Saturday, July 14, 2012

Are We On The Threshold Of Perfect Anesthesia?

We are currently tantalizingly close to achieving perfect anesthesia. What is a perfect anesthetic? In my opinion, it should be a substance that has a rapid onset, zero to minimal side effects, and fast elimination. Several substances that are in the experimental stages are leading us toward this holy grail.

I recently mentioned the finding that methylphenidate, or Ritalin, has been discovered to quickly reverse the effects of propofol. The problem with giving propofol was that a patient's ability to regain consciousness depended on how quickly the drug is eliminated from the blood. Ritalin appears to stimulate the upper neural pathways that leads to more rapid emergence. Now with a combination of propofol and methylphenidate, a patient can be awakened at will without the anesthesiologist guessing how long the elimination time is for a particular person.

The next drug that will lead to the perfect anesthesia is Sugammadex. Even though Sugammadex has not been approved by the FDA for use in the United States, it has already been used in Europe for years. The drug rapidly reverses the paralyzing effects of rocuronium by wrapping itself around the rocuronium molecule, quickly making it unavailable to cause paralysis. Its effect works faster than even succinylcholine elimination, the current gold standard. The FDA denied Sugammadex approval because of some reported allergic reactions, which have been found to be minimal in medical studies. By contrast, succinylcholine is known to cause profound and feared complications, including hyperkalemia, muscle rigidity, cardiac arrhythmias, allergic reactions, and even death. Sux is one of those drugs that, if it had not been grandfathered in by the FDA decades ago, would never be approved today. But it is the only muscle relaxant that can achieve such rapid onset of paralysis required for emergency endotracheal intubation. Rocuronium can achieve similar onset of paralysis with none of the side effects of succinycholine. But its drawback has always been its prolonged effects. Now with Sugammadex, that will no longer be an issue and another dangerous drug can be taken out of the anesthesia cart and put into the museum of outdated drugs like ether and methoxyflurane.

With a combination of these two pairs of drugs, we can finally eliminate the expensive anesthesia machines and its complicated vaporizer system. Total IV anesthesia will be the way to go. Volatile agents such as sevoflurane and desflurane require vaporizers that are expensive to maintain. Refilling them can contaminate the air in the operating room. And they can fail leading to overdosage to the patient. Inhalational agents also cause malignant hyperthermia, the much dreaded nightmare of every anesthesiologist. Plus, what anesthesiologist hasn't walked into an operating room in the morning and found the the previous night's anesthesiologist forgot to turn off the vaporizer completely, gassing the OR all night? Vaporizers are difficult mechanical devices that can be easily removed and not missed at all with the use of TIVA.

What will be left is just a ventilator. By using TIVA, the OR can use the same ventilators as the ICU and eliminate the anesthesia machine. All we need is an Ambu bag to mask the patient then connect him to a regular ventilator with its myriad of vent settings at our disposal. This will save money by getting rid of the anesthesia machine and standardizing ventilators througout the hospital. If we ever get approval for injectable oxygen, conceivably the ventilator could be history too. Yes these are exciting times for anesthesia.

Thursday, July 12, 2012

Injectable Oxygen. A Potential New Anesthesia Paradigm

Most medical research attempt to show incremental improvements to already proven treatments. But a team out of Boston Children's Hospital is working on a project that I believe will truly revolutionize anesthesia, and medicine in general: injectable oxygen. John Kheir, MD, et al, have been studying ways to bypass the lungs' oxygenation function and give the oxygen directly into the bloodstream ever since he and his colleagues had the misfortune to watch a pediatric patient die from severe respiratory distress and hypoxia in 2006.

Attempts at oxygenating blood directly have been tried for a century. Unfortunately the early experiments met with failure when patients developed air embolism instead. Later, machines such as the cardiopulmonary bypass machine and ECMO were invented that simulated lung function outside the body. While the machines are generally successful, they also carry high risk complications. First of all, they are highly invasive, requiring tricky cannulations of central vessels with large tubing. The machines are also bulky, tethering the patient in place with no possibility of mobility. Then there are all the complications associated with these devices. Patients have suffered air embolism, thrombotic embolism, bleeding catastrophes, and strokes when placed on these machines.

Dr. Kheir and his team changed the whole concept of oxygenating the blood by not trying to simulate the lungs. They used a machine called a sonicator that emits sound waves to mix together oxygen and lipids. The resultant emulsion carries three to four times the amount of oxygen that is carried by our own red blood cells. The lipid-O2 particles can be safely injected into the bloodstream without causing an embolism. They tested their creation on rabbit models which had their trachea occluded for up to 15 minutes. After injecting the rabbits with the emulsion, the rabbits' hypoxia immediately improved. Dr. Kheir states that currently only small amounts of the emulsion can be given. It cannot be infused over a prolonged period of time as the patient would likely get fluid overloaded receiving that much volume to maintain oxygenation. He envisions keeping small syringes of the emulsion in a crash cart for emergency situations.

I say he is being too modest. While the research team claims that the amount of emulsion that needs to be infused is currently too large to support more than a few minutes of oxygenation, I have confidence that they will refine and improve their technique to incorporate larger amounts of oxygen into their system. Once that happens, the product could truly change the practice of anesthesia. Imagine the potential of bypassing the lungs during an operation. Anything involving the use of the cardiopulmonary bypass machine would immediately become obsolete. Performing a double lung transplant would be a snap. Lung resections and pneumonectomies would no longer require the intricate placement of double lumen endotracheal tubes. We won't have to rush patients to the operating room for emergency tracheostomies because of foreign body or tumor occlusions of the airway. ENT can perform their laser surgeries in the oropharynx with little fear of causing an operating room fire because no oxygen will need to be blown into the lungs. Intubated ICU patients will suffer less barotrauma if they can give their lungs a rest for even a few hours a day. The possibilites are truly astounding.

The use of this oxygenated lipid reaches beyond the hospital walls. Firefighters would carry oxygenated lipids into a fire instead of pressurized oxygen. They can inject flame victims with the stuff to get them safely out of an inferno. Near drowning victims can be injected with oxygen instead of receiving the less efficient mouth to mouth or bag-mask resuscitation. The list goes on and on. I wish the Boston team the best of luck on improving their wondrous work.

The Agony Of Triage

American businessman and multimillionaire Christopher Cox suffered a horrendous blow when he was involved in a car accident in his Ferrari 250 GTO the other day. He and his wife were in France taking part in a caravan of Ferraris celebrating the fiftieth anniversary of the GTO when the incident happened. Mr. Cox's car was estimated to be worth over $30 million. Besides the devastating blow to the rolling money on wheels, Mrs. Cox was reported to have suffered a broken leg. I can just imagine what went through Mr. Cox's mind when the accident occurred.

What the f***! Somebody just hit my $30 million car! S***! Who are the morons that did this?! Honey, will you stop screaming? The car will be okay. We just need to fly my private mechanic here and spend a few more millions to restore this car again. It's been done before. What do you mean your leg is hurting? Oh. I don't think your leg is supposed to bend like that. God where is my cellphone. I need to call the restoration guys right away. You want me to call the ambulance? My car just suffered millions of dollars in damages and you're worried about your leg? That leg will heal for free with the universal health care they have here in France. I have to spend mucho dinero to get this car fixed up.Stop grabbing me. I need to go out to see how much damage was done. Geez I'm glad I left the mistress back in Monaco. Your leg will be fine. The old sawbones will put a couple of pins in there and you'll be as good as new. Where am I supposed to get pristine body panels for this fifty year old masterpiece? How can I ever show my face again at the Pebble Beach Concours? Everybody will know this car is damaged goods. Alright, alright. I'll call for the ambulance. (Whispering into phone) Siri, locate the closest Ferrari body shop to Saint-Etienne-des-Guirets, France. Make sure they accept American Express Black Card. Next make a call to Hotel Metropole. I'm going to need Bridget for the next few weeks.

Tuesday, July 10, 2012

Obesity Epidemic In China, If Pepsi Gets Its Way

An article in the Wall Street Journal today details PepsiCo's plans to expand in the second largest consumer market in the world, China. According to the paper, the company will try to increase the Chinese consumption of its snack foods by developing more regional flavors favored by the locals, such as fish soup flavored potato chips and fungus flavored oatmeal. Its commitment to the market is highlighted by its sixth factory being built in that country.

How much more money does the company think it can make in China? Here are the startling statistics from the company itself. Currently, the Chinese buy only one small bag of potato chips every couple of weeks. By comparison, Americans buy fifteen bags in the same time period. The average Chinese only buys 230 beverages per year. The Americans? How about 1500 drinks per year.

Are those numbers correct? One thousand five hundred drinks per year? That's over four drinks per day. I'm going to assume they mean soda drinks, not alcoholic beverages which the company doesn't sell. And I'm sure not all the drinks are diet sodas or bottled water. What about all those chips? We eat about one bag of chips per day? Altogether that's hundreds of extra empty calories that are consumed on a daily basis which have little hope of getting burned off during the course of our sedentary American lifestyle. Do we really want to lead another country down this path of ruin? Do we need an extra one billion obese people on this planet? It's a good thing the Chinese government has trillions of dollars in reserve. They're going to need it to treat all their citizens in the future who come down with the same obesity related diseases as Americans.

Saturday, July 7, 2012

When Fireworks Ignite

I was reviewing my pictures of fireworks from Fourth of July when I was struck by this one. I must have captured it just as it exploded. Pretty cool. I wonder if that was what the Big Bang looked like twenty billion years ago.

Friday, July 6, 2012

What A Job Solicitation Card Means To Me

The perfect job?
As one of the perks of being in anesthesiology, one of the most desirous and stable professions anywhere, I frequently get postcards advertising absolutely seductive job prospects in some exotic locations that I just must take a look at and move to. They frequently feature eye catching photography of happy and fun loving families, gorgeous scenery, and golf greens. But everybody in the field knows that the best jobs don't need to be advertised; they fill themselves automatically and quickly. So I always look at these solicitations with a gimlet eye. I try to read the meanings between the lines on the job descriptions and decipher their true intent.

For instance, take this card I recently got in the mail. I'm sure virtually every member of the California Society of Anesthesiologists received one. Naturally it features the majestic Angel Falls in Yosemite National Park. Who wouldn't be drawn to that image? I know I wouldn't mind looking out the window of my house to look at that natural beauty every day. So they are saying the job is somewhere around Yosemite, which could be anywhere within a one hundred mile radius.

Now let's look at the job opportunities they list. First, in bold highlight is "Partnership track". Funny they don't say in how many years. Does it take two years to become partner, or seven years, or only when a partner moves or dies? Hmm. That might be an important detail to know before joining their group. The next perk sounds pretty nice, $520,000 gross income guaranteed. Who could turn down a guaranteed income of half a million dollars? But notice it says gross, not net. So do you have to pay for your own health insurance, malpractice insurance, tail coverage, dental and vision, or billing fees? Does the group take a cut of that "gross income" to cover office expenses? How long is that amount guaranteed for? Is it like a teaser loan rate that's not guaranteed after the first year?

Next, the card promises that you'll work out of one facility only. Why is that? Is it because the group is uncompetitive with other anesthesia groups in town and can only get a contract with one hospital? Is it because the hospital is in such a small town that it can only support one health care center? Curious minds want to know.

I love the next line. In big, bold, black letters, "No Obstetrics or Gynecology." Like that is total anathema to anesthesiologists. Yes we all hate doing OB/GYN cases. Other cards I've seen showed similar distaste for neurosurgical cases and thoracic cases. They must think promoting the lack of these important surgical fields will draw better and more qualified anesthesiologists.

Low volume of heart cases. It probably means that they have to helicopter their active MI patients to the nearest tertiary care hospital fifty miles away after you've been called in to intubate and stabilize the patient. Orthopedic cases most prevalent. So most of their cases are agricultural injuries, motor vehicle accidents, or elderly hip fractures.

What does a friendly call schedule mean? Does that mean operating room staff say hello to you at 2:00 AM when you're in there doing an open compound fracture of the ankle and femur? I'm not at the hospital to make friends with the call schedule. And, finally, I can get all this with less work hours than the average anesthesiologist? So they are trying to entice me with getting more for less? Well golly gee, where do I sign up? An alarm bell is going off in my head that's warning me against promises that are too good to be true. Work fewer hours and make more money? Does the anesthesia group own the rights to an oil well under the hospital?

The postcard's description of the local community helps to pinpoint the location of the anesthesia group. First they say they have easy access to both mountains and oceans. That would be easy: Los Angeles. But it can't be L.A. because there is a picture of Yosemite on the card. So that must mean it is somewhere in the Central Valley of California. Not a good start. Nothing against the good people of the Central Valley but having one of its major cities declare bankruptcy does not inspire confidence in the capabilities of its municipal employees to run an efficient organization. The rest of the card goes on to further confirm the job is in the Central Valley. Day trips to wineries, ie/ Napa Valley, or hiking and skiing in the mountains, ie/ Yosemite or Tahoe, places the northern Central Valley as the likely job location. Lest you think you will be living in some sort of paradise with "unlimited outdoor experiences," the card tells you that you can live in a gated golfing community five minutes from the hospital. So the hospital is in a ghetto that requires you to live behind gates to feel safe? I think I'll pass.

So for anesthesiologist who gets a cold call for a new job prospect, take a very cynical view of their touted benefits. Advertised perks aren't always what they seem. Like your father warned you, if it's too good to be true, it probably is. If you are still interested in the job after reading between the lines you better ask very penetrating questions during the interview. It will save you from having to move twice within twelve months.

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.