Sunday, August 30, 2009

My Confession

I have a confession to make. Please don't think less of me after you read it. I'm just being honest with my readers and also making a point about the health care debate. Ready? Here it goes: medicine for me is not a calling. There. I've said it. Do you think I'm less of a doctor now that you know the truth? Don't get me wrong. I love my job. It's a very honorable field and we do good things for our fellow human being. But it is not a religious experience.

The reason I brought this up is because of several articles I've read recently. First there is the opinion piece in the Wall Street Journal by Dr. Ronald Dworkin, an anesthesiologist. He says that to the current generation of upper middle class professionals, a career satisfies an interest and the income sustains them once the interest inevitably subsides.

Then there is this comment to Dr. Dworkin's editorial by a Mr. Thomas Elmo. Mr. Elmo rebuts, "You don't become a teacher, policeman, fireman, minister or doctor if you DON'T think it is a calling." I wondered if that is truly how the public sees doctors, that we are doing this work because it is our "calling" and thus undeserving of higher compensation?

I will bet that 99.999% of people doing their jobs are not in it because of some "calling." Unless one is going into ministry, nearly everybody has an economic or personal reason for making a certain career. Maybe the profession runs in the family. Or somebody wants to make a bucket load of money. Or maybe they were inspired by a mentor. But very few people actually hear a calling, despite what Mr. Elmo says. In fact, other than priests and nuns, the list of people who heard a calling probably starts with Jesus and ends with Martin Luther King, Jr., with Gandhi, Mother Teresa, and Joan of Arc somewhere in there.

I can honestly say I never heard a voice telling me to go into medicine. My father is a physician, as was his father. My brother went into medicine too; it's what we know. Is that any different from the auto plant worker who's children follow them into the factory? Or the lawyer whose children join the same law group? Or the politician whose entire clan gravitates toward the same profession? Do you think President Obama heard a calling to become the POTUS? If so should he work for minimal wage or free since that is his destiny? What about the members of Congress? They like to think they're there to make the country a better place and do what's right for the citizens. Would they be so high-minded if they made less? The truth--they give themselves raises and private jets every chance they get, budget deficit be damned.

Other professionals like lawyers aren't ashamed to say they do it for the money. So why are doctors held to a higher standard? Is it so wrong to say medicine gives me a nice income to support my family and make a nice living? By saying doctors should be completely altruistic it gives opponents an excuse to lower doctors' reimbursements in the name of holding down health care costs. But some doctors are already making less than their local plumbers on an hourly rate. Plumbers (just to use as an example) don't have to answer calls in the middle of the night. They don't work weekends. They don't have to shell out tens of thousands of dollars for malpractice insurance (when was the last time you sued your plumber?). They want cash on the spot, no freebies from these guys. And they didn't go through at least eight years of higher education after high school before even starting residencies. Yet this health care debate revolves around cutting Medicare reimbursements even lower. If the public option based on Medicare rates gets passed, we'll see who really is in medicine because of a calling.

So to wrap up this tirade. I like my job. I like my income. I don't think I'm less of a doctor because I'm not working at the free clinic every day. To those who think doctors shouldn't mind making less money because the work is their destiny, I say come walk in my shoes. Try working 60-70 hours a week, practically nonexistent family time, and the threat of a malpractice lawsuit hanging over your head with every patient you see. Then you can tell me how little income you'd be willing to work for.

Saturday, August 29, 2009

God's shoes


Ha ha! Al Bundy did receive a message from God. The NY Times reports on the latest fad in running, barefoot to minimal shoe covering. There is apparently little evidence that the hundreds of dollars that runners pay for their shoes actually improves their performance or endurance. In fact, some people believe shoes impede the ability of feet to adapt to running, making it more prone to injury and dependent on shoes for support.

Thus there is the trend of running barefoot. The "shoes" these runners wear look like foot gloves. And coincidentally, they look just like the golden shoes Al Bundy created when he had a conversation with God.

Friday, August 28, 2009

Case Report #2

I go into preop to see my next case, a transmetatarsal foot amputation due to gangrene. Looking through the H+P, the patient reads like an oral board certification case presentation. Patient is in his 50's with insulin dependent diabetes. He has ESRF, with dialysis the morning of surgery. They helpfully removed 2 liters of fluid that day. He has ischemic cardiomyopathy with an ejection fraction less than 40%. Of course he has coronary artery disease s/p PTCA and stenting but still has CAD not amenable to any further intervention. He had an internal cardiac defibrillator placed a month ago due to his low ejection fraction. His pulmonary artery pressure was 64 mm Hg. And to top it off, the preop nurse told me his blood pressure is 75/26. Huh?

We measure the BP in the other arm and it is the same. We look through his chart and it shows his BP has been in the 70's for the last five days. We call the floor nurse who was taking care of the patient to see if she had brought up this problem with the primary care doctor. She said she was not aware of his hypotension because she was not the one measuring his BP's. I wanted to report that nurse right there and then but thought that wouldn't really make any difference to the patient now. The cardiologist left a helpful note in the chart that was pretty much illegible chicken scratches other than something about patient being fully optimized for surgery. Gee thanks. The surgeon said the foot is causing sepsis and needs to get amputated now. The patient's mental status is best described as drowsy. I couldn't tell whether that's because he has been receiving narcotics for pain or his brain was not getting adequately perfused. Okay.

So a general anesthetic was pretty much out of the picture as well as a spinal. I didn't feel like experimenting with critical hypotension in the OR tonight. So an ankle block was placed. I attempted an arterial line but of course the patient is vasculopathic. No palpable pulses anywhere and my attempts with blind sticks were not successful. I started a levophed drip to get his BP up into the 90's while giving him just enough sedation with versed and propofol to maintain amnesia. The surgery went well but as expected the ankle block was not all that helpful during the bony amputations. At least the patient doesn't remember.

The surgeon and I agree that the patient should go to the ICU at least overnight. I continued his levophed drip in recovery to maintain some semblence of normotension. The surgeon calls the internist to come write ICU orders. I get a page from recovery saying the internist wants to talk to me. I thought he might want some details about such a challenging case. Instead I get a lecture from him about how bad levophed is. He tells me the patient LIVES on BP's in the 70's. I tell him I wasn't going to give anesthesia to somebody that hypotensive and with CAD and cardiomyopathy. He orders the levophed discontinued. The BP promptly drops into the 60's. He said he was fine with that. I throw up my hands in frustration. Who am I to argue if the patient's primary care doctor doesn't mind having a patient with such critical hypotension? In situations like this, the best thing that can be said is that the patient lived through the surgery. What comes afterwards is out of my hands.

Thursday, August 27, 2009

Deficits you can believe in

From the LA Times: White House projects bigger deficit, bigger debt.
"Figures released by the White House budget office foresee a cumulative $9 trillion deficit from 2010-2019, $2 trillion more than the administration estimated in May."

From the NY Times: Deficit expected to reach $9 trillion.
"The Obama administration’s Office of Management and Budget raised its 10-year tally of deficits expected through 2019 to $9.05 trillion, nearly $2 trillion more than it projected in February."

From the Wall Street Journal: Decade of debt: $9 trillion.
"Plunging tax receipts, soaring spending and a sluggish recovery will push the nation's deficits dramatically higher over the next decade, creating new complications for President Barack Obama's domestic agenda."

From President Barack Obama at a town hall meeting in Colorado on the cost of health care reform:
"Now, what I’ve proposed is going to cost roughly $900 billion — $800 billion to $900 billion. "

Uh huh.

V.I.P.=R.I.P.?

In today's Well blog in the NY Times, they discuss the curse of the VIP patient. VIP's can be anyone from celebrities to physicians to the mother of the hospital administrator. VIP Syndrome is well documented in the medical literature. Patients considered VIPs frequently wind up with worse outcomes than "regular" patients. It is a well known medical axiom that patients who are doctors and nurses frequently have unforeseen complications during the course of treatment. The Well blog discusses how the extremely wealthy father of a patient arranged to have five different physicians from five different hospitals take care of his son. None of them could agree on a course of treatment since nobody was actually in charge. As a consequence the son received worse care than he otherwise would have.

In the city where I practice, we have celebrities and other VIPs everywhere. You can see them jogging on the sidewalk or bump into them at the Whole Foods Market. Naturally we treat them all the time at our hospital. I've treated rock stars, billionaires, TV and movie celebrities. You can always tell when you are going to get a VIP patient. On the OR schedule there is an unusual pseudonym. When you log onto the hospital computer system to look at the patient's lab work, a warning comes up about how you are being monitored. While preop does not allow an entourage inside, there is usually the Patient Advocate standing at bedside to take care of any needs that might arise. Most of them are really nice, just regular folks, but there are a few that are notorious for being a pain in the ass. They get special cordoned off areas in preop and recovery. People walk on eggshells around them. I have to admit I still get butterflies when I treat a very prominent VIP. I wouldn't want to read in the newspaper the next day that so and so "died in the hospital during a routine procedure due to anesthesia complications." The horror.

Yes we try to treat everybody the same. But we are all human. We will treat VIP's differently despite our best efforts. We just hope we don't wind up being household names like Dr. Conrad Murray.

Wednesday, August 26, 2009

Genius


"Dr. Z. You're a genius. I felt nothing." said my patient after she had her colonoscopy with propofol sedation. This from a patient who had put off her colonoscopy for years because she was afraid of feeling pain. Ah propofol. A wonder drug in the right hands.

Tuesday, August 25, 2009

Shakespeare was right

In today's Prescriptions blog in the NY Times, Dr. John Creighton Campbell, professor emeritus of political science at the University of Michigan and a visiting researcher at the Tokyo University Institute of Gerontology (how's that for a title?) discusses the difference between the health care system in Japan vs. the U.S. Despite their more rapidly aging population, the Japanese government has not had to substantially increase its health care spending. Dr. Campbell goes on about the healthy Japanese diet, lack of obesity or violent crime. Everybody there has to buy insurance based on their income and physicians are not rewarded for doing more procedures. Yada, yada, yada.

What struck me like a sore uninsured thumb was that he did not mention the Japanese also do not SUE their doctors like we do. In Japan, there are only 22,000 lawyers vs. over 1,000,000 in the U.S. In the U.S., there is one lawyer for every 270 people. In Japan, it is one for every 5,800. None of the five health care bills floating through Congress mentions meaningful tort reform. The people who make out like bandits in these bills are the lawyers, the insurance companies, and big government. The people who get screwed are the patients, the doctors, and the hospitals.

The insurance companies get a huge new base of customers since the government is going to subsidize everybody to buy insurance. The public option has pretty much been pushed off the table. The feds have a vast new bureaucracy to support itself. More people on government payrolls with lifetime civil service employment and more generous government pensions to fund in the future. The lawyers have more potential patients as clients to sue physicians. With the rationing and long waiting times patients will have to face with "health care reform" you can bet there will be plenty of disgruntled patients who will be calling a TV commercial malpractice attorney.

Whatever happened to limits on punitive damages? What about limits on pain and suffering? What about forming a medical court, similar to family or tax court, that has a medically trained judge presiding over malpractice cases instead of having an uninformed jury make nonsensical judgements which they understand little about? How about a system to credential "expert" witnesses so we can be confident they actually know what they're talking about and aren't just some hired gun? How about a system of "loser pays"?

King Henry VI may have been a little extreme, but he was on the right track, "The first thing we do, let's kill all the lawyers."

Can I have more (drug) cocktail please?

Dr. Murray reportedly told the police he gave Michael Jackson Valium 10 mg, Ativan 2 mg x 2 and Versed 2 mg x 2 before giving him propofol 25 mg the morning he died. This according to the Houston Chronicle. This doesn't sound like a particularly lethal dose, especially given MJ's known addiction to prescription drugs. Something doesn't quite add up in Dr. Murray's statements. Let me quote Dr. Joseph Naples, chairman of Anesthesiology at Methodist Hospital, "The whole story sounds fishy, but who knows?" Curiouser and curiouser.

MJ also reportedly asked a British physician to give him prescription drugs while he was doing his This Is It tour in London. Dr. Susan Etok said MJ asked for propofol and Demerol amongst the list of drugs he requested. She said MJ offered up to $800,000 for her services in obtaining and administering the drugs. Dr. Etok, bless her soul, refused MJ. When she told Michael her decision, Michael emailed back not to worry, he will find some other doctor who would. Hello, Dr. Murray?

Monday, August 24, 2009

HOMICIDE


The LA County coroner's office has ruled Michael Jackson's death a homicide. Surprise, surprise. According to the LA Times, the coroner's office said "lethal levels" of propofol was found in MJ's system which led to his death. Dr. Conrad Murray told the police he usually gave 50 mg of propofol every night to help MJ sleep but on the morning of his death, he only gave 25 mg after valium, ativan, versed, and "various drugs" failed to help his insomnia. After MJ went to sleep at 11:00 am, Dr. Murray went to the bathroom. When he got back, MJ wasn't breathing so he started CPR. At one point he went downstairs to the kitchen and sent Prince Michael upstairs to his dad's room.

There are so many holes in this story it's hard to find the truth among all the fiction. First of all, I don't know what a "lethal level" of propofol would be. Certainly 25 mg is miniscule and I've hardly ever seen anyone fall asleep with that small amount, unless they were 90 years old. Of course Michael had a ton of other drugs on board which would synergistically enhance the effects of propofol. The police confiscated a whole pharmacy of sedatives from Dr. Murray, including valium, tamsulosin, lorazepam, temazepam, clonazepam, trazodone and tizanidine. But Dr. Murray should have known that and not leave Michael alone at any time. Plus 25-50 mg boluses of propofol would put you to sleep for a few minutes only. Dr. Murray says MJ received 50 mg nightly to help him sleep. Unless propofol was given as a drip, that would not help him sleep through the entire night. The police say they found no evidence that Dr. Murray ever prescribed or purchased propofol but propofol was found in his personal belongings. So where did the doctor obtain his supply? Somebody besides Dr. Murray is going to get into a heap of trouble here.

Dr. Murray said he performed CPR until the paramedics arrived. But he already said he stopped CPR to go downstairs to talk with security and sent MJ's son to the room. The police have cell phone records that show the doctor was talking for 47 minutes after 11:18 am. Who was he talking to while MJ died? Who was doing CPR while he was talking on his cell? Why would he stop CPR to go downstairs? And why would he send MJ's 12 year old son to his dead father's bedside?! This is beyond comprehension.

In the article, there are two versions of what happened after MJ fell asleep. One part said Dr. Murray went to the bathroom and came back to find MJ apneic. Another section said he was on his phone talking to his Houston office when he came back and found him apneic. I imagine it was probably a little of both. He went to the bathroom first (get a TURP or some laxatives doc) and started talking on his cell, as the 47 minutes on his phone records would indicate. Who knows how long MJ was dead by then.

Surgical tech passes on hepatitis C


The LA Times reported on a surgical tech, Kristen Diane Parker, who may have infected scores of patients with hepatitis C. She traveled from Texas to Kentucky to Colorado before she was finally caught stealing narcotics in the OR. Now thousands of patients are being tested for hep C and unfortunately a few have come back positive.

This article raises some serious issues. Ms. Parker apparently would go into the OR and switch syringes of fentanyl with dirty syringes, thus passing on her disease. Why were there syringes of narcotics lying around on the anesthesiologists' carts. Were these syringes not locked up or did she have the keys to the carts? If she was able to replace the narcotics with another syringe, why did she use dirty needles for the new syringe? She had access to new syringes but not clean needles? She was in the OR. There are needles everywhere and she couldn't find a clean one? You can bet JCAHO will be all over these hospitals' OR procedures in the very near future.

She says she didn't know she had hepatitis C because she didn't go see a doctor due to lack of health insurance. For goodness sakes she worked in hospitals. They don't provide health insurance for their employees? She was fired from one hospital for stealing fentanyl last April but she was able to move pretty quickly to a surgery center. Don't these places perform due diligence and investigate the backgrounds of their applicants? So many questions that need to be answered and accounted for.