Friday, November 13, 2009

Mercedes SLS AMG Gullwing

Another car for my future midlife crisis.

I have always been a fan of the 1954 Mercedes 300 SL Gullwing. I loved that car even while in high school. While others had posters of the Lamborghini Countach or Ferrari Daytona on their bedroom posters, I have always dreamed of owning a Mercedes Gullwing someday. Alas I knew I would never earn enough money to own one of those million dollar originals. Now Mercedes has updated the Gullwing so that I can own one for a minimum of 200 freaking thousand dollars. Alas, like back in high school, that might as well be a million dollars.

People have the mistaken image of doctors as fat cats driving around in their Rolls Royce on their way to Per Se to dine on imported truffles and caviar before jetting off to Paris to watch an opera. While doctors are relatively well off, we're not Bill Gates or Warren Buffett rich. We may not be worried about where our next meal is coming from but most doctors live paycheck to paycheck, saving just enough for our mortgages and children's college educations. When the federal government talks about raising taxes on people making over $250,000 it directly affects people like physicians, who make just enough to have to pay higher taxes but not enough to not be bothered by it. If somebody is making a million dollars a year, they probably have enough to cover the extra tax payments. But a physician who makes $250k will have to cut back in order to pay the higher taxes.

So even though I'm making a very decent income, the Mercedes SLS AMG Gullwing is still a pipe dream, just like the Porsche Panamera. It's nice to dream about but for now I'll be getting into my seven year old Honda Accord to get to work.

Wednesday, November 11, 2009

My cellphone rings...

My cellphone rings. "Dr. Z. Where are you?" I look at my alarm clock. Shit! My first case was supposed to have started ten minutes ago. What happened to the alarm? Have the kids been playing with it again? Nope, just plain overslept. Do I have time for a shower? No. I'll just put on extra deodorant today. Good thing I got a short haircut last week, less of a grungy matted hair look. God I smell like my gym's locker room, a decidedly musky rancid odor. Shave? No time for that either. Guess I'll go with the lumberjack look today. Got to brush my teeth though. Throw on my scrubs. Got my wallet, my keys, my beeper, and my evil iphone. Out the door we go.

God I hate commuting at this hour. So many crazy drivers trying to get to work. Oh crap I forgot to change my underwear. Oh well just another reason to slow down and not get into an accident. C'mon lady! The light turned green five seconds ago. Stop applying your makeup and move it. And can you try driving with at least one hand on the steering wheel please? Stay calm. Turn on some soothing classic rock on the radio. Nobody at the hospital will give a shit if you die while trying to get to work. Man look at this line of cars trying to get into the hospital's parking lot. So this is what it's like when people come to work during normal working hours. Damn it. Why is there always some idiot who suddenly realizes he can't find his ID badge just as he pulls up to the parking gate? Got lucky today. Found a spot that's not a day hike away from the door.

One of my partners has graciously started my case for me. Thanks man, I owe you one. No problem, it happens to everybody. Is it just me or is he standing a little further away from me than normal? Okay now I'm good. I am in my element. I rearrange the anesthesia cart to the proper way, MY way. Check the patient. No twitches. Good. Sit back. Everything's good.


10:00 Hey I'm doing okay. I thought that late night case last night would wipe me out. But I'm doing okay after only four hours of sleep. This is going to be easier than I thought.


12:00 God why do the nurses and surgeons get breaks but not the anesthesiologists? I'm dying here. If OSHA knew the working conditions of anesthesiologists they would declare it a dangerous occupational hazard. I'm fading, fading... Where is my power bar? I need some rehydration but I don't want to have to run to the bathroom later. I'll just sit here and swallow my saliva instead.

13:00 "Anesthesia! Patient's waking up!" Huh? Oops. Sorry. Where is that syringe I drew up? There. No more twitches for you! Jesus I got to stay awake, I mean alert. Get up off your chair and walk around. That'll do the trick.

14:00 There is a God; this wretched case is finally wrapping up. Call preop. We're closing in here. Is my next patient ready? Really? The OR scheduler moved my next case to another room? Is she going to put anything else in here? Thank God. I have to remember to buy her something for Christmas this year.

Early out for once. So that's what the sun looks like. I won't have to take my Vitamin D supplement today. Gee it feels strange to be driving home with all this traffic. Hey buster do you mind not throwing your freaking cigarette ashes all over my car? Smokers are so disgusting. They think the world is their ashtray. Whatever happened to ashtrays inside cars, not that anybody would use them anymore. Just toss it out the window.

Get home in time to take a nap before the kids come back from their afterschool activities. I really need one. Then it's dinner time, play time, reading time, and finally bedtime for everybody. Try to recharge for another day. Only twenty more years until retirement. Got to remember to set my alarm clock really LOUD tonight.

Tuesday, November 10, 2009

Don't call your patient a C.O.W.

In our rush towards electronic medical record keeping, perhaps we haven't fully examined all the possible consequences. At our surgery center the patient's history is entered in preop holding on a computer workstation that is placed on a rolling cart. When the patient is taken to the operating room, this Computer On Wheels follows the patient in, thereby ensuring continuity of the patient's records.

One day as a rather portly patient was brought into the operating room, the circulating nurse yelled, "Bring in the C.O.W.!" I guess the patient took offense to that remark. She remembered enough about that incident to write an angry letter to the hospital administrator complaining about the staff's lack of courtesy calling her a cow. Now we never mention the word cow in the O.R.

Monday, November 9, 2009

Best thing about my iphone

I've had my iphone for almost a month now. It is a fascinating piece of technology; all that power that I can carry in the pocket of my scrub shirt. I find I can type on the virtual keyboard fairly easily, if slowly. That's okay because I'm not trying to compose a novel on the thing. The browser works as expected but without Flash support. It was neat to watch U2's concert stream on YouTube on that little thing, like having a portable TV in my pocket. The iphone's ability to pinpoint my exact location and give me real time traffic report for the streets around me is both fascinating and creepy in a 1984 sort of way. The apps, like I've said before, are overrated. I suppose some people download dozens of games and whatnots on their iphone. But I've only downloaded about 20, most of them news apps. I paid $0.99 for a couple of games (80's arcade style games is my thing) and used them hardly at all. There are no worthwhile anesthesia apps to download.

The best thing about my iphone actually is the screen. Not the touchscreen functionality, but the fact that it accumulates no grease. It is quite amazing. When I first got the phone I thought this touchscreen would be a bitch to clean. But after a month, there is no fingerprints on it. For comparison, my wife got a touchscreen phone from another manufacturer and her screen is totally smudged with fingerprints and face grease. She wouldn't believe that my iphone screen would dissipate skin oils automatically so she rubbed my phone all over her face, leaving a giant smudge on the screen. I put the phone away. When I brought it out again 30 minutes later, the face grease was almost gone. The screen stays shiny and clean, almost like new. Magical.

Apple has put on what they call an oleophobic coating on the screen to solve this problem of oily skin. Bill Nye has a nice short explanation of this. It really works well. It is smart thinking like this that makes them a $200 a share company. Wish I had been an Apple stock believer earlier. Sigh.

Sunday, November 8, 2009

Best anesthesia song ever

I'm talking of songs about legally prescribed sedation, not illicit drugs. So that eliminates most rock songs like "Lucy In The Sky With Diamonds" and "White Rabbit" (though that is now street slang for propofol). Every time I hear this song I feel like the song was written by an anesthesiologist. Not only is it a great song about anesthesia, according to Wikipedia this song contains one of the greatest guitar solos of all time and was voted the best song ever by this band. Of course I'm referring to Pink Floyd's "Comfortably Numb" from their album "The Wall." Most people probably could relate more with "Another Brick In The Wall" with its rebellious anthem "We don't need no education. We don't need no thought control." But as an anesthesiologist "Comfortably Numb" makes me feel like I had written the song myself if I was ever that brilliant. Sometimes I'll say a couple of these lines almost verbatim to a patient when I'm taking a history. Unfortunately nobody has ever accused me of being the next Roger Waters.

Come on now. I hear you're feeling down.
I can ease your pain, get you on your feet again.

Relax I'll need some information first.
Just the basic facts. Can you show me where it hurts?

There is no pain you are receding.
A distant ship's smoke on the horizon.
You are only coming through in waves.
Your lips move but I can't hear what you're saying.

O.K. just a little pin prick.
There'll be no more aaaaaah!
But you may feel a little sick.

Can you stand up?
I do believe it's working good.
That'll keep you going through the show.
Come on it's time to go.

According to Rolling Stone magazine, the song was conceived during Pink Floyd's concert tour promoting their Animals album in 1977. Waters was having severe stomach cramps in Philadelphia when the house doctor came and gave him a tranquilizer so he could continue the show. Ah the sacrifices great artists make for their art. I thought about including a YouTube clip of "Comfortably Numb" from their movie "The Wall" on this blog but I didn't like the movie much and the visuals distract from the poetic lyrics so I'll let you readers surf over there yourself if you're interested. A must have song on any anesthesiologist's playlist.

A close second for best song about sedation might be The Rolling Stones "Mother's Little Helper." However that song's subject might be more appropriate for a psychiatrist's playlist than an anesthesiologist's.

Friday, November 6, 2009

What do anesthesiologists do?

What do anesthesiologists do for three hours when the patient is asleep on the operating room table? Here is a funny video parodying anesthesiologists. Video probably came from the U.K. based on the singer's accent and the spelling "anaesthetists." It's funny because it's (half) true.

Death of a surgeon

There is a shrine in one of the operating rooms at my surgery center. It is dedicated to a young surgeon who died a few years ago. The shrine consists of his framed picture and a mix music CD he liked to play while operating. He always liked to finish his cases playing Quiet Riot's "We're not gonna take it."

Working in that room the other day, I'm reminded of one of the most surreal moments in my life. I was on call on a Saturday night. That surgeon books a laparoscopic appendectomy to start around midnight. He is very nice and well liked by all the staff. He comes in cheerful as usual. The case goes well without any drama. He leaves the operating room around 2:00 AM, saying thanks and goodnight to everybody. He looked the picture of health and good cheer.

Come Monday morning he doesn't show up to the operating room, which is extremely unusual for him. The OR pages him and calls his cell phone without success. They call the police to his place. He is found dead in his bed. No signs of foul play. He was single with no dependents. Everybody is completely shocked. Word spreads quickly throughtout the hospital. Some nurses are brought to tears. I realized I may have been the last person he saw and spoke to before he died. The hospital held a memorial for him and he was eulegized by many surgeons and anesthesiologists. He was only forty years old.

Thursday, November 5, 2009

Annoying surgeon's request

Okay so I've detailed a couple of outrageous, maybe even dangerous, surgeon's requests. Now here is one that is simply annoying. We were in the middle of a breast biopsy. The surgeon was operating by himself with just the scrub nurse helping him. Suddenly he looks at me and asked me to hold a retractor for him through the drapes. I was taken aback. I thought, was he serious? When I refused, he appeared surprised and irritated. He then asked the circulating nurse to hold the retractor for him.

So now this became a hassle. Everytime the surgeon needed a new suture or the phone in the OR rang, the nurse had to drop the retractor. Plus she was standing at the head of the bed, partially obstructing my access to the patient. The broader implication of this request was that the surgeon had no respect for my job. He thought I had nothing better to do than to stand there holding a retractor for him, as if I was behind the drapes only playing video games or something. He obviously did not appreciate my work keeping the patient stable so he could have a successful operation. If I was holding a retractor, that would make it impossible for me to adjust the anesthetic if the patient got too light, or give her a pressor if her BP got too low, or a hundred other things I do during a case that the surgeon doesn't see and apparently doesn't care.

When I querried other anesthesiologists later about this, some of them surprisingly said that they have been asked and have assisted the surgeon by holding the retractor during a case. But it gnawed on their dignity while they were doing it. It was just easier to help out the surgeon than to look him in the eye and say no. But by doing so, the surgeon gets the idea that he can get away with operating without an assistant by asking the anesthesiologist to do the work, trivializing our job. So this is a good lesson for me. Sometimes you have to do what's right for the patient, even defying the surgeon if necessary. By saying no, the surgeon may be upset but at least he'll know I take my job seriously; I'm not some gasman sleeping behind the drapes.

Doctors, no money for you

The proof that physicians have no friends in Congress is at hand. The Senate passed a bill that will extend unemployed benefits to 99 weeks and continue the home buyers tax credit. The tax credit now will be open to anybody, not just first time home buyers. The income limit for eligibility has also been raised so more people can use it, maybe even allowing some doctors to take advantage of it.

It didn't seem to matter that the original tax credit has already cost the government $10 billion in tax revenue during a time of trillion dollar deficits. This new tax credit is calculated to cost $11 billion. It also didn't make any difference that there is rampant abuse of the original home buyers tax credit. Many people who are ineligible have applied, and received, the money. Some people have used their children's name, some as young as four, to claim a first home. Others have used it to buy investment property. One tax preparer in Jacksonville, Florida has been sentenced to prison for helping his ineligible clients get the credit then pocketing $1000 for himself each time. The IRS is investigating over 100,000 cases of possible violations of the tax credit rules. Into all this the Senate has deemed an urgent need to throw in another $11 billion. Maybe it's because Sen. Harry Reid of Nevada, the Majority Leader of the Senate, comes from the state with the most use of the credit on a per capita basis.

With all this money being thrown at a "systemic risk" Congress couldn't find in their multitrillion dollar budget the money to prevent a 21% cut in Medicare reimbursement next year. Again doctors are playing by other people's rules. While lawyers, insurance companies, homebuilders, car dealers, etc are throwing millions of dollars into lobbying Congress, doctors just sit back and pray that Congress will see their plight, or the plight of the elderly, and dribble some money our way.

Wednesday, November 4, 2009

Outrageous surgeon's requests

As an anesthesiologist, I try to make sure everything in the OR runs as smoothly as possible. To do that, it helps not to step on anybody's toes and try to get along with everybody as much as possible. But sometimes a surgeon will make a request that can be simply outrageous, even downright dangerous to the patient.

There was this one surgery center I used to work at that performed a lot of arthroscopies. A surgeon who worked there, and may have been a partial owner, was known to be a real tyrant. He went through dozens of anesthesiologists who all eventually refused to work with him. His main request, or more accurately demand, was that during his arthroscopies, the patient's systolic blood pressure be less than 100, in the 80's if possible. It didn't matter that the patients he brought had all sorts of morbidities: morbid obesity, hypertension, diabetes, coronary artery disease. The preop workup was usually minimal, practically nonexistent. He would have his patients up in the sitting position for the shoulder arthroscopies, constantly looking over the drapes to check the blood pressure. If the BP went over 100, like 101 or 102, you got a good yelling. It got to the point where right before the BP cuff inflated, I would give a small dose of nitroglycerin to make sure the BP appeared low. Cerebral perfusion pressure be damned. After a few months of this, I left that surgery center and got my self esteem and sanity back.

At another site that I used to work in, they did a lot of pain procedures such as epidurals, facet joint injections, etc. The way to make money in a pain center is to drive through huge volumes of patients. The pain doc, really an overpaid egotistical anesthesiologist, didn't want his patients to feel any pain upon injection and didn't want to wait for a routine anesthetic to kick in. So he demanded all his patients receive Versed 10 mg and Fentanyl 100 mcg IV boluses right before he injected. Of course that cocktail put the patient's out like a light switch. Since pain procedures usually take about ten minutes to perform, the patient was usually still sound asleep when he was finished. Now you can't clutter up a small recovery room at a pain center with a bunch of sleeping patients. So the routine there was to give a bolus of Flumazenil and Narcan when the procedure was completed. That usually woke up the patient right away though many still felt groggy. They were discharged pretty quick, before the reversal agents wore off and the patients fell asleep again. It's surprising not more people had complications from this.

There are so many other difficult surgeons I could write about. These are the reasons why I don't understand the desire of many anesthesiologists to work in surgery centers. They are usually owned by the surgeons and your bread and butter really depends on satisfying their every whim, no matter that fulfilling their requests would probably get your anesthesia board certificate revoked. I don't work in these places anymore but it's scary to think that many are still out there.