We're Not In Kansas Anymore

Here is a riveting account of what happened inside St. John's Regional Medical Center in Joplin, MO when it was struck by an F5 tornado last week. It is written by Dr. Kevin Kitka, one of the emergency physicians who was working in the hospital at the time. The story is both horrifying in detail and fascinating in terms of the human spirit. What the people of Joplin went through, and is going through, is definitely no Wizard of Oz fantasy. Though the road to recovery will be long, I have no doubt that their spirits remain intact and the city will be rebuilt better than ever.

The Wisdom of Dr. Seuss

"Your Majesty, please...
I don't like to complain.
But down here below,
we are feeling great pain.

I know, up on top
you are seeing great sights,
But down at the bottom
we, too, should have rights.

We turtles can't stand it.
Our shells will all crack!
Besides, we need food
We are starving!" groaned Mack.

Yertle the Turtle, by Dr. Seuss

When I read this passage to my kids, my mind immediately turns to...Obamacare. The tale of a turtle with visions of grandeur feels very apropos in our country's healthcare debate. While we doctors are struggling with medical malpractice run amok, decreasing reimbursements, and escalating expenses, our political leaders and visionaries, who mostly have no idea how medical economics works other than what they read in their white papers, are making decisions for us that are mostly detrimental to our practices but sound good enough to help them get reelected.

Oh sure it may seem wonderful that over 30 million people will have health insurance once Obamacare takes full effect. But the insurance for these millions of new patients will only pay at a Medicaid rate, something which is already unacceptable today. What other professional field is forced to accept work that will only pay ten cents on the dollar? Then there is the lack of malpractice reform. A bone was thrown to us with a few reform programs being tested around the country. But true conviction on reigning in ambulance chasers is still just a fantasy.

The people and organizations who are supposed to be looking out for our welfare are mostly AWOL from the scene. The AMA? Look who they sided with during the debate over Obamacare. They are in bed with the politicians and thus not trusted by most doctors in the country. Republican lawmakers? They are in the pockets of the lawyers, bankers, and insurance companies. The President? He's too busy building a new Socialist Republic of the United States of America to care about the plight of physicians. His plans to raise taxes only on the "rich" or anybody making over $250,000 hits mostly the professional class. We are the people who are paying back enormous student loans, attempting to meet payroll and other office expenses, and laying out serious money for malpractice insurance. Most doctors will tell you they don't feel "rich". For people who are truly rich, the sports stars, Hollywood actors, Goldman Sachs partners, Silicon Valley entrepreneurs, and other multimillionaires, the new taxes hardly affect them as they already have more than they could possibly spend and can stash their loot in various tax free vehicles not accessible to the rest of us.

When will this pyramid scheme known as Medicare/Medicaid collapse under its own weight? When do doctors finally say "enough" to the humiliating exercise of begging for the status quo each year when the CMS threatens to cut reimbursement because of the ridiculous SGR formula enacted in the 1990's? When will Yertle the turtle come crashing down as enough turtles finally give up on propping up this illusion?

The New Standard

The Anesthesia Overlords have spoken. Starting July 1, end tidal CO2 monitoring will become mandatory in sedation cases. The addition of capnography in an anesthesiologist's arsenal for patient safety was detailed in the Standards For Basic Anesthetic Monitoring released by the ASA House of Delegates on October 20, 2010 and effective July 1, 2011. I printed an excerpt below relevant to our discussion. This is reprinted from section 3.2.4 of the Standards. Click on the picture below if the printing it too small to read.

Notice that it says, "During moderate or deep sedation the adequacy of ventilation shall be evaluated by continual observation of qualitative clinical signs AND monitoring for the presence of exhaled carbon dioxide." It doesn't say "or". It says "and". So no longer is just observing for chest wall movement or listening for breath sounds adequate. If a caregiver giving sedation wants to stay within acceptable standards of practice, that person will also have to monitor ETCO2.

This is good news for all patients. Capnography has been essential in the ASA's drive to making anesthesia as safe as possible. This, along with the invention of the pulse oximetry, has drastically improved patient safety over the past twenty years. Why the ASA doesn't make ETCO2 monitoring mandatory immediately is puzzling to me. How can delaying this by nine months from its approval help patients?

This is also a shot across the bow for medical personnel who have been lulled into thinking anesthesia is so safe that anybody can give it with little consequence. I'm speaking to you gastroenterologists, who push versed, demerol, dilaudid, or your holy grail, propofol, into your patients for their endoscopies. I'm talking to you cardiologists who give sedation for your cardiac caths but don't realize the patient has become apneic until the O2 sat has dropped into the 70's. Or the interventional radiologists who think they can give some sedation without adequate monitoring of the patient's physiologic status. This new ASA standard makes no distinction between caregivers. Whether they are MD's, CRNA's, AA's, or RN's, ETCO2 monitoring must be performed if sedation is being given.

People think that moderate sedation is somehow less dangerous than general anesthesia. My contention is that it is just as, or even more dangerous, than general. The airway is not protected. It is often given by people who are not familiar with the full consequences of sedatives. And if an airway emergency occurs, people familiar with emergency intubation are not immediately available. So this new mandate from the ASA is long overdue. And all you doctors who don't follow the new guidelines, well I'm sure the malpractice lawyers will have a field day with you in the courtroom when, not if, an airway incident happens.

When Disaster Strikes A Refuge

Here's a shout out to our medical colleagues at St. John's Regional Medical Center. The Joplin, MO hospital suffered a direct hit by a deadly tornado yesterday. As the pictures show, the building suffered nearly complete damage, with blown out windows and tattered roofs. Medical records and X-ray files have been scattered as far as 60 miles away into a neighboring county. The number of dead in the region currently stands at 116.

This makes you wonder how prepared you and your hospital are prepared for natural and man made disasters. What happens when the place people look to for medical care after a devastating event is itself disabled? How would you respond as a physician? What do you think you can do without electricity, clean running water, or any equipment so crucial to modern medicine? CT of head or abdomen? Nada. Phone consultation to a colleague? Not if the phone system is down. Emergency surgery for intracranial bleed? No power for anesthesia machines. Pretty grim indeed.

The hospitals of New Orleans were also crippled after Hurricane Katrina. The tales of horror that beset the patients and doctors there made national headlines. One doctor was even prosecuted for providing substandard levels of care at the time, as if there is a standard of care when there is no electricity, water, or medicine to treat patients. 

We doctors everywhere wish our fellow citizens well after this season of unusually deadly twisters. The patients in Joplin are being transferred to all areas around southwestern Missouri, including Springfield, MO and Wichita KS. Good luck and prayers to everybody in the area.

Doctors And Money

There is an interesting discussion over at the Kane Scrutiny blog at Medscape. The author asked the intriguing and relevant question, "Why aren't doctors allowed to care about money?" Lawyers are allowed to care about money. The partners of Goldman Sachs are allowed to care about money. But for doctors it is unseemly to think about it. The article has gotten thousands of reads and hundreds of written comments. Judging from the comments it is apparent there is a lot of anger and frustration in the medical community.

The responses fall into several categories. The doctors are to blame. We've been too passive as the government has rolled back reimbursement for our critical services. Doctors somehow have equated stagnant reimbursements and wages in an era of high medical cost inflation as a victory. We've allowed the insurance companies to lull our patients into thinking they shouldn't have to pay for anything, even the copays. While other important services from plumbers to lawyers to car repairmen have demanded cash on the spot, we doctors somehow have been talked into providing our work first and asking for money later. Does that even make sense? There are also too many doctors that make headlines for defrauding the public. Thus there is little sympathy for the plight of the majority of doctors among the public.

Perhaps the patients are to blame. They resent us. They hate us because even the lowest paid medical field earns two to three times more than the average salary in the United States. They don't understand us. They never take into consideration all the late night and weekend hours we spend taking care of patients and the administrative hassles that are required to get paid for doing it. Patients also never think about, or don't care about, the years of sacrifice doctors go through to get their medical degrees and the debt that comes with getting one. They don't want to hear from whiny doctors.

The government is to blame. It only cares about getting itself reelected. But doctors don't contribute nearly as much money to political action committees as the lawyers, insurance companies, or banks. Is it any wonder they pay scant attention to the needs of physicians? We are also too uninvolved with matters involving our own needs. The teachers union in Wisconsin can shut down their state government for weeks with massive protests all because they are being asked to pay a few percentage more on their health care benefits. Yet doctors continue to work like whipped dogs for less and less money while the AMA "quietly" works behind the scenes and within the system to preserve the meager payments we currently have. People may think doctors should be grateful for ObamaCare and its millions of newly insured patients coming our way. All doctors will see are millions of patients who demand 100% perfection from their physicians while getting paid cents on the dollar for the service.

All are relevant points. And there are no good answers for the foreseeable future. For any college students who are thinking about going into medical school, this should be required reading.

Operating Room Jokes Can Be Clean Too

One of the best ways to break the ice and relieve tension with a patient is to tell a good joke. It doesn't even have to be a good one. Any attempt at humor is always appreciated in preop holding and in the operating room. I've previously quoted a joke I heard in the OR that was downright X-rated. But not all jokes have to be dirty to be funny. These jokes I got from a pediatric surgeon who was telling it to his young patient and family. It got a laugh from the patient and a groan from the parents. So as the old cereal commercial used to say, kid tested, mother approved.

Why didn't the skeleton cross the road? It didn't have the guts.
Why else didn't it cross the road? It didn't have the heart.
Why else didn't it cross the road? It lost its nerve.

Cute but effective.

Wacky Wednesday

It's been a strange, wacky kind of day, and week so far. Here in SoCal we have been experiencing record amounts of rainfall. Don't worry blog readers. We haven't been inundated like the residents along the Mississippi River. Around here 0.25 inches of rain puts us in the record books. Still this is highly unusual for L.A. in mid May.

Other wacky California news include the revelation that our ex-governor Arnold Schwarzenegger fathered a love child with one of his household staff ten years ago Apparently that was the cause of his recent separation with his wife of 20 years, Maria Shriver. Everybody thought they were breaking up because of their political differences but the truth came out. Our Governator has been as busy and horny as the rumors have implied.

Then of course there is the bizarre story of the arrest of the savior of the capitalist world. No, not President Obama you silly. I'm talking about the rape charges against IMF chief Dominique Strauss-Kahn. I guess what's a perk for the French elite isn't so acceptable for the Americans. Now the economies of several European countries may collapse because of this guy's dalliances. Wacky.

All of which leads me to this, the 15th annual Wacky Warning Labels contest sponsored by The Center for America. They highlight five of the most frivolous warning labels on consumer products that are present only because of the American judicial system. How do we know this is a uniquely American experience? The warning label on a package of pens sternly advising one not to put a pen cap into one's mouth because it may lead to suffocation is written only in English, not in French, Spanish, or German as the rest of the package is written in. I guess Americans have an infantile need for more handholding and supervision while our European friends are busy with their more "adult" pursuits. Other warning label finalists include one that advises users to take the top off a jacuzzi tub so one doesn't drown when soaking inside and a bicycle brochure that warns the pictures of the happy people riding the bikes are professional riders, even though one of them is a small child riding with training wheels.

I took this picture of the warning labels on the playground of our local park. Click on the picture to make the words more legible. There are more stickers on the play set than there are beams on the monkeybars. We are told what ages children should be allowed to play on the equipment. How we should never allow kids to play without adult supervision. And how children have been strangulated when their clothes have gotten caught on the bars. Gee doesn't that sound like a load of fun for a bunch of kids to climb around in. Whatever happened to telling the kids to go to the park and play for a couple of hours? Now there is at least one adult at the playground for each child present. No child is allowed to play without the wary eyes of his parents fixated on his every movement. And heaven forbid if you try to help out somebody else's child at the park--people might mistake you for some sort of child molester and call the police on you.

Thanks to the trial lawyers in America nobody is allowed to get hurt or to have an unexpected injury. If something did happen, then of course it's never our fault. Somebody else must be to blame. Hopefully that somebody is a big company with very deep pockets and good insurance coverage. Then we can nurse our fragile bones and egos back to health with a large settlement check.

LMA And Morbid Obesity? Maybe Not Such A Good Idea.

A woman in Connecticut was recently awarded $10.5 million by a jury for a medical malpractice suit against Anesthesia Associates of New London and specifically Drs. Thomas Meitt and Bart Calobrisi (recently deceased) and Jean Richeimer, CRNA. Karla Rosa was a 44 year old patient who went in for surgery in 2006. I'm unable to find the type of surgery she was undergoing. According to the reports, the patient was morbidly obese but she was given a general anesthetic using an LMA.

The patient subsequently aspirated during the operation. She suffered a massive aspiration and was left in a coma for 26 days and stayed in the ICU for nearly a month. She required a tracheostomy and PEG tube for feeding. She also claims memory loss and neurologic, physical, and psychological damages.

Wow. I personally love LMA's. They are very easy to use, cause less damage to the upper airways than an endotracheal intubation, and are a life saver (literally) when there is an unexpected difficult airway. In fact, it's in the ASA's guidelines for managing difficult intubations. LMA's have been sold as being so benign that I've heard reports they are used in Europe even for laparoscopic cases. Outpatient surgery centers love them. Since most surgery center cases don't involve the abdomen, anesthesiologists routinely use LMA's as the patient remains breathing spontaneously and can be extubated quickly at the end of the case. Quick turnaround = more $$$.

But I've also seen cases where anesthesiologists felt pressured to use an LMA to facilitate rapid turnover of cases. Yes, sometimes that involves placing LMA's into morbidly obese patients. The surgeons think putting in an LMA is almost the same as a MAC case in anesthetic complexity whereas if they see the anesthesiologist intubate a patient, they start asking why an intubation is necessary. It's as if they think the general anesthesia is somehow more gentle with an LMA than an ETT.

I've never had an incident yet of an aspiration while the patient had an LMA. I've only seen one case, during anesthesia residency, of a patient who aspirated with an LMA. It was not my patient but I heard the resident and attending noticed the aspiration immediately and successfully intubated the patient with an endotracheal tube and the patient had no prolonged consequences. However since then the risk of aspiration is never far from my mind when I'm using one. And it's unfortunate that morbidly obese patients are the ones most likely to have a difficult airway and thus are the most tempting targets for using an LMA. But if you say you are going to use an LMA on a morbidly obese patient during oral board exams, get ready to answer the question of what you're going to do when he aspirates on the table and you can't get an ETT in as now the mouth is full of vomit. Not a pretty picture and not something I want to risk in real life.

The Shifting Continues

One of our local hospitals recently added laborists to their OB/GYN staff. This will now allow them to handle vaginal births after cesarean sections. I had never heard of laborists before but it makes sense. Laborists are obstetricians who only work in a hospital setting, similar to the concept of hospitalists for internists and family practitioners. The idea is the patient will have all her prenatal care by her personal OB. Once the patient goes into labor she is admitted to the hospital and the laborist takes over her care. This can really help the poor nursing staff who were frequently the only medically trained personnel in the labor ward who was helping the patient with her contractions. The OB doc usually didn't want to be called until the patient was dilated up to seven or eight centimeters either because he didn't want his office schedule disrupted or it was in the middle of the night. Frequently that meant the doctor would get to the hospital too late and it was the nurse who delivered the baby. From my personal experience, our OB doc didn't show up at my wife's bedside until she had been in labor for over 24 hours on a weekend. After about ten minutes he determined she should have a C-section instead. Gee thanks for showing up doc. I hope you made it to your golf game later that afternoon.

This continues the trend of more doctors embracing shift work into the daily schedule. Anesthesiologists have long been derided as not being "real" doctors because we frequently work in shifts, handing off patients to the on call person at the end of the day. But patients are becoming more comfortable with the idea of having a doctor in house all the time who they can talk to even if it's somebody they've never met before. Who wants to wait until the end of office hours before they can see their doctor? And usually that doctor will be tired and impatient, with little time for the myriad of questions one has accumulated during the day waiting for him to show up. As the experience of anesthesiologists, hospitalists, laborists, emergency physicians, and many other fields shows, doctors working in shifts do not decrease the quality of patient care. In fact I would bet that the care is better as the physician is not as tired or grumpy. He won't be burdened by what happened at the office earlier in the day. And the patient will have more access to his doctor. It's a win-win for everyone.

Not surprisingly, the last holdouts on shift work are probably the general surgeons. There is a machismo involved in that field that derides anyone who doesn't have the temerity to work at least 24 hours straight. Even now the surgical attendings belittle the work ethic of their own residents for not being allowed to work more than 80 hours a week and being given at least one weekend off a month. With attitudes like that it's not surprising how unpopular general surgery residency has become with current medical school graduates.

As more doctors are repulsed by the idea of working for days on end like the previous generation of doctors, maybe we'll have a more pleasant and well rounded generation of physicians. Who wants a doctor who admonishes a patient for poor eating and exercising habits when they themselves don't follow the same rules? Who wants a robot doctor who only knows work but doesn't even know the name of his own son's favorite baseball player or his daughter's best friend? I think shift work will bring humanity back into medicine.

The Negotiation

At the end of every surgical case, the anesthesiologist holds a negotiation with the surgeon on one of the most tedious aspects of surgery, determining the estimated blood loss (EBL). It certainly is important to estimate how much blood was lost during the case. This helps determine if the patient received an adequate amount of fluid replacement, the need for any blood transfusions, the cause of any acid base disturbances, any potential for kidney injury, etc.. As you can see, getting the proper EBL is essential for a successful operation.

But arguing with the surgeon over the EBL gets really tiresome. Some surgeons feel their manhood is at stake when it comes to how much blood they lost during the case. As the anesthesiologist, I am there watching the entire operation and have a pretty fair assessment of the amount of bleeding going on. But some surgeons always think they know better based on how much blood they see welling up from the patient's wounds. Believe me, they always underestimate how much bleeding has occurred.

In cases with significant hemorrhaging, they always ask how much is the EBL by looking at the suction cannister. If I say 500 cc, then they counter, "Well, there is some irrigation fluid mixed in there." I'm pretty sure I took that into account as the suction fluid looks like thinned Koolaid, not whole blood. I point out to them the huge stacks of dark red lap sponges hanging in the back of the room that the nurses count to make sure none are left inside the patient. That usually gets their attention.

What's worse are the surgeons who quibble over the tiniest amount of bleeding. In cases with minimal blood loss like an inguinal hernia repair or laparoscopic appendectomy, the back and forth can border on the ridiculous. If I say there was a 10 cc blood loss for the case the surgeon will counter that he thinks there was only 3 cc blood loss. Some surgeons will actually state that there was zero cc blood loss even though there are obviously some splotches of red on the surgical sponges. Logically our computerized electronic medical record will not allow an input of zero cc blood loss for any case where skin is cut. With surgeons like that I just sigh and accept whatever EBL the surgeon desires. I am not going to waste my time arguing over a difference of 7 cc EBL out of a total blood volume of five liters. If that's how they maintain their virility by low balling the EBL, let them. Who am I to emasculate a surgeon by saying the patient bled out an excess 7 cc of blood?

This is literally a game that all anesthesiologists have to learn to play. It starts from the very first day in the operating room during residency and it never ends. We want to be accurate about the true blood loss for all the reasons I described earlier yet appease the surgeon so that we can both feel good about ourselves. Perhaps some day we can have truly bloodless surgery like in Star Trek. Somehow I think even in the 24th century a surgeon will still argue with an anesthesiologist about something.