Friday, January 29, 2010

Osama Bin Laden, The New Al Gore

Osama Bin Laden has now become an environmentalist. No, this is not a headline from Jon Stewart. In a statement released yesterday Bin Laden wants the whole world to abandon trade with the U.S. and stop the use of the dollar as a global currency because he accuses this country of causing global warming. Says Bin Laden, "Talk about climate change is not an ideological luxury but a reality. All of the industrialized countries, especially the big ones, bear responsibility for the global warming crisis."

Is he getting desperate because his jihadist messages are no longer resonating with his fellow Muslims? Does anybody think the Palestinians, the ones he claims to be fighting jihad for, care a rat's a** about global warming? I think Bin Laden is taking a page from Al Gore and trying to court the elite Hollywood crowd. He may even get an Oscar or a Nobel Peace Prize if he continues this new anti-Western message. Knowing the candidates the Nobel Peace Prize committee have rewarded, they may just give one to him.

Thursday, January 28, 2010

The Zen of Anesthesia

I was giving a MAC anesthesia to a patient in a sitting position for a brain biopsy. The head is completely draped and inaccessible. It is also pinned to a metal frame fixed to the OR table by a Mayfield device so an emergency laryngoscopy would have been virtually impossible. The case went very well. At the end of the case the surgeon looks at me and says, "It must be nice to get paid for just sitting there and doing hardly anything."

I was shocked he made this statement. I replied, "I only make it look easy." Internally I was indignant. I would never deign to presume that his work is simple and mechanical. Somehow he felt it was appropriate to make that remark to me. What he doesn't see is all the internal calculations that are a constant when a patient is under anesthesia. Is the patient's cerebral perfusion pressure adequate? What precautions have I made in case the patient gets an air embolus. Is the anesthesia deep enough to make sure the patient doesn't move while his head is pinned to the table? Is it light enough so that the patient can maintain a patent airway? If the anesthesia is too deep and he obstructs should I put in an oral airway? What if he starts coughing when an airway is put into his mouth? The patient has coronary artery disease and has had a cardiac bypass. Are his coronary arteries being perfused adequately? Are his blood pressure and heart rate optimal? He's rebreathing some CO2 under the drapes. How is that going to affect his pulmonary artery resistence pressure? How does his ETCO2 waveform look? Do the diminished waveforms mean the patient is obstructing or has the sample line moved? Are the patient's extremities adequately padded? Are his eyes protected from corneal abrasions?

All these questions and more go on inside my head throughout the procedure. But on the outside I exude the calm and confidence of a professional with years of experience in the OR. Thus the surgeon leaps to the conclusion that the anesthesia was "easy." I frequently tell surgeons that they want to see relaxed anesthesiologists. If they see their anesthesiologist running around at the head of the OR table, frequently ducking under the surgical drapes, and otherwise working frantically, then you know your patient is in trouble. So don't make the assumption that because your anesthesiologist is sitting there that the anesthesia is undemanding. It just means your anesthesiologist is in complete control of the patient's situation and you have nothing to worry about and can conduct your procedure with confidence. While you surgeons perform your single-minded task at hand, know that the other physician in the OR is watching out for the patient to make sure the operation is a success.

Wednesday, January 27, 2010

iPad=Feminine Hygiene?

Seems like the great Evil Empire that is Apple has stumbled badly when it came time to name their new tablet. I'm already sick of all their products that start with the letter "i". With all the billions of dollars they make can't they think of more creative names besides putting an "i" in front of a noun? (Same with McDonald's whose creativity ends at putting "Mc" in the front of their food names like McNuggets, McMuffin, and McGriddle).

When the iPad was announced, the association with feminine products quickly became obvious. Snarky remarks like this, "Heavy flow? There’s an app for that!" quickly made the rounds. The New York Times interviewed several people who noticed this awkward title. Says one public relations expert, "I’m waiting for the second version that comes with wings."

So I can see this happening somewhere sometime in the near future. A man goes to Best Buy to buy the new tablet. He asks the sales clerk where is the iPad. The clerk replies Walgreen is down the street. Ha ha.

Doctor Jokes Heard In The O.R.

An anesthesiologist calls a plumber to fix a clogged drain. The plumber comes, spends 30 minutes fixing the drain, and hands the anesthesiologist the bill. The anesthesiologist looks at the bill and is shocked by the cost. "I don't make this much as an anesthesiologist," he grumbles. The plumber replies, "I didn't make this much as an anesthesiologist either."

Five physicians go duck hunting in the woods. There is a pathologist, a radiologist, an internist, an orthopedic surgeon, and a surgical oncologist. Suddenly a bird flies out of the deep grass and into the air.
The radiologist says, "Let me study its shadow to see what kind of bird it is."
The internist says, "We need to form a committee and take time to study the bird's colors and texture of its feathers to determine the bird's species."
The orthopedic surgeon attempts to throw a rock at the bird.
The surgical oncologist grabs his gun and shoots down the bird. He hands the carcass to the pathologist and says, "Tell me what kind of bird this is that I just shot."

Tuesday, January 26, 2010

Labor Anesthesia With A Full Stomach

The New York Times highlighted a provocative research paper that advocates more leniency of NPO status in women undergoing labor. The paper is published in The Cochrane Review and is a meta-analysis of 11 studies looking at the rate of birth complications and likelihood of Caesarean sections as related to NPO status. The analysis shows no difference in APGAR scores, need for C-sections, or pain scores between women who were allowed to eat and those who were kept NPO. Thus the authors recommend that women should no longer be kept NPO during child delivery.

I say that's a bunch of hogwash. The official opinion from the American Society of Anesthesiology is not mentioned until at the very end of the article. Dr. Craig Palmer, Chairman of the Committee on Obstetrical Anesthesia said of the study, "From an anesthesiologist’s perspective, they missed the boat on this one. They looked at the impact on the progression of labor, but to be honest, that’s not an issue for anesthesiologists. Our primary concern is patient safety."

From my own personal experience most women who undergo C-sections have extreme nausea and vomiting during the procedure, especially when the uterus is brought out of the abdomen and hard pressure is placed on the dome to push out the baby. It is ugly enough when bilious emesis spews forth. I couldn't imagine the complications if the patient had a full stomach. The authors also fail to take into account well documented changes in gastric physiology of women with term pregnancies, including delayed gastric emptying, higher acidic content, and decreased lower esophageal sphincter pressure.

The news article mentions one OB/GYN who compares labor and delivery to driving a car. She says people can have accidents anytime, requiring emergency surgery. But we don't keep people NPO before getting into their cars. I'd counter that the argument is naive. Up to 25% of pregnancies now end with C-sections. If 25% of all vehicular trips end in accidents requiring surgery, then yes people should be NPO before getting into their cars. The authors also say that with improved techniques, the risk of aspiration with general anesthesia during labor is extremely low. Well that is a totally circular argument. The reason labor anesthesia is so safe nowadays is precisely because of rules advocated by anesthesiologists, including keeping patients NPO, that lowers the complication rates for the patients and their OB docs.

So this article is misinformative at best, dangerous at worst. The article leads with a mention of the low likelihood of gastric aspiration during labor anesthesia but that is not what the study is about. Now patients will be clamoring for their doctors to change their diet orders in Labor and Delivery when in fact the study does not compare the risk of aspiration in full stomach vs. NPO laboring patients. And frankly, a real randomized double blinded study like that will never be performed. If any women would like to volunteer to be in the full stomach branch of that study, be my guest. As long as they sign wavers absolving all legal responsibility of their doctors when they wretch up that oatmeal and bacon they had for breakfast and aspirate into their lungs.

Monday, January 25, 2010

Should You Eat It?

Hilarious algorithm for when to eat food after dropping it on the floor. Courtesy of SFoodie.

Sunday, January 24, 2010

I Hate Costco

Just finished the weekend with another brutal trip to Costco. Can there possibly be a worse shopping experience in America than going to Costco on a weekend? I think not. Sure the warehouse company is doing mega business and I wish I had bought its stock five years ago. But as far as shopping there one shouldn't go there if he is trying to control his blood pressure or anxiety. At least double your medications before heading out to the store.

There is something about having a massive number of people all crammed into one store that brings out the worst in humanity. It all starts in the parking lot. You circle the parking lot for an eternity, warming up the Earth's atmosphere another two degrees Celsius in the process, eventually stalking a shopper heading for her car. You feel like an idiot driving along at one mph following a total stranger, hoping she doesn't cross over into the next lane. When she finally gets to her car, she spends fifteen minutes unloading enormous quantities of frozen pizzas, toilet paper, wine bottles, and potato chips. Then as she leaves and you are ready to make your move, some moron coming from the opposite direction cuts into the space. You scream obscenities that will land you in the third circle of Hell and continue the Search for a Parking Space at Costco.

When the parking Gods finally grant you a spot, you are now faced with the daunting task of actually shopping inside the store. Giant grocery carts are whizzing by, with nobody giving anybody an inch of extra space or courtesy. Even NASCAR has rules about driving and passing. It is so bad I'm afraid to let my five year old walk next to me. I put her in the cart lest she gets into a hit and run with another shopper. Again huge numbers of shoppers are congregated around, well, everything. Good luck trying to get a free sample of food; somebody will steal it right out from under your fingertips. And whose stupid idea was it to put all the produce inside an open freezer? Sure it keeps it fresher but on a warm day when you're wearing T-shirts and shorts you don't want to walk into a room that's only forty degrees.

Finally the greatest challenge arrives, the checkout. An immense number of check out lines are open but each line stretches back halfway into the store. Which line might move the fastest? Let's see. One line has only five carts but each cart is packed to the rim. Another line has seven carts but fewer items in each. I'll try the seven cart line. Then you wait and wait and wait. Why does that person have to pay with a check? Doesn't she know it's the 21st century? Who doesn't own a debit card in this day and age? The next person says his wife is bringing more stuff and will be here in a minute. Ugh. I think my aneurysm is going to explode and leave a convulsing mass of human tissue here inside Costco, as if anybody would care.

Suddenly the aisle next to me opens up. I make a dash for it. The person on the other side also makes a run for the open line. Ha I made it first. Oh boy he doesn't look too happy. Hey what the hell. He has put the separator bar ahead of my stuff and is putting his items ahead of mine on the conveyor belt. What the f***? Of course the Costco employees are just standing there doing nothing, just talking about how much longer until closing time. I want to give this a**hole a karate chop right into his cricoid but alas, he is six inches taller and fifty pounds heavier. I think better of it and try to control my rage, and humiliation. Besides self preservation, it wouldn't look good if the newspaper reported that a local anesthesiologist was arrested for assault and disturbing the peace. Our group might not appreciate that kind of publicity. I tell myself, I'm letting this gentleman ahead of me, out of courtesy and respect for my fellow human being. Uh huh.

Finally, made it out of the store. Walk slowly back to the car, dodging all the traffic. Predictably there is a car tailing us as we walk all the way back. Okay, now it's my turn to slowly put my things in the car and strap the kids in the car seat while a stranger is lurking right behind me. Getting into the driver's seat, I let out a huge sigh of relief. Made it through another weekend at Costco. Until next week.

Friday, January 22, 2010

Medical Marijuana, Unlimited

In a victory for stoners in California, the California Supreme Court struck down laws passed by the state legislature that limited the amount of medical marijuana one can legally possess in the state. In 1996 California voters passed a ballot initiative allowing the use of medical marijuana. The state legislature later placed limits on how much drug one can hold. The maximum a person can possess was decreed as 8 oz. of dried mj and grow no more than 6 mature or 12 immature plants.

The Supreme Court ruled that the medical marijuana initiative that became part of the state Constitution never placed a limit on how much drug one can have. So now if somebody has a doctor's excuse, he can have as much marijuana in California as is "reasonably necessary."

Of course it is ridiculously easy to obtain a doctor's prescription for medical marijuana in California. I've written before how a doctor can moonlight as a medical marijuana prescription dispenser and make mucho bucks, all in cash. You don't even need to be certified in marijuana expertise because, well, there is no such thing. I know of no medical school in this country that even teaches a course on medical marijuana. So next time you visit California, don't be surprised if you see a bunch of bleary-eyed people driving around searching for White Castle.

Thursday, January 21, 2010

A Fool And His Car Are Soon Parted

If any of you are avid viewers of the Weather Channel, you know that we've been having epic rainfall here in Southern Cal. Floods, mudslides, tornadoes, mountain blizzards, we've had all that. The worst thing about all this bad weather is that Angelenos just don't know how to drive in wet weather. Take this picture from the LA Times for instance. Dude, you are about to drive a $130,000 white Mercedes sports car into God knows how deep that flood is. What the hell are you thinking? I can only dream of owning a car like that someday and you are getting ready to submerge this exquisite piece of machinery into that swirling tempest of water and mud. Better to return to the DMV to get a refresher courses on driving in rainy weather.

Tuesday, January 19, 2010

Lego Avatar

Some people are just so creative, and have a lot of free time. Check out these Pandora recreations using Legos. I don't have so much free time and admit that I haven't yet seen Avatar. I presume these are pretty good copies of what you see in the movie.