stopping the surgery, the surgeons continued with the resection.

The anesthesiologists noticed blood emanating from the endotracheal tube, mouth and nose of the patient. Labs at 12:32 pm showed Ailee's potassium had jumped to 8.2, a critically high level. Then 15 minutes later, she had another cardiac arrest. An operating room nurse desperately searched for help and found Dr. Poage, the medical director of pediatric surgical services and "begged him to come to the OR." He threw his anesthesia colleagues under the bus and refused to get involved. 

The surgeons continued with the operation despite the second arrest. She was now bleeding profusedly everywhere and the anesthesiologists kept pumping more PRBC and FFP. By now, the anesthesiologists stopped documenting the amount of blood products they were giving. Ailee's heart stopped again. Several times during the resuscitation, the ETT fell out, requiring the anesthesiologists to reintubate her while chest compressions were taking place.

When the surgical team finally realized the operation was futile, they went to the waiting room to inform the Jongs and asked for permission to stop the resuscitation. The parents refused and demanded to see the little girl in the operating room. They were informed that that was against policy but relented. 

When they walked into the OR, they noticed a stack of bloody towels on the floor three feet high and a nurse doing chest compressions. The room smelled of blood. They said Ailee was unrecognizable. Her head was massively swollen and blood was seeping out of her eyes, ears, nose, and mouth. After almost five hours of CPR, she was declared dead at 5:12 pm. 

The lawsuit the Jongs are bringing against the hospital complained that the anesthesiologists did not transfuse an adequate amount of FFP to allow her body to clot properly, leading to the massive hemorrhage. They also said that too much PRBC was given, leading to the critical hyperkalemia. The lawsuit claimed that "By 12:32 p.m., Alee was massively poisoned by the anesthesiologists."

This story illustrates that there is more to an operation than just the surgeon. It takes an entire ecosystem to successfully perform surgery. John Muir Health was not candid with the Jongs when they assured them that the hospital could do the hepatectomy despite internal warning flags raised by staff. The anesthesiologists, who only recently completed in their pediatric anesthesia fellowships, probably had not done such a complicated case since they finished training. The Jongs were wowed by the hospital's decor and amenities but were not given relevant information about the experience of the hospital and its staff in doing pediatric liver resections. Just a sad case for all involved.

Monday, March 28, 2022

The ASA Wants To Help You Get Into Anesthesia

The president of the ASA, Randall Clark, MD, FASA, praised in his Monday Morning Outreach newsletter the highly successful anesthesia match that just took place. As I previously mentioned, 99.9% of the anesthesia PGY1 residency spots were taken. It is one of the highest fill rate of any medical field. 

It seems that the ASA and Dr. Clark have a problem with that. He noted that thousands of applicants did not get into anesthesia residency. In fact, 59% of anesthesia applicants were left on the sidelines in 2022 when they were denied entry into a training program. Their simple solution is to expand the number of programs and spots available to accommodate the high demand. They plan on having a Workforce Summit meeting in June to discuss this possibility.

I am dubious about this idea. Anesthesia residencies have already greatly expanded in the last five years. In 2018 there were only 1,253 PGY1 spots available. This year, there were over 1,500. Other highly competitive residencies are not expanding at the rate that they could. Orthopedic surgery has grown from 742 in 2018 to 845 today. ENT from 316 to 361. Diagnostic radiology PGY2 from 944 to 997. Any of these specialties could easily have more residents if they choose to. Yet I don't hear orthopedic surgeons wringing their hands worrying about not having enough of their own graduating every year. Instead, they relish the exclusivity of their field, to the point of being a national scandal

The ASA's plan to flood the market with anesthesiologists is only good for the ASA. It helps them fight off the encroachment of CRNA's with a legion of anesthesiologists desperately looking for a good job. It also fills their coffers with the millions of dollars in annual dues, conference fees, and CME paid by members each year. Is the ASA really looking after their own, or just stuffing its treasury on the backs of hard working anesthesiologists?

An Anesthesiologist's Perspective On The Oscars Slap

Jerome Adams, MD, ASA member and former US Surgeon General, gives his views about the infamous slapping of Chris Rock by Will Smith at the Academy Awards last night. He uses the incident to highlight the need for mental health maintenance in all people, even the rich and famous. But he also points out that nobody should make fun of another person's medical condition, especially if the condition can't be hidden from view. 

What I first considered a clearcut case of unprovoked physical assault witnessed by millions of people has turned into a much more nuanced debate about mental health, personal privacy, and sensitivity to health issues. I guess that's why I'm not a deep thinker like Dr. Adams.

Sunday, March 27, 2022

Terror In The MRI

RaDonda Vaught, former nurse at Vanderbilt University Medical Center, has been found guilty of negligent homicide in the death of Charlene Murphey, a 75 year old patient under her care. Back in 2017, Ms. Murphy was admitted to the hospital for a stroke. The patient was supposed to get an MRI scan and was anxious, which is not uncommon in patients undergoing an MRI. Ms. Vaught, as her nurse, went to the drug cabinet to fetch some versed, an anxiolytic. Instead, she took out vecuronium, a paralytic agent. She injected the muscle relaxant into Ms. Murphey, how much is unknown, and left the patient to get scanned. By the time the scan was completed and Ms. Vaught returned, her patient was braindead.

As an anesthesiologist, this drug mixup is very perplexing. Versed comes in liquid form. Vecuronium, on the other hand, comes in a powder. It has to be dissolved in a liquid before it can be administered to a patient. How the two drugs got mixed up is incomprehensible. As an ICU nurse, Ms. Vaught surely has given versed in the past to her patients. She may also have given vecuronium to intubated patients to help them ventilate more easily. She should be familiar with both drugs. The two are nothing alike. This mistake isn't even like the heparin debacle a few years ago in Los Angeles, where the children of Hollywood celebrities were overdosed due to a high concentration solution being injected instead of the standard concentration. Versed and vecuronium are packaged completely differently and don't look ANYTHING alike. 

The responses from the medical community have been predictably defensive and disappointing. Some tried to blame the drug dispensing machine, which got the first few letters of the medications mixed up and gave her the wrong one. The American Nurses Association issued a statement lamenting that, "The nursing profession is extremely short-staffed, strained, and feeling immense pressure. This ruling will have a long-lasting negative impact on the profession." Excuse me? The ANA is worried that there won't be enough nurses because of the criminal actions of one of their own? You know what? Right now there are real shortages of police officers all over the country. Should we have let Derek Chauvin go free because finding him guilty might cause other officers to quit? 

Let me picture for you the gruesome ending of Ms. Charlene Murphey that fully justifies Ms. Vaught's verdict. Imagine you're going to get an MRI done. The test usually takes at least 30 minutes, frequently longer. You're stuck inside this long narrow tube with barely any room to move your body. There are loud strange noises reverberating in the machine throughout the entire procedure. Not surprisingly, many patients ask for a sedative to make them feel a little more relaxed during the exam. 

Ms. Murphey asked her nurse for something to calm her down. Ms. Vaught decided to get versed, which is a fairly standard sedative for this procedure. Inexplicably, she grabbed vecuronium instead. Without ever reading the label on the drug vial, she dissolves it in a solution and injects the drug into Ms. Vaught. 

The patient, fully trusting of her nurse, then goes into the scanner. Vecuronium is not a fast acting paralytic agent. It can take a few minutes for it to fully kick in. By then, her nurse would have been out of the room so they can proceed with the scan. When the patient realizes something is amiss and she is having great difficulty breathing, it's too late. There is nobody around. The only people nearby are the staff in the control room where they can see the patient at all times. But all they can tell is that Ms. Murphey was laying there quietly, not disrupting their scan. 

The patient obviously was not being monitored or else the staff would have noticed her vital signs kick into overdrive as the body realizes it can't breathe. There was no monitoring to detect when here oxygen saturating started drifting lower. The patient, fully conscious because she has been paralyzed without any sedation at all, is locked in and has zero ability to communicate. As her brain screams for help, her body is helpless to escape this situation. Finally, after several minutes of agony, Ms. Murphey would have gone into cardiac arrest and brain death from the lack of oxygen, with a room full of people just on the other side of a large window unwittingly watching her die.

This is the worst nightmare for anesthesiologists, to have a patient awake under the knife. But at least we're still providing ventilation so the patient isn't suffocating. Ms. Murphey was left all alone to die because her trusted nurse didn't do something as basic and routine as read the drug label before she killed her. 

Friday, March 18, 2022

Anesthesiology Is Still One Of The Most Competitive Residencies

Match Day 2022 has come and gone. Parsing through the latest data from NRMP, it's astonishing how competitive anesthesiology residency has become. Even with an ever increasing number of residency positions, medical students hoping to get into anesthesiology have their work cut out for them.

This year, there were 1,509 PGY1 anesthesiology spots available across 165 residency programs. That is up from 1,460 last year and only 1,253 as recently as 2018. The incredible part is that, even with so many more positions, only a single one did not get filled. That's a match rate of 99.9%! That's the most competitive residency of any large specialty with more than 1,000 spots available. In fact, of all residencies with more than 500 spots available, only orthopedic surgery is more competitive, with all their PGY1 positions filled.

There were a total of 2,691 applicants for those anesthesiology residencies. Of those, 1,489 were MD Seniors. Another 505 were DO Seniors. The number of MD Seniors who matched were 1,054 or 69.8% of all who matched. DO Seniors were successful in 263 instances, or 17.4%. 

Anesthesiology has become more popular over time as more medical students decided they want to get on the ROAD to riches. In 2022, anesthesiology was chosen by 5.7% of all MD Seniors. This is up from 5.6% last year. In 2018, only 4.9% of MD Seniors chose anesthesiology. 

Congratulations to all the students who are now going to be anesthesiologists. You've successfully come through the gantlet of medical school and match day. Your future is brighter than ever and I can't wait to meet our new class soon.

Sunday, February 6, 2022

What Do Anesthesiologists Do?

I love this op-ed from MedPage Today. Written by Amy Pearson, MD, she goes over the daily activities that anesthesiologists confront every day and the misconceptions that the general public, and frankly many doctors, have about our specialty.

Dr. Pearson explains some of the myths about being an anesthesiologists such as:

Anesthesiologists sit around all day. She points out that she and her colleagues burn about 3000 calories per day working their usual daily routine in the hospital. In fact, many times we hardly have any opportunity to even go to the bathroom

Anesthesiologists answer to "anesthesia." It's true anesthesiologists hate to be called by that term. We're people with names just like every other member of the operating team. We graduated from medical school and anesthesiology residency. We deserve the same respect given to the person operating on the other side of the ether screen.

Anesthesiology is mostly boring work with occasional scary moments. We have years of training to make sure we are taking the best care possible of our patients. We make it look easy because we spent thousands of hours in residency learning this craft. That doesn't mean it is easy

Anesthesiologists get blamed for everything.

In truth, despite its many shortcomings, anesthesiology is one of the best jobs in America

Sunday, January 30, 2022

War With CRNA's At The VA

With exquisite timing, right in the middle of National CRNA Week, the president of the American Society of Anesthesiologists sent a blistering email to ASA members lambasting the Veterans Administration for not taking seriously concerns about CRNA's practicing independently.

The Spokesman-Review article that Randall M. Clark, MD, FASA referred to describes attempts by anesthesiologists at the VA hospitals to use a whistleblower program called "Stop the Line" to report unsafe patient care conditions outside the normal chain of command. This is in response to the VA allowing CRNA's to practice independently at the nation's veterans hospitals. 

The anesthesiologists have used "Stop the Line" four times but have received zero response from the department. When news of these reports were discovered, the nurse anesthetists were not terribly happy. They threatened work stoppages and slowdowns in retaliation. 

Predictably the CRNA's are framing this as an access issue. Without their presence, they warn that veterans will have less access to lifesaving surgery and face major delays in care. 

Frankly, I find this latest skirmish between anesthesiologists and CRNA's pointless. If the ASA is trying to prevent CRNA's from practicing independently, that horse left the barn years ago. The Covid pandemic opened the door to the nurses practicing without physician supervision nationwide during the Trump Administration and the nurse-friendly Biden Administration is unlikely to change that. 

Once nurse anesthetists have a taste of independent practice, it is very difficult to force them back into a care team model. It's the same feeling when anesthesia residents finally become attendings--nobody wants to have somebody looking over their shoulder when they've had the opportunity to make their own decisions about patient care without being second-guessed.

At this point, it really is futile to try to return to the care team model where CRNA's have already practiced independently. The best outcome for the ASA is a tenuous detente where we maintain the physician supervision that is still in place and attempt to not lose any more ground. 

Saturday, January 29, 2022

ICE or BEV With Your Blizzard?

Just a quick introduction. I don't own a Tesla or any electric vehicles but I found this information very educational as we head off into our battery powered future.

Remember that blizzard in Virginia on January 4 that made national headlines? The state highway system came to a complete stop, trapping travelers on the road for nearly 24 hours. A truck driver tweeted that a Tesla driver knocked on his cab window and asked him for a blanket to keep his kids warm. He wondered what would happen when the Tesla ran out of juice. Would that poor family freeze to death as they waited futilely for a rescue?

That tweet became major news. A Washington Post op-ed (paywall) worried about what will happen when the country's transportation goes completely battery electric vehicles (BEV) only. Electric cars are much more difficult to get off the road when they run out of power compared to internal combustion engine (ICE) powered autos. You just need to add a couple of gallons of fuel into the tank and the car is good to go. 

The good folks at Car and Driver decided to run a little experiment with this scenario. They took a 2019 Tesla Model 3 Long Range and idled it next to a 2022 Hyundai Sonata N to see which car would last longer. The average outside temperature during this test was 15F though it got as low as 9F. They set both cars' climate controls to 65F.

Well guess what--the Tesla could last nearly as long as the Hyundai in this demonstration. The Tesla has the advantage of Camp Mode which turns off every part of the car except for climate control when the car is in park. The Hyundai's engine idled at full power the entire time. The Tesla started out with 98% charge on the battery and ran for 37 hours straight, leaving about 17% charge or 50 miles remaining. In theory, it could have continued for a total of 45.1 hours. The Hyundai's engine was stopped after 24 hours but they calculated it would have gone a total of 51.8 hours with its 16 gallon gas tank.

US Dept. of Energy

The Tesla was able to achieve this because BEV's have more efficient motors. The Model 3 used up 1.6 kWh per hour while the Hyundai burned through 10.6 kWh per hour. Another reason BEV's are safer in unexpected emergencies is because electric vehicles are more likely to have a full "tank" every time they go on the road since most owners charge their cars at home overnight. Meanwhile, ICE owners don't usually fill up their cars until well under half-tank. Good luck trying to find a gas station when there is an emergency evacuation order. 

So next time you snicker at the BEV driver and their worries about range anxiety, just remember that they are more likely to have a full tank in their car than what you're currently driving. In fact, when was the last time you even saw a BEV stranded on the side of the road because they ran out of juice? In Los Angeles, cars are stranded on the sides of the freeways every day because they ran out of gas.

By the way, that truck driver later tweeted that the Tesla family did just fine when the Virginia highway finally opened up. They still had 18% charge on their Tesla when they finally made it off the road to the nearest Supercharger station. I'd be more worried about trying to find a bathroom in a blizzard than getting stuck long enough for an electric car to lose all of its battery power while trying to stay warm. 

Monday, January 24, 2022

Anesthesiologist Who Killed Surgeon Goes To Jail

Just a follow up from a story from back in 2017. Dr. Stephen Kyosung Kim was charged with murder when his patient, Dr. Mark Greenspan, a 71 year old orthopedic surgeon, died after surgery. Blood and urine drug tests showed Dr. Kim had Demerol and Fentanyl in his system at the time of the incident.

Dr. Kim admitted that he had stolen Demerol 50 mg from the Rodeo Drive Plastic Surgery Center in Beverly Hills that morning. He administered a general anesthetic to Dr. Greenspan even though they had discussed using regional anesthesia. Dr. Kim then left the operating room to give himself Demerol and Toradol. He subsequently fell down and hit his head but came back to the OR to finish the case. While in recovery, Dr. Kim overdosed Dr. Greenspan with Demerol and the patient became apneic and went into cardiac arrest. Dr. Kim tried multiple times to intubate Dr. Greenspan but was not successful and the surgeon died. 

The anesthesiologist admitted to the prosecutors that he had a drug addiction and had taken narcotics over 150 times while at work. His medical license was subsequently revoked. After four years, Dr. Kim pleaded guilty on December 2021 to manslaughter and was immediately taken to jail. It is expected that he will return to court in December 2023 and be sentenced to two years of jail time which he will have already served. 

This tragic case once again illustrates the unfortunate link between anesthesiology and drug addiction. It's well known that anesthesiologists have one of the highest incidents of addiction in medicine. I have unfortunately covered multiple incidents of drug addiction among anesthesiologists, including here and here. Eighty percent of US anesthesiology residencies have had at least one drug impaired resident. Almost a fifth of all residencies have experienced the death of a resident due to drug overdose. Male anesthesiologists are considered the highest risk for drug addiction and suicide among all physicians. A deadly combination of high stress work and easy access to narcotics makes drug addiction an ever-present risk of working in the field. If you suspect an anesthesia colleague may have an addiction problem, say something. It may save his, and his patients', lives.

Saturday, January 22, 2022

Doctors Are Vassals Of The State

If there is any doubt that doctors do not have autonomy in their workplace, recent court decisions regarding vaccine mandates have proven it. A couple of weeks ago, The Supreme Court ruled that the Biden Administration's vaccine mandate for all employers with more than 100 employees was unconstitutional. Congress never authorized this action and the executive branch doesn't have that authority no matter how the administration contorted the laws. Then last week a US District Court in Texas found that vaccine mandates for federal employees were also unconstitutional, again citing overreach of the administration in their use of federal laws. 

So does anybody in the US need to get the vaccine? Large employers cannot force their employees to take the coronavirus vaccine. Federal employees also cannot be required to accept the vaccine. Small employers have not had any federal mandates for their employees to receive it or get fired. The only federal mandate for vaccines that was accepted by the Supreme Court was for doctors, nurses, and all medical industry who accept Medicare and Medicaid reimbursements. Yup, it's all about the money.

The reason the Centers for Medicare and Medicaid Services was able to force healthcare workers to get jabs despite deep concerns among large groups of the population, including doctors and nurses, is that there is a clause in the Medicare laws that states the government can do whatever it takes to make sure the programs function smoothly. Therefore it gives the Secretary of Health and Human Services broad authority to make sure they run uninterrupted, which in this case means healthcare workers who accept money from CMS do not get sick from Covid and they do not transmit the virus to their patients.

I am not a vaccine skeptic. I got my first shot the first week that it was available at our hospital. I have since been boosted. I just find it frustrating that even though physicians are some of the most highly educated people in the country, we are under the boot of the federal government with little recourse for dissent. 

Besides vaccine mandates, other government rules keep doctors on a very short leash. EMTALA laws tell us who we can and cannot treat (spoiler: we have to treat everybody). HIPAA laws decide what we're allowed say. Through the Joint Commission, they dictate what we can wear, where we can eat, how we dispose of trash, and essentially all functions of a healthcare facility. Doctors are threatened with loss of their livelihoods if they exercise their freedom of speech to talk about their skepticism of the consensus. Our incomes are based on the whims of the federal government where they threaten to cut reimbursements every year. Medicare reductions of 1-2% are considered a win for the healthcare community even though inflation is soaring all around us. 

Do physicians have any constitutional rights left? When physicians first got into bed with the federal government, many were anxious about cozying up with such a large entity. We were assured it would be just a small program, costing only a few billion dollars each year. Besides, shouldn't doctors just suck it up so the elderly and destitute can receive their rights to decent healthcare? Half a century later, as the programs expand their eligibilities and the demographics of the population has changed, Medicare and Medicaid enrollment are now over 100 million people

The medical community essentially cannot function without government money. With so little leverage, is it any wonder the Congress can so easily talk about cutting medical reimbursements each year and face almost no backlash? We are required to follow rules that would have a private employer facing an ACLU lawsuit within five minutes. If we're going to ride the bull, we're going to have to expect to get gored.