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.