Thursday, July 5, 2012

Will Ritalin Lead To The Demise Of Anesthesiologists?

A recent study in the journal Anesthesiology showed that the common drug Ritalin, or methylphenidate, can quickly reverse the effects of propofol. The research was done by Jessica Chemali B.E.; Christa Van Dort, Ph.D.; et al. out of the Massachusetts General Hospital. They conducted several studies on the emergence from propofol anesthesia in rats who were given Ritalin.

Their first study used rats who were given a propofol IV bolus of 8 mg/kg. That amount, by the way, is pretty large since the usual induction dose for propofol in humans is only 1-2 mg/kg. One set of rats was then given a normal saline bolus while another set was given a bolus of IV Ritalin. The rats given NS redeveloped their righting reflex with a median time of 735 seconds. The rats given Ritalin started righting themselves at a median time of 448 seconds, or almost a 40% improvement in recovery.

In a second set of experiments, the rats were given propofol infusions through their tail veins. After achieving a concentration of propofol that kept the rats supine, NS was injected into the rats along with the removal of a stimulatory probe. This produced no changes in their activities. Then IV methylphenidate was given to the rats . All the rats started exhibiting signs of arousal such as kicking or blinking, with complete righting at a median time of 82 seconds.

This is very promising research and is good news for anybody who has ever had difficulty arousing a patient after giving propofol anesthesia, ahem Dr. Murray. Once again, because of our profession's single-minded pursuit of patient safety, research may be pointing the way towards even safer anesthesia.

But here is where the situation becomes difficult for anesthesiologists. The administration of propofol has been widely cautioned in the past as having no antidote. Therefore we have always recommended that only doctors with years of training in injecting propofol should be giving it to patients either in procedure rooms or the ICU. Now that there may be a reversal agent for the drug, will this give the gastroenterologists, CRNA's, cardiologists, and virtually anybody who wants to sedate a patient an opening to claim more cases from anesthesiologists? Once narcotics and benzodiazepenes could be reversed quickly and safely, they became drugs that could be given by virtually anyone with some sort of medical license. Will Ritalin's ability to rapidly produce emergence from propofol anesthesia lead to a similar calamity for anesthesiologists? Damn you Mass General and your overachieving researchers.

OxyContin For Kids In The Pursuit Of Profits

In an attempt to extend the patent protection of OxyContin, Purdue Pharma is conducting clinical trials of  the narcotic in children ages six to sixteen. The company is doing this because OxyContin currently rakes in $2.8 billion a year. Purdue hopes to prolong its Oxy patent by another six months if the FDA approves its studies. That would work out to $1.4 billion of extra sales. That sounds like an investment any company would make.

But is it a wise move for children? OxyContin is one of the most addictive prescription pain medicines on the market. Its destructive properties have been widely publicized. The drug has been implicated in the addictions or deaths of numerous celebrities, including Rush Limbaugh, Lindsey Lohan, and Heath Ledger. The CDC estimates that one in five high school students have used prescription drugs without a doctor's prescription. How do they get the drugs? Usually from their parents' medicine cabinet or, if they have the money, the local street dealer.

I'm not saying that children don't feel pain. They have nerve endings just like everybody else. But children are incredibly adaptable in dealing with pain and injury. Usually an NSAID or acetaminophen is all that is required to alleviate pain in kids. If a narcotic is required, something less potent like Tylenol #3 is more than adequate for almost all maladies. Now if the FDA approves OxyContin use for children, I'm afraid that we'll be raising a whole new generation of drug addicts before they even have a chance to grow up and make mature decisions for themselves about what they want to put into their bodies. Or worse we'll have an army of kid drug dealers going through our schools distributing their doctors' prescriptions to any willing buddy with cash. You think pain doctors have a difficult time catching drug addicts hoarding prescriptions for narcotics? Wait til they have to say no to a parent who demands more OxyContin for their poor suffering Johnny because he has uncontrollable pain. The only one who wins in this pursuit is the drug company itself.

Tuesday, July 3, 2012

Dr. Deane Marchbein

This is pretty awesome news. Dr. Deane Marchbein, an anesthesiologist affiliated with Massachusetts General Hospital, has been named president of Doctors Without Borders. She first joined the Nobel Peace Prize winning group in 2006. She served in the Ivory Coast at that time behind enemy lines and helped establish a rudimentary burn unit at the hospital. She recently worked in Lebanon and helped  smuggle medical supplies into Syria to aid the massacres that are happening there.

If you think everybody respects this humanitarian organization, you'd be wrong. Two people from the group were killed in Kenya six months ago while two others were kidnapped in Somalia this year. So working for Doctors Without Borders is not for the faint of heart.

However, if you're interested, they are always looking for volunteers who are willing to make a time commitment of six to twelve months to join the group and alleviate the suffering of millions around the world. Dr. Marchbein herself takes an unpaid leave of absence from her job to work there. I salute the generosity of people like her.

Monday, July 2, 2012

Work-Life Imbalance. I Just Had My First Vacation In Four Years.

It's hard to believe but I've just had my first extended vacation in four years. By extended I don't mean I took 80 days off to cruise around the world on the QE2. My grand vacation lasted all of ten days. But that is quite an extended leave of absence by my standards. Prior to this, I had to satisfy myself with simple holiday journeys, the longest one being a road trip to Texas over Thanksgiving a couple of years back.

How can this be, you might ask. Don't anesthesiologists enjoy the most luxuriant lifestyles and carefree schedules of any medical profession? The short answer would be no. You see, many anesthesiologists, like myself, are really small business owners. We run a shop where customers pay for our goods and services. We have a billing department that keeps track of my accounts receivable, equipment to maintain, and other mundane business practices, just like a shopkeeper. Therefore, like a sole proprietor of a small store, when I go on vacation, I turn off the lights, lock the doors, and my income suddenly drops to zero when I am no longer offering my services while I'm out.

However, unlike a small business owner, my practice is unlikely to get bigger, hire more employees, and expand. When small businesses get bigger, the owner can usually hire a staff to take care of the shop while he goes on vacation, while the store is still raking in money. That doesn't happen in medicine. I can't suddenly hire a bunch of anesthesia extenders like AA's or CRNA's to do the cases while I vaca to Paris and cruise down the Seine. I still have to be present while the procedures are being performed. I suppose that I could someday open up an ambulatory surgery center or pain center then hire people to work there. But then I'd be busy as an administrator when I'd rather be a practitioner.

I sometimes fantasize about being a doctor employee, you know the kind that clocks in from 7:00 to 3:00 and doesn't give a darn about expediting cases and operation room efficiency. I could work at an academic institution or a large hospital group where I'd be nothing more than a cog in a giant medical industrial wheel. Then I'd be guaranteed paid vacations and benefits. Sure the pay is less and you have to work with a bunch of doctors who are just showing up for their retirement pensions. Think VA hospitals. But perhaps when I am older and the kids have moved out, that wouldn't be such a bad option.

Oh, who am I kidding. I love my current job. Sure the last few years have been a little rough fiscally speaking. After all, we bought a new house a couple of years ago then spent months undergoing an extensive remodeling. I didn't have the time or the money to go on a long break. But this year, finally, I could exhale with relief as my finances edged back from the fiscal cliff. (For those who have remodeled your house, you know what I"m talking about) Thanks to my ginormous anesthesia income, this was made possible faster than any 99%er could fathom.

From now on I vow to improve my work-life balance. I will take care of myself and my family better in the coming years by not working for 48 months straight. Life is too short to worry about where the next intubation will come from. The children are growing up too fast. The months just seem to fly by and here we are another half a year is behind us. I'm already looking forward to my vacation next summer.

Wednesday, June 13, 2012

The Dirtiest Part Of The Body

Do you want to know what is the dirtiest part of the human body? It's not where you think. No, it's not the anus. While all sorts of nastiness are expelled regularly from your bottom, it is quickly and meticulously wiped away with paper designed specifically for the task. So I wouldn't call the anus the most unsanitary body part.

Well then, what about the mouth. Many people would consider the mouth the filthiest area of the body. Sure there are billions of bacteria that are breeding in the oropharynx that will give a horrendous infection if it is used to bite another person. But how bad can it be if people don't mind using their mouths to kiss and lick each other, sometimes with total strangers?

If you have ever had the opportunity to observe a case in the operating room, you would know that the body part that gets the most derogatory comments for being unclean is in fact the navel. The belly button receives all sorts of derision from the nurse who has to wash it before every abdominal procedure. If it is particularly disgusting, people descend to the level of elementary school kids in their mockery of the patient's inability to maintain proper hygiene.

Please wash this
What's so bad about the belly button? I think the main issue is that for being such a prominent and easily accessible body part, people rarely seem to wash it with the same care they use for other areas of the body, like the axilla or groin. Particularly in overweight patients, the navel can hide some pretty gross debris. There is the lint that somehow gets trapped deep inside, never seeing the light of day and allowed to molder in the dark depths for years at a time. Then there are the dead skin, hair, and old sweat that accumulate in that little hole. It eventually turns into a brownish mud that must be washed out to prevent a surgical wound infection after a procedure. That stuff reeks to the high heavens and makes the nurse completely apoplectic. The only time I've ever seen a more extreme reaction was when a nurse had to prep an adult male for a circumcision and she had to pull off a huge chunk of smegma out from under the foreskin. I think she almost lost her lunch on that one.

You say you don't have an unclean belly button because yours is an outy instead of an inny? Well you've got bigger problems because you probably have an umbilical hernia. These will eventually require a surgical repair to prevent incarceration of small bowel and an emergency operation.

So if you don't want to disgust the operating room nurse before your surgery, please remember to wash out your navel the night before you come to the hospital. The OR staff will thank you and you'll be spared the disparaging remarks that comes with neglecting your personal hygiene.

Doctors Who Are In It For The Money

First of all, a little disclaimer. This is a purely personal opinion. You are free to vociferously disagree with any and all choices I've made in assembling this list. In fact, since we live in a free internet, you can go publish your own list if you so choose.

After practicing medicine for a decade, I've made some observations of why some people want to become a doctor. Sure we all told the medical school admissions committee that we want to be a physician to help people. But soon enough it becomes obvious that some people want to be doctors to enrich themselves. And there is nothing wrong with that. Who says doctors have to be altruistic all the time? No doctor ever took a vow of poverty. We certainly don't begrudge MBA's and JD's for wanting to make money so why should doctors be looked down on for doing the same thing?

But first I want to list the medical fields who are definitely NOT working for the money. They represent the purest examples of what people believe doctors should be. Not surprisingly most of them are in primary care. Unless otherwise noted, the income numbers come from Medscape's Physician Compensation Report 2012.

1. Pediatrics. These gentle souls are taking care of the next generation of humanity. They certainly deserve more recognition and income than what they are receiving now. Mean income: $156,000. Twenty-four percent make less than $100,000.

2. Family Medicine. They're busy treating every member of the family, cramming in 30-40 patients a day into their busy office schedules. They see everybody, from babies to geriatrics yet are paid a pittance. Mean: $158,000. Making less than $100,000: 23%

3. OB/GYN. Nobody goes into this for the money. The work is nerve racking. The risks are high. So many things can go wrong that is beyond your control. And lawyers are always just a phone call away. Mean: $220,000. Less than $100,000: 19%

4. Infectious Disease. This is the Dirty Jobs of medicine. They are treating contagious people all day while risking contamination to themselves or their families. You couldn't pay me enough to go into ID. Mean: $170,000. Less than $100,000: 14%

Now for my list of Dr. Moneybags. These are physicians who seem overly concerned about what kinds of cars they should possess, what type of insurance their patients carry, and how many free "educational conferences" they can wrangle out of their drug reps.

1. Cosmetic surgeons. Notice I don't lump all plastic surgeons in here. Many plastic surgeons do wonderful work on burn patients and cleft lips. But cosmetic surgeons are in the business of telling people they should be ashamed of their bodies which should be altered to fit into an idealized, homogenous world. They'll gladly accept any credit card you have to pay for the procedures. You only have Medicare? Too bad. You'll just have to stay ugly.  Mean income: $323,434.

2. LASIK surgeons. This field is all about the volume of patients. Thus there are the incessant radio commercials for the local LASIK surgery centers with their "Harvard trained" doctors and "latest" technology. They even advertise that they'll do a free insurance check and financing is available. Doesn't sound that different from a car dealer commercial. I was unable to find a reliable source for LASIK surgeons' incomes but at $1,000-$2,000 per eye, you do the math.

3. Dermatology. Such a hot field right now with medical students. Why? No calls. No emergencies. No life threatening illnesses. And like cosmetic surgeons, most of the patients are more worried about their looks than their actual health. No kid ever grows up thinking he wants to look at ugly skin lesions for the rest of his life, but once the income level is factored in, it suddenly becomes the must have residency in the country. Mean: $283,000.

4. Gastroenterology. A lot of gastroenterologists do life saving work treating severe GI hemorrhage, inflammatory bowel disease, or cholangitis. But all too many run GI sweat shops that aim to do 20-30 endoscopies in the morning, and just as many in the afternoon at a few hundred dollars or more per procedure. If that is not enough, more and more GI docs now want to own ambulatory surgery centers where they hire anesthesiologists on a salary so that they get a cut of anesthesia compensation too. Mean income: $303,000.

5. Spine surgery. Here is a field whose procedures have not been scientifically proven to be more effective than conservative management yet make some of the highest salaries in medicine. It also seems to regularly make the news in committing insurance fraud. So why are so many patients referred for all sorts of spinal fusions, laminectomies, and diskectomies? Is it to support their astronomical compensation? Mean income: $688,500.

Some people may scoff and ask where is anesthesiology in the category of money grubbers. With a mean income of $309,000 a year, our field is a ripe target for the jealous and the ill-informed. However, I submit that anesthesiologists are under compensated. It is through the advances in anesthesia over the years that make much of modern medicine possible. Sure you can excise a skin lipoma without anesthesia, but it wouldn't be pleasant. And obviously nobody would perform spine surgery without anesthesia and all the safety equipment in the operating room that makes the procedure possible. So, no, anesthesiologists aren't getting paid nearly enough for all the services we render. But then, we're not in it for the money.

The ROI Makes Medicine Still Worthwhile

Congratulations to the new medical school and residency graduates. All of you will be venturing out into the world with a massive store of knowledge prepared to treat the ills of the world. Never mind that many of you will be burdened with some of the highest education debt of any college graduates.

But I'm not here to remind you of how much money you owe. I'm here to give you encouraging words on your career choice. Even though it may not feel like it right now, you are embarking on one of the most fiscally sound professions anywhere. Sure it may seem that you'll never be able to pay off the six figure student loan in your lifetime, but believe me, you will. And you are in a better position than many of your buddies who went into other fields.

You don't believe me? Let's say you have a $200,000 school loan you'll have to return. At least you'll have a job where the median salary for primary care is over $200,000 a year according to the latest Census Bureau statistic. And you'll have plenty of work to help pay off that loan. In the next ten years it is estimated that another 168,000 doctors will be needed to take care of our aging population and replace disgruntled retiring physicians. So there will be lot of opportunities to erase that debt.

By comparison, thousands of college graduates are facing the prospect of unemployment this summer. Let's just pick on one profession, the lawyers. There are an estimated 45,000 new law graduates flooding the market this summer. That is a scary thought, for both us and the lawyers since there are only about 28,000 new job positions available. Therefore many lawyers don't even work in law, or they're being hired to review documents in sweatshops at $30 per shift. Underemployment is so bad among lawyers that even a $10,000 a year job finds dozens of inquiries. Compared to doctors, these new lawyers are going to have a heck of a times paying back their $100k law school loans when they are either unemployed or making $10 per hour.

So to all you new doctors entering the world. You've wisely chosen a career that has an almost guaranteed full employment. Though your debt is high, your return on investment is sound. You've watched with envy as all your friends graduated years ahead of you but now you have the last laugh. While many of them have moved back home with their moms and dads, you've reached the next adult milestone of finding and keeping a respectable job. All those nights that you were collapsed on the sofa from exhaustion while they were out partying are history, at least for the residency graduates. Now the tables have turned. Just try not to smirk too much when you treat your nonphysician friends to a night on the town and have to listen to their tales of woe and joblessness.

Monday, June 4, 2012

Wouldn't You Rather Have Propofol?

 I walked into the GI procedure room one morning while a colonoscopy was underway using conscious sedation. The GI doctor was ordering vial after vial of sedatives while the nurse was frantically trying to get the drugs from the lockbox, chart the patient's vital signs, and attempt to hold down the patient all at the same time. I would have stepped in to help except, well, I was not requested for the patient's sedation and thus did not give the patient an informed consent for anesthesia.

I quickly peeked at the amount of drugs that the team was having to give in order to somewhat relax the patient. So far, as you can see in the picture, the gastroenterologist had given the patient eight milligrams of midazolam and two hundred micrograms of fentanyl. This seems like a lot of drugs for what should be a simple procedure where the patient is supposed to be given just enough for relaxation.

Needless to say, when patients are informed that are going to be under conscious sedation, they are given the sugar coated story about how they'll only feel a slight pressure as the colonoscope is passed through the colon and they should be able to tolerate it with deep breathing and minimal amounts of sedatives. While that may be true for a few diehard people, the majority of patients find it very uncomfortable and will request more medications until they are knocked out, thereby converting a conscious sedation into a MAC sedation.

In order to give that much sedation, it's not unheard of to give double digit milligrams of midazolam and hundreds of micrograms of narcotics, especially for younger or larger adults. Unfortunately for the patients and the doctor's office, a colonoscopy concludes very rapidly, within minutes after the scope reaches the cecum. Now you are left with an unconscious patient with drugs that will persist in the bloodstream for hours. All those narcotics, along with the distended bowel caused by the endoscope, potentiates postoperative nausea and vomiting. You are left with a semiconscious patient in the recovery room that you can't discharge because of their sedation and postop nausea sitting around waiting for the drugs to wear off. This slows down the workflow of the operating schedule and potentially leads to expensive staff overtime. In my opinion, that doesn't sound very cost effective.

Wouldn't you rather just have an anesthesiologist give a single vial of propofol, which is more than enough for most colonoscopies, and bypass all these potential complications? Plus it has been shown that more polyps are picked up by the gastroenterologist when an anesthesiologist is present to give the sedation. Yeah, it sounds like a no brainer to me too.

What The Heck Is This World Coming To?




There has been a rash of stories in the news lately about bizarre and downright grotesque human behavior. First there was the guy in Miami who was shot by police after he was found to be eating off the face of a homeless person. Then there was the story about the Canadian man who murdered a college student, dismembered his body parts, and mailed the human remains to different branches of the Canadian government.

Now here is this tidbit about a man who turned his dead cat into a helicopter. Dutch "artist" Bart Jansen preserved his dead cat Orville after it was hit by a car. He attached propellers to each paw and as you can see, the cat can now fly, spread eagle fashion, through the air. Mr. Jansen calls his creation the "Orvillecopter" and claims his cat would have been happy since he is now "flying with the birds." Sounds pretty sick to me. Must be global warming.
Orvillecopter

Friday, June 1, 2012

EMR Starts. Hilarity Ensues

Writing orders on paper charts used to be so simple, if labor intensive. First you have to hunt down your patient's chart. It could be located anywhere: in the patient's room, at the nurses' station next to the room, at the nurses' station at the other end of the ward, in the nurses' break room where a consultant took it while getting his coffee and didn't bother to bring it back. Once you find it, you write your order and put the chart into the orders rack where the secretary will take it down and inform the nurse about the order. Most medical charts also have little color coded flags you pull out depending on the type of order: green for a routine order, red for stat order, yellow for discharge orders, etc. It was tiresome, but effective.

With the advent of electronic medical records, the days of searching for a patient's chart are over. The chart is nothing more than a plastic binder with next to nothing inside. All information are conveniently found within the nearest workstation. What can possibly go wrong?

As it turns out, many doctors are still stuck on the old ways of doing things. We recently got a memo from the hospital's chief of staff admonishing physicians for improperly entering orders into the computers and communicating it to the nurses. It seems that some doctors were writing computer orders without letting anybody know about them. It was up to the nurse to serendipitously discover the orders hours later, orders that can be time sensitive or vital to the patient's health. Some of the examples he cited include:

"Hold heparin until after cardiac biopsy"

“Call the Code Blue team to assess the patient.”

“The patient may take her own sugar packets from Starbucks, if she falls into a coma from hypoglycemia”

“Please ask family for doses of diovan, cardizem and amiodarone, then start immediately”  

These were actual orders entered into the computer by doctors and not verbally relayed to the nurse. Obviously no names have been attached to them to protect the innocent, or the ignorant. You can imagine the outrage of the dumbfounded nurse who stumbles across such orders hours after it was placed by the physician. 

So the hammer has come down on the doctors at the hospital. If an order is important, it is imperative for the physician to find the nurse and let her know about it. Otherwise the nurse cannot be held responsible for delay in patient care. Are we having fun with EMR's yet?