Friday, December 18, 2009


Telebation is a term coined for a remote intubation with the aid of telemedicine. This was first demonstrated at a small community hospital in Arizona which required an urgent intubation for a patient with severe COPD. The physician on staff was not comfortable with his intubation techniques so he set up a telemedicine conference with the University Medical Center in Tucson. With the use of a video laryngoscope, an attending in Tucson was able to visually assist the intubation and secure the airway before transport to a tertiary care center.

The outcome in this situation was favorable, but it raises some troubling questions. First, was the intubating physician ACLS certified? If he was he should have been familiar with the intubation technique. He would also have learned the other modalities of securing an airway, including the use of the Combitube. The Combitube was designed for scenarios exactly like this, when there is a difficult airway or when the user is not experienced with intubations. This small community hospital has the funds for a video laryngoscope and telemedicine equipment; it must or should have other intubation aids available.

How long did it take to set up the telemedicine conference call? If this was an emergency intubation, how would the small hospital have dealt with the situation? What would have happened if the remote user lost the airway? Video laryngoscopy is helpful but it is no panacea. There have been many times where even with the use of video I was only able to get a Grade 3 view, essentially no view of the cords. What would have happened then? Again it goes back to knowing how to use other equipment like the Combitube or the LMA.

The use of telemedicine here also promises interesting possibilities. If we can treat a patient remotely by telling somebody else what to do, does that mean anesthesiologists can work from home? Imagine hiring some medical student, or even a premed student to sit in the OR for you. Using telemedicine you can have him intubate the patient for you. You can then electronically monitor the patient's vitals and tell the student what meds to give. At the end of the case the student will show you the train of fours and then you tell him to reverse and extubate the patient while you are sitting at home in your PJ's watching CNBC on your 52 inch LCD. This would be even cheaper for the hospital than hiring a bunch of CRNA's.

Thursday, December 17, 2009

Gloves Gloves Gloves

Our hospital uses a profusion of gloves. As you can see from these pictures, they come in all sizes, colors, and textures. Most are latex free, some are not. Some provide better grip when wet. Some have better grip when dry. Some people have dermatitis with one kind so they have to use another.

Therefore we are not able to standardize on a particular type and have to buy a whole rainbow of colors of gloves. This is your health care dollar at work.

Please Don't Wash Your Hands

I saw this sign posted in a Chinese fish market. It's kind of gross to think people will actually think about washing their hands in a tank full of clams and then go handle produce and other goods. It's no wonder people get hepatitis and other infectious diseases. Ironically, I think the sign is there more to protect the clams than the customers.

Tuesday, December 15, 2009

Surgery Without Anesthesiologists

Another aspect of the story in the New York Times about a heroic 43 hour surgery really bothers, no angers, me. Besides the enormous expense of this procedure for questionable long term benefits, on a more personal note this article barely mentions the anesthesiologists involved in the care.

Toward the end of the surgery, when the liver was reimplanted, the operating team encountered some serious difficulties:

The liver bled profusely. Transfusions could barely keep up. Over the next few hours he needed 30 pints of blood. But even as the bleeding abated, his blood pressure and body temperature dropped, and his blood turned dangerously acidic. Drugs to correct one problem made others worse. He was sinking into a vicious cycle that could kill him.

Who was there giving all the transfusions, and the pressors, and other life saving maneuvers to try to salvage this 43 hour operation and the patient's life? There is not a mention of the work of the anesthesiologists at this critical juncture in the operation. It's as if all those interventions happened by magic. There is a single quote from an anonymous anesthesiologist in the entire article. Of course he, or she we will never know, is talking about the surgeon, describing him as having "soft hands." Blech.

On the 8th photo of the slide show, they actually described what the anesthesiology team was doing during the operation:

During surgery, anesthesiologists transfuse blood and other fluids and drugs, and monitor the patient's heart, breathing, blood pressure and blood chemistry, in addition to administering anesthesia.

That sounds like a pretty generic job description, something I do every day. That gives no indication of the exhausting work that must have been going on behind the drapes keeping this patient alive. Even the surgeon's PA had a picture and was mentioned by name in the article. But the team actually responsible for keeping the operation going is only shown as a single arm hanging up albumin and PRBC. Anybody can slice and dice a body into pieces. It is up to the skill of the anesthesiologist to make sure the patient survives this "attack" and wakes up afterwards in relative health and comfort. But thanks to writers of the New York Times, the public will continue to be ignorant of the vital roles we play.

Why Medicine Is Bankrupt

The New York Times has an incredible article about a 43 hour surgery for excision of an intraabdominal liposarcoma encasing the patient's internal organs. The surgery involved removing the tumor en bloc with the liver and other organs that it had invaded, excising the tumor, then reimplanting the liver.

The surgery was estimated to cost over $300,000 but I imagine ultimately it will cost at least $1 million after including postop care. The patient is described as a business owner who feels, "I've got too much fun ahead of me." My guess is that the patient has very good health insurance if he feels he can have an operation that expensive and still have enough money afterwards for "fun".

Isn't it ironic that right now there is so much debate about the cost of health care in this country yet the NY Times (We must have a public option) is glorifying a surgeon who performs an operation like this? Unless this patient is paying for everything in cash, you and I will ultimately pay for this. It is people like this who will cost the rest of us much higher insurance premiums and tax dollars. How can we have a rational talk about saving health care dollars when there are patients who refuse to accept a situation and are able to find doctors who will treat them, no expenses spared? And how did they convince the insurance company to pay for this? When these companies hire people to deny requests for a $10 lab test, they approved a million dollar operation of questionable medical value? It is no wonder no rational conversation about health care expenses is possible in this country.

When To Get A Cardiology Consult

Z, walking down the hall minding his own business.

Gastroenterologist: Hey Z, I've got a quick consult for you.

Z: Okay

GI: I've got a 95 year old patient from a nursing home here for a PEG placement. Her troponin level is elevated. Her primary care doctor says it is only a troponin leak. Do you think the anesthesiologist for her case will want a Cardiology consult?

Z: Yes

GI: I thought so. Thanks.

Z, thinking "Duh."

Elevated Troponin Level After Oral Sex

From a case report in Obstetrics & Gynecology.

A 29 year old pregnant woman was taken to the Emergency Room unconscious one hour after having oral sex with her partner. Cardiology was consulted for elevated troponin levels. It was determined the patient suffered from an air embolism after having air insufflation of her vagina leading to a troponin leak.

There you go. Make of that what you will.

Monday, December 14, 2009

What's It Like To Be In Primary Care

In a post in KevinMD, Dr. Ed Volpintesta describes his typical day as an internist. It sounds like a nightmare. Granted he has been in practice for 35 years so no longer takes night and weekend calls, inhouse patients, pediatrics, or GYN. He doesn't come in until 8:00 AM and leaves by 4:30 PM. Doesn't sound half bad does it? But then he describes an endless parade of phone calls, pharmacy refills, geriatric medicine, grief counseling, etc... And how much of this work is actual billable work? Makes me so glad I'm an anesthesiologist. I'm sure this article will further dissuade more medical students from primary care.

Friday, December 11, 2009

Christmas Party

How long does it take to finish off twenty boxes of pizzas and buffalo wings? In the case of our department Christmas party about ten minutes.

Thursday, December 10, 2009

Petri Dish Cookie

Thanks to Not So Humble Pie, we have the perfect dessert for the Microbiology department Christmas party.