Burka Barbie

For the little girl who dreams of growing up illiterate and being forced into marriage with a total stranger. At least these burkas are of Italian design.

Alternative Christmas Trees

In the Wall Street Journal today, there is a hilarious article on alternative Christmas trees. Why spend $200 on a standard green dead or faux tree when you can recycle your trash to make your own personal statement? It is "green" in an ecologically correct way. There are pictures of trees made from coat hangars, Mountain Dew cans, and even beer bottles. Read it and you'll never look at a toilet brush the same way again.

From ROAD to RAPERS

I've mentioned before about the acronym for specialties that medical students are seeking out for their exquisite lifestyles and ginormous pay packages, ROAD (radiology, ophthalmology, anesthesiology, and dermatology). Of course the term ROAD is used in a condescending and derogatory manner by other specialties.

Now here is another acronym that includes anesthesiology. Again, it is used in a patronizing tone by other doctors who are not privileged enough to be included. Courtesy of the Happy Hospitalist, now we have RAPERS (radiology, anesthesiology, pathology, ER, and surgery). It represents the fields whose doctors are free to eat all the food in the doctors lounge before anybody else has the opportunity to get any.

Hilarious, and oh so true if my hospital offered free food for doctors. I have to brown bag my lunch every day. Of course one reason for that is that I rarely have time to go down to the cafeteria to buy lunch. Plus I'm cheap. By bringing my own food, I can nosh discretely in the OR without fainting from hypoglycemia. But I've been at other hospitals that do have free lunches for physicians and the anesthesiologists there were usually first in line. Their reasoning is that they have to eat first so they can give lunch breaks to all the CRNA's they are supervising. Sweet life those lucky anesthesiologists.

A New Public Option Pt. 2

In the previous blog entry, I pointed out the Senate is working on a plan to let the general public enroll in a health insurance plan similar to what federal employees get in the FEHBP. The Urban Institute wrote a study critical of how that might be achieved. Here are my interpretations of those criticisms.

The study said that Democrats in Congress and President Obama object to the fact that the public who would enroll in the FEHBP may not be able to afford the plans, therefore they would receive higher subsidies than what federal employees get. And that is JUST NOT FAIR. I guess these policy wonks really don't live in the real world. Here, when we buy insurance, healthy people pay more to subsidize sicker patients who actually use their insurance plans. That's what's called risk pooling. And my tax dollars have been subsidizing Medicare enrollees ever since I started working.

The Urban Institute also said there is a misperception about how generous the FEHBP benefits really are; they are not the Cadillac plans many people think. They are no more generous than the plans that large private employers offer. Well thank you very much. Not all of us are lucky enough to work for large private employers. Most people who would enroll in an FEHBP-like plan would be poor or self employed, like myself. We don't have the luxury of generous benefits. We choose the cheapest plan we can afford. So being allowed to enroll in a federal plan would be a huge step up for most people.

Other nit-picky objections in the study include that the FEHBP is not really a public option; it is a subsidized plan to buy private insurance, such as Blue Cross. Okay, I can live with that. They can call it whatever they want.

They are concerned that many people who are not happy with their current private insurance would move to this new plan if it became available. Well yeah. That's called competition. Isn't that what Congress wants to give health insurance companies?

The people who move to a federal plan would be the sickest and poorest enrollees, potentially burdening the new plan with higher costs. Again that is called risk pooling. A federal plan would have one of the largest number of customers to spread the risk. And isn't one of the reasons we're talking about health care reform is because of all the horror stories of people without health insurance becoming bankrupt and destitute because of their health care expenses?

Finally all these new sick enrollees would create a burden on the Office of Personnel Management, the federal department that determines the benefits offered in the FEHBP. I say that is their job. If they are unable to handle an influx of new enrollees, then fire them and find somebody who can.

It seems like the Senate may be onto something here. This could potentially please both sides of the aisle. We have a quasi Public Option to satisfy the Democrats while Congress would be forced to use the same health insurance plans as the public which would appease the Republicans. Let's hope no distracting sideline issues like federal funding for abortions and religious spiritual treatments trip up this progress.

A New Public Option

In the Senate's desperate attempt to pass health care reform, some senators are putting together a new plan. The plan calls for the public to enroll in health plans similar to what Congress and other federal employees get in the Federal Employee Health Benefits Program. This is an idea that many people have been clamoring for.

In the FEHBP, all federal employees and their families are accepted, regardless of any pre-existing medical conditions. The plans are portable nationwide. So if an employee gets transferred from Washington to Kansas City, he can keep the same plan. The plans are also portable across different jobs, as long as it is a federal job position. Even after an employee retires, he can keep the same plan with the same premium, something everybody else can only dream about. Right now, when a person retires from a company, the private insurance premiums are so expensive that nearly everybody enrolls in Medicare. Currently half of the people enrolled in FEHBP are retired. There is also choice, with ten different plans for federal employees to choose from. Most people, if they have a choice, only have two to three from their companies. Federal employees pay 25% of the insurance premium for the cheaper plans, with the government (you and me as taxpayers) picking up the rest. For higher priced plans, the employee pays a larger share.

Sounds perfect right? A nationwide portable health insurance plan, no denials for pre-existing conditions, and multiple plans to choose from. What could be easier than explaining to the public that they would get the same health insurance benefits as their Congressman, rather than the current labyrinthian proposals on the table. According to a study by The Urban Institute, there are some risks to allowing the public to enroll in health insurance plans similar to the FEHBP. Some of the downsides noted in the study don't seem justified, and I'll explain why.

Originally this was going to be one entry. But it got so long that I decided to split it into two sections. You can read part two tomorrow.

When Relatives Stay For The Holidays

This is what happens when relatives and their small children move in for the holidays. Good thing Thanksgiving and Christmas only come around once a year.

I Got Spanked

As every doctor eventually learns, don't ever cross the nurse in the hospital. You will be truly sorry if you don't remember this lesson each and every day. I just got back from a painful meeting with my chairman. He said a nurse complained about my behavior a few days ago. He wanted my side of the story.

I told him I vividly remember the details of that encounter. I was in a particularly grouchy mood that day, which I won't go into. I gave the nurse an order which she promptly disregarded. That set off my short fuse that day. I promptly marched up to her and "talked" to her very loudly. Unfortunately I didn't have the sense to do that in private but in front of the whole OR. Well guess what? For her act of insubordination, I get written up and could eventually be investigated by a Well Being Committee and sent to Anger Management class. The nurse? Well she gets to play the victim of the crazy out-of-control doctor. Any complaint about her now will seem petty and vengeful.

My chairman was sympathetic. He's heard this all before. His advice? If I feel I might be losing control, go to a dark closet and scream my head off to myself before doing something that I will come to regret much later. He said, sounding quite Shakespearian, the world is a stage. We have to go out on that stage and perform to the expectations of our audience, whether they be the patients, the nursing staff, other doctors, the janitorial service, our spouse, our children, our friends, etc. We cannot let our guards down. Of course he was right.

The relationship between doctors and nurses is pretty one-sided, and it's not to the advantage of the doctor despite what nurses may think. We've had physicians here fired because of complaints by a single nurse. But nurses are almost impossible to get fired by the complaints of a doctor. I had a severe case of remorse after that angry encounter and I barely made a peep afterwards. But the damage was done. I've been written up, for the first time ever. My reputation has now been carved into stone. The nurses on that ward will always remember me as the anesthesiologist who cannot control his temper and screams at poor innocent nurses.

Men, Time To Bend Over

The Senate passed the first amendment to the Healthcare Reform Bill. The amendment, sponsored by Sen. Barbara Mikulski, forces insurance companies to provide screening tests for women's health issues at little to no cost. Another win for another interest group.

Let's count the winners so far in America's health care debate. As just mentioned, women will now get virtually free screening exams courtesy of insurance premiums paid by all. The elderly in Medicare are sacrosanct, as exemplified by the Senate's vote tonight to leave all Medicare benefits untouched, despite the pledge by Congress to cut $500 billion from Medicare spending. Veterans are protected with free health care from the VA. Poor to middle class children are covered by SCHIP. Poor and disabled adults are covered by Medicaid. Illegal immigrants get charity care in county hospitals and the emergency room.

Who are the losers so far in this debate? It is the hard working middle to upper middle class men in America. It is these men, the most productive members of American society, who have been left out to dry. We are the ones who earn most of the income from which Congress will redistribute to everybody else. We are the men who spend so much time at work to make sure our families are well taken care of that we miss our own physical exams, our own screening tests for prostate or colon cancers, our own dental and eye exams. Nobody in Congress dares to mention the inequity of it all. While it is compassionate to offer free health exams for women, it would be completely sexist if the same bill applied only to men.

So men, get ready. The rubber gloved finger of government is about to become a fist.

Uvula Piercing

While doing some research on intubation injuries, I came across this lifestyle procedure, uvula piercing. It is not very common but unless you ask you never know. Hopefully you would catch this when you ask the patient to open his mouth to evaluate for Mallampati classification. We've been surprised in the OR when the patient, upon being undressed to get ready for their skin prep, to find body piercings anywhere from the nipples to the genitals. Facial piercings are also very common. Besides the ears, I've seen piercings in the eyebrows, nose, lips, tongue, chin, cheeks, and forehead. Just about the only thing on the face that can't be pierced is the eyeballs.

Check out this blog on how a uvula piercing is performed. Notice the recipient's earlobes. One of our OR techs has something like that. It is usually filled with a large colored disk, not hanging as a giant loop. Also note the anxiety on his friend Marty's face in the background as he is getting pierced. All this raises the question of WHY? Probably the only explanation is because it can be done. Ah, the insanity of youth.

Dude, are you working out?

I walked into the operating room to see if my colleague needed a break after a long night on call. I hadn't seen him in about a month and I was immediately struck by how BLOATED he looked. His scrub shirt looked like he was hiding the Incredible Hulk underneath. His neck seemed to have gained four inches in circumference. I asked him the polite way of asking somebody if they've been gaining weight, "Dude, have you been working out?" He said no. He does have a home gym in his garage but basically what he has been doing finally is eating on the job. He said he was tired of feeling cold, hungry, and dehydrated all the time in the OR.

We have a large number of anesthesiologists in our group, over fifty. There is just no way to give everyone fifteen minutes for a lunch and pee break. So each person is on his own. My friend began to worry about his health. While the nurses give each other breaks (it's in their nice little contracts) and the surgeons can leave anytime during a case to go to the bathroom, anesthesiologists are stuck in the OR all day or in too much of a hurry to get their next case started to give a break to themselves. This has led to several anesthesiologists here getting kidney stones, some requiring surgery. Some have nearly passed out and needed an IV bolus to keep going.

I was on call a few weeks ago and I worked nonstop from morning until the following morning after 2:00 AM, with no breaks in between cases. As soon as one case was finishing, the OR scheduler would page me and tell me to go set up another room as the surgeon was here and the patient was ready in preop, just waiting for me to get the case started. It went on like this for nearly eighteen hours straight. This is the reason many anesthesiologist will bring a snack into the operating room, usually something discreet like a power bar and bottled water. It's not like we're bringing in take out from McDonald's but we do need to rehydrate ourselves. And everybody in the OR knows this. I've never been reprimanded for snacking in the operating room. The nurses sympathize with our plight and the surgeons know that anesthesiologists snacking in the room allows for quicker turnover as no lunch break is needed between cases.

So despite the fact that JCAHO highly frowns on eating in the OR, we stealthily munch away behind the drapes. My friend realized that nobody was going to look out for his well being in the operating room. He now brings fruits and other snacks with him to work. He has gained twenty pounds since he had this revelation. And he feels 100% better.