Wednesday, June 30, 2010

My First 3D TV Experience

Some of you long time readers may remember my rant a few months ago about the harrowing, hair-raising, teeth-gnashing, nail-biting experience we had with buying a house in Southern California. With all the talk of a real estate depression we thought buying a nice house would be a piece of cake.  Instead the two month ordeal with trying to buy a short sale caused me to lose ten pounds and got me written up for my sour mood at work.  Ultimately we didn't get the house.  Then a miraculous event happened.  An even better property came on the market a couple of weeks later, just two blocks away from our lost house.  And this time we got it, after minimal fuss and no more hair or weight loss.  In fact I've gained back those ten pounds and then some.

Notice I said "property", not house.  The lost house was a newer and bigger house.  But our new house is on the "better" side of the neighborhood and has a much bigger lot.  It is the oldest and cheapest house in the best part of the neighborhood.  So now we have a remodeling project to attend to, which I was not anticipating when we set out to buy real estate.

But a nice thing about remodeling is that we get to upgrade the house with the latest equipment, from kitchen appliances to light fixtures, to, get ready, a NEW HOME THEATER SYSTEM. I'm so psyched.  With the success of Avatar, there is a whole slew of new TV's with 3D capability coming on the market.  While I normally don't buy first generation electronic equipment (I waited until the 3GS before buying my evil iPhone and I won't even touch an iPad until maybe the third generation if ever), the timing is such that equipping my new home theater with a 3D TV makes sense.  Why buy a new TV when it might be outdated as soon as next year if it doesn't have 3D?

I read through all the reviews of the models already on the market.  There's all this video jargon about ghosting and cross talk and other geek terms that made my eyes glaze over.  Then I traipsed to Best Buy to take a look for myself.  They had several models set up for 3D viewing.  The actual content available to watch in 3D was pretty minimal.  They had several 3D animated movies to watch, like Monsters vs. Aliens and Cloudy With A Chance Of Meatballs.  A Samsung model could convert any 2D programming into 3D on the fly so we watched some World Cup soccer in 3D.  That was kind of cool except the image appeared slightly distorted because of the artifical 3D created by computer. 

The first set I tried was a Pioneer plasma.  The 3D glasses were nice looking. They fit surprisingly well over my regular glasses.  They also felt extremely light.  I don't know how my ears and nose would hold up after watching Avatar for 3 1/2 hours with two glasses on my face though.  The 3D screen was, um, interesting when you first put on the glasses.  It definitely is 3D.  Images do seem to pop out of the screen. The picture also stayed 3D even when not standing directly in front of the TV, something that some reviewers had criticized about.  But after a few minutes I could feel my eyes getting tired.  This was concerning.  I certainly don't want to spend this much money on a TV feature that causes eye strain.

So I moved on to the Samsung LCD.  The glasses were not as attractive but they were equally light and fitting.  The depth of the image didn't seem as impressive as the plasma.  Maybe it was because I saw the plasma first that gave me that important first impression.   But I also noticed that my eyes didn't hurt after watching the Samsung.  It felt very natural. Perhaps something about the LCD vs. plasma? Also the Samsung has the 2D to 3D conversion, something the Pioneer doesn't.  But when you turn on the 3D feature, the image becomes unwatchable for anyone without the glasses.  The TV screen shows overlapping split images in 3D mode. Everyone in the room will have to wear the glasses to watch TV or everybody splits up to their own rooms to watch their own programming.  They didn't have the Sony set up yet for 3D so that's something I'll have to go back and try later on.

We're still in the middle of our remodeling so I don't have to decide just yet.  Maybe I'll wait until Christmas to read more reviews as people gain experience with these new sets and see if the price drops a little bit.  Perhaps more companies will come out with 3D TVs and I'll have more choices.  Right now it's a wonderful problem to have.  I love my new house, my new neighborhood, and being a lucky member of the ROAD professions.

Tuesday, June 29, 2010

Are You Smarter Than Goldman Sachs?

So you graduated from a top rated medical school.  You went through the toughest residency offered in the country.  Your CV would make the Dos Equis beer guy jealous.  Now let's see how you would do on Wall Street.  The following is the formula a Goldman Sachs analyst uses to calculate the value of Berkshire Hathaway.  Now do you feel the GS guys deserve their millions they make every year?


The Greater Fool

Any suggestions about what you would do in this next situation? I'm interviewing my next patient for outpatient surgery.  While discussing her previous surgical history, she says that she had a similar procedure done last year and her insurance wouldn't pay for the anesthesia.  So my billing office had been sending her letters requesting reimbursement for the anesthesia provided.  The patient says we had coded the case erroneously and we should have upcoded the case to a more complex procedure so the insurance company would reimburse for anesthesia services.  She claimed she had been going back and forth with the office about why she refused to pay.

I explained to her that the procedure today is similar to that prior one.  The anesthesia coding would probably be the same.  It would be a crime for us to change the procedure code just so we would get reimbursed from insurance.  She said if that was the case she is highly unlikely to pay for anesthesia services if the insurance company won't pay.

So now what do you think?  Should I have cancelled the case and risk the ire and wrath of the surgeon and the surgery center because of MONEY? Or would it be reasonable to proceed? Who is the greater fool, the patient for not paying money for services rendered, or me for proceeding with a case knowing that there is a high risk I won't get paid for it?  Should we all just become employees of the federal government and ObamaCare and forget about all this billing thing?

Monday, June 28, 2010

Call Us If You Need Us

A report from JAMA says that hyperoxia during cardiac resuscitation can actually be detrimental to the patient's health.  Patients whose blood gases came back with a pO2 of greater than 300 mm Hg were found to have an 80% greater chance of dying compared to patients with normal oxygen tension. 

I recently came back from an ACLS recertification course.  During the course they said the new recommendations are that patients should not have their chest compressions interrupted for the ten seconds it takes to intubate and protect the airway.  Also the patients should be bagged at a rate of no more than 8-10 breaths per second as hypocarbia can worsen tissue hypoxia, as demonstrated with the oxyhemoglobin dissociation curve.

Well great.  That means anesthesiologists no longer have to go running to every Code Blue in the hospital to emergently intubate.  The American Heart Association says intubations only delay the resuscitation algorithm.  Intubations usually lead to hypocarbia worsening tissue hypoxia.  And now hyperoxia leads to greater mortality.  Call me after you get the patient's pulse back.

Yeah It's Been Fun. Sorry It Didn't Work Out. I'll Call You. I Promise

Sorry U.S. Soccer.  Your second consecutive loss to Ghana in The World Cup has deflated the whole notion of America embracing soccer as the next great sport.  I'll see you in four years, assuming you qualify for the next World Cup.  Now it's back to the great American sports traditions.  Baseball's All Star game is just around the corner and the NFL preseason is less than two months away.  Are you ready for some (American) football?!!!

Friday, June 25, 2010

Propofol's Annus Horribilis

The one year anniversary of Michael Jackson's death is upon us.  With his death came the worst kind of notoriety for our favorite anesthetic propofol.  Previously, patients had no clue what kind of anesthetic they were receiving.  All they knew was that they did not wake up until the surgical procedure was finished and that was fine with them.  Now when they ask about their anesthetic, the word "propofol" elicits a universal "Oh, the Michael Jackson drug."  I've even had patients tell me they refuse to get propofol because of MJ's death.  Only after carefully explaining the negligent role of Dr. Conrad Murray do they understand that there is nothing wrong with the drug, just the administration of it by an incompetent physician.

The following twelve months did not improve propofol's reputation.  In July 2009, the FDA forced TEVA to recall 57,000 vials of propofol.  At least forty people were sickened by a batch of bacterially contaminated drug. Two lots of drugs were found to contain bacterial endotoxin.  Luckily despite some fevers and chills nobody died despite their sepsis.

Then in March 2010 Hospira was forced to recall several lots of propofol when tiny particles of stainless steel from their manufacturing vats were found in some specimen.  There were no reports of embolic injuries to patients with this finding. 

Finally in the greatest bombshell of propofol's horrific year, a jury in Las Vegas last month awarded a couple $500 million when the husband contracted hepatitis C after receiving propofol at an endoscopy center.  Dozens of patients were contaminated when the medical staff used a single bottle of propofol on multiple cases.  The jury ruled that Teva and Baxter were at fault for selling the center extra large vials of propofol, thus tempting the staff to use them on multiple patients to save money, despite the fact the bottles clearly state they are for single use only.  The pharmaceutical companies vowed to appeal but the week after the ruling, Teva decided to pull out of the propofol market completely. 

So what will the next year bring for propofol?  Is the end nigh?  Now that Teva has withdrawn from the market there are only two manufacturers left, and one of them is European.  The continued fear of lawsuits against this low margin generic drug may eventually force these last two companies to also drop their propofol production.  Then where will we stand?  There is still the old standby pentathol.  Maybe our pharmacy can dig up a few dusty boxes of them in the back of their cabinets. Versed and demerol is still widely used by gastroenterologists everywhere who refuse to use the services of an anesthesiologists. 

Then there is the promise of fospropofol, the water soluble successor to propofol.  It is a precursor drug that is metabolized into propofol in the body.  There is less risk of bacterial contamination because it is not preserved in a lipid medium.  It produces less discomfort with injection.  However because it is a precursor drug its affects maybe slightly more difficult to titrate than propofol.  Since it is a new drug it is also much more expensive.  Fospropofol is classified by the FDA as a controlled substance, similar to narcotics. So the ease of reaching into the anesthesia cart's drug drawer to grab a bottle of propofol will be a distant memory for anesthesiologists. The next year may prove to be quite consequential to our dear old friend.

Wednesday, June 23, 2010

U.S. Soccer On A Roll

Congratulations to the U.S. soccer team  on their win today against Algeria at The World Cup.  For the first time in 80 years the U.S. won their round and will go into the Sweet 16 against a team that has yet to be determined.  Poor England came in second but will also advance to the next round.

Now I've never been much of a fan of soccer.  Growing up in the Midwest the only football I knew started preseason in August and ended with the Super Bowl the following January.  Soccer wasn't even offered in our school system.  It was just the basic American school sports triumvirate of football, basketball, and wrestling, with a little tennis and track and field thrown in.  My feelings towards soccer can best be illustrated by this clip from The Simpsons below. 

Having lived on the West Coast for nearly twenty years, I've come to appreciate the energy and excitement every four years when The World Cup rolls around.  Most people here grew up with soccer, both at school and at home.  They know all the great soccer powers in the world and their legendary players with their legendary footwork.  As for me, I admit I'm still ignorant of the rules, "What, there is no time out?"  You might as well be talking hockey to me.  I couldn't tell you the difference between a striker and a defender. 

But I'm learning.  It's much easier when there are lots of soccer experts around to explain how offside in soccer is different from offside in football.  And why handball in soccer is a dirty word.  As the latest fair weather fan of American soccer, I'll be rooting for our team as far as they can go in the world's most watched sporting event.  But come August, the NFL will have my attention and my big screen tv for the next five months.  Go Chiefs!

Tuesday, June 22, 2010

What Happens When You Have Too Many Lawyers

What happens when there are too many law students and everyone is trying to be above average?  You lie, cheat, and do whatever you need to do to show your competency, that's what.  In an interesting NY Times article, Loyola Law School in Los Angeles will automatically add 0.333 to every law student's grade point average to bolster their transcripts.  Apparently it's a tough economy out there for lawyers.  New law grads are complaining that they aren't able to find jobs after graduation and are blaming their law schools.  In an effort to stand out in the jobs market, Loyola will supplement the students' GPAs to make them smarter than they really are.

This grade inflation seems to becoming more prevalent among law schools.  Grading curves have become more lenient all over the country, from UCLA and USC on the West Coast to NYU and Georgetown on the East Coast.  Ivy League schools Harvard and Yale have eliminated grades completely, relying on a pass/fail system.  Some schools are even paying law firms to hire their grads for a few months to "test drive" them and hopefully hire them after a couple of months of tryouts.  Says Stuart Rojstaczer, a former geophysics professor at Duke, “If somebody's paying $150,000 for a law school degree, you don't want to call them a loser at the end. So you artificially call every student a success.”

Now every law student will be like residents of Lake Wobegon, where everyone is above average.  But of course the averages move up when this is done.  So the schools and students will have to try even harder to deceive their new employers on their viability as legal "professionals".  Maybe they'll dumb down the bar exam so that there won't be as many "losers" and everybody will get their trophy JDcertificate for just showing up.

And why did Loyola choose 0.333 as the addition to their students' GPAs?  Their first year students' GPA's averaged 2.667 while other California law schools' students had GPAs of 3.0.  You can do the math.  Or maybe not if you're a law student.

Thursday, June 17, 2010


Congratulations to the Los Angeles Lakers!

2010 NBA Champions!

Now start working on your threepeat!

Wednesday, June 16, 2010

8 Simple Rules To Being A "Good" Anesthesiologist

Want to learn how to be a "good" anesthesiologist?  In the OR, it has nothing to do with clinical excellence.  Surgeons just assume that all anesthesiologists possess the same intubation and induction skills.  That's why they consider us interchangeable.  If you try to cancel a case, they just demand another anesthesiologist to work with since, well, we are all one and the same.  No, to be a good anesthesiologist, as in "Oh, I'm working with Dr. Z today.  He's a cool guy.  We like working with him," is more than just being the smartest guy in the room.  It doesn't matter that I just passed my board recertification and can recite the FA/FI ratios of seven different inhalational agents.  I might as well be speaking Klingon to the surgeon who may prefer to work with somebody who was grandfathered in with a lifetime board certificate and has not read a single journal article in 20 years but can wax poetic about the advantages of pancuronium over all these new fangled muscle relaxants.  No, to be a "good" anesthesiologist requires a certain je ne sais quoi that is not taught in any residency.  Follow along to discover how to be the most popular anesthiologist in the operating room.

1.  It helps to be female.  It sounds sexist, but alas it's also true.  Male surgeons like to have a Chatty Patty in the room to talk to, especially if the female anesthesiologist is also young and pretty.  Bonus points if she is still single.  Female surgeons like the XX camaraderie. Since the circulating nurse and scrub tech are also usually female, the OR becomes one big sorority pajama party.

2.  Play good music.  One of our partners likes to play music that can best be described as modern day Gregorian chants.  Needless to say he is not very popular in the OR.  Classic rock will usually suffice as most surgeons are of the age where they grew up with that music.  But be flexible if some surgeon decides to relive his adolescence and wants hip hop despite being fifty and balding.  The biggest mistake? Not bringing any music at all.

3.  Avoid temper tantrums.  Surgeons feel insecure if you can throw an object at the operating room wall harder than they.

4.  Be a comedian.  Nothing endears an anesthesiologist to a surgeon more than telling a really bad joke.  I'll get you started.  What's the difference between a Beverly Hills plastic surgery office and Whole Foods Market?  At Whole Foods the melons are all natural.  Ba da bing.

5.  Show no initiative.  Surgeons don't care what you think.  They only want you to do what they tell you to.  They hate it if you think a case in preop should be delayed because you want the patient to get an echocardiogram when you hear a 3/6 holosystolic murmur that has not been previously documented. 

6.  Watch ESPN as if it was the second coming of The Sopranos.  Surgeons love it if you can discuss sports stats as adeptly as interpreting an ECG.  Be especially vigilant about understanding the local sports scene.  For instance in Los Angeles you should be able to effortlessly parry a surgeon's stats about the greatness of Kobe Bryant by coolly dissecting the career of Magic Johnson.

7.  No eccentricities.  Surgeons dislike anesthesiologists with any kind of character.  They want faceless masked robots who will put their patient to sleep without drama.  A smidgen of wit is good.  Logorrhea is bad.  It is a very fine line.

8.  Buy food for the OR staff.  It can be as simple as blueberry muffins from Costco for breakfast or pizzas from Dominoes for lunch.  Sometimes a giant bag of tortilla chips with salsa will suffice. This last advice is very important.  It makes the surgeon and the OR staff very happy and will make up for a lot of deficiencies in the anesthesiologist.  This is probably the best and cheapest way to ensure your likability. In tough situations the well fed OR staff is your best bet to help you cover your ass.

There you have it.  Don't say you don't learn anything reading blogs from anonymous doctors who may or may not know what he's talking about.  But I guarantee that if you follow these rules, you will be the "best" and most popular anesthesiologist in your hospital.