Tuesday, November 27, 2012

My State's Legislators Are Getting Feted In Hawaii While I'm Buying My Pens From Costco

I've finally used up the last of my stash. After years of accumulating drug rep pens, I have finally run out. They have all been used or the ink has dried up inside so they won't write. Well it was fun while it lasted. I remember the good old days when the salesmen from the pharmaceutical companies would bring breakfasts or lunches to the doctor's lounge. For five minutes of my divided attention I could get a nice pasta or baked chicken lunch while getting educated on the advantages of their latest product offerings. Of course I would try to grab a few pens and notepads on the way out.

This was all strictly educational of course. I had no control over what kind of drugs I could use. That was controlled by the hospital pharmacy. I decided in the operating room which drugs were best for my patients, not what the drug rep told me was the best on the market. I'm not so greedy as to use medications just because somebody bought me a sesame bagel with a large schmear of lox for breakfast.

But a a few years ago our wise politicians decided that doctors were being bribed by drug companies into prescribing expensive meds. They believed this was the reason healthcare costs were rising at unsustainable rates. How can doctors possibly not be affected by all the free gifts that were being showered on us? Who couldn't resist the sales pitches of these oily drug reps as they try to push the latest antibiotics and antihypertensives on us poor helpless physicians? Therefore doctors and hospitals pretty much succumbed to political pressure and bad P.R. and stopped accepting gifts of all kinds, even from grateful patients and families. Now I use scratch paper from the back side of junk faxes and buy my own pens from Costco.

On the other hand, the politicians themselves don't seem to have any second thoughts about receiving presents from the myriad of lobbyists that surround them every day. Even though the election is not even a month old, our good old California elected officials are already grabbing at every freebie they can get their pudgy little hands on. The LA Times reported on a group of newly elected state representatives enjoying a basketball game together in AT&T's luxury box in Sacramento. Says Jose Medina, assemblyman from Riverside, hobnobbing with lobbyists is "part of my job. At the end of the day I'll make my decisions based on what is best for the people I represent." I'm sure the free food and drinks in the luxury suite will have absolutely no bearing on how he votes.

Then there is the group who jetted out to Maui after the election for a five day "conference" on matters important to Californians. The trip was sponsored by a tobacco company, various drug companies, utility companies, and state public workers' unions. As one freshman representative tried to rationalize his reason for flying to Hawaii to learn about California's many problems, "I was learning about the issues. There were some things I didn't know--such as how businesses really need help to flourish here in California." Others flew as far away as Brazil, Australia, and China, on lobbyists' expense, to gain insight on how to help the people who just elected them.

The hypocrisy would be laugh out loud funny if it wasn't so disheartening. Politicians accuse doctors of not being able to tuck a few cheap pens into our pockets without being influenced into prescribing expensive drugs while they have no qualms about accepting tickets and hotel rooms to exotic locales from lobbyists in the name of education. I feel gypped. If I have to accept Obamacare and its impending reimbursement cuts, at least let us have our old pens and notepads back.

Monday, November 26, 2012

All Choked Up

In general I think all eating contests are disgusting. It's pretty gross watching people stuff massive quantities of food into their gullet. Not only is it nasty, it is downright dangerous. I'm always surprised that not more people die of asphyxiation at those pie eating or hot dog eating contests. But this one really blew my mind.

A man in West Palm Beach, Florida won a cockroach eating contest last month. His prize was supposed to be a python. He wound up eating a bucketful of roaches, 60 grams of meal worms, and 35 three-inch long "superworms." Shortly after he won, he started retching and died. People wondered whether eating the cockroaches led to an anaphylactic reaction or he was poisoned by those nasty critters. Turns out to be neither. The medical examiner ruled it an accidental death due to asphyxiation from aspiration of gastric contents. The man choked on cockroach parts. Ewwww! Could you imagine the EMT intubating the man and finding a mouthful of roach bits inside? The horror!.

Hope you all have digested your Thanksgiving dinners by now.

Monday, November 12, 2012

The Free Lunch Society

Americans love to get something for nothing. We doctors are acutely aware of this attitude. People go to the emergency room hoping and expecting to get medical care for free. Patients refuse to pay their insurance copays. A physician's medical bill somehow gets placed at the end of the line for payment, behind other life necessities like cable TV, cell phones, and Netflix.

Here in California, the election last week fully exposed how society has become accustomed to receiving freebies. There were two propositions on the ballot: Proposition 30 and Proposition 38. Millions of dollars were spent trying to get both propositions passed, or failed, during the election. The funny thing was that both were ostensibly written for the exact same purpose--increasing funding to the schools. The main difference was that Prop 30 would increase the state income tax by 1-3% for the millionaires and billionaires of California ie/ anyone with incomes greater than $250,000. It also increased the state sales tax by a nominal 0.25%. However, though Gov. Jerry Brown claimed otherwise, nothing in the proposition specifically says all the tax money had to go to the schools. It could be directed by the state legislature to any government project it judged worthy.

Prop. 38, on the other hand, increased the state income tax on everybody, anywhere from 0.4% to 2.2%. But it was written so that the money would be specifically directed towards school funding.

Well guess which one passed? Proposition 30 sailed through by 54% to 45%. Meanwhile, Proposition 38 failed 72% to 28%. So all those voters, particularly the young people who came out en masse for Obama, decided that they want more money for schools. They just don't want to pay for it themselves. California now has the highest state income tax level in the entire country. The Hollywood and Silicon Valley liberal elites, big proponents of Prop 30, will barely blink an eye over paying an extra 3%. The majority of the electorate won't be affected. But somebody has to pay for more money for the teachers' pension funds. Everybody wants to enjoy the good life, as long as it's not coming out of their own pockets.

Wednesday, November 7, 2012

The Most Important Article In The History Of NEJM Is...

This is really amazing news, especially for somebody like me who loves reading about history. After a survey of its readers, the New England Journal of Medicine has declared that the most important article in its two hundred year history is the description of the first ether anesthetic ever published. What's even better is that NEJM has made the article available for download in its entirety in pdf format.

The article is titled, "Insensibility During Surgical Operations Produced By Inhalation." It was published on November 18, 1846 in The Boston Medical and Surgical Journal, the precursor to NEJM.  It was written by Henry Jacob Bigelow, M.D., described as "one of the Surgeons of the Massachusetts General Hospital." Dr. Bigelow starts the article with a brief description of the first public demonstration of ether by Dr.William Morton on October 16, 1846, which to this day has been immortalized as Ether Day.

He goes on to describe the history of ether and the various experiments in its development. I find it interesting that in his far ranging discussion of ether's development, he even quotes a French journal. How many American physicians even know French, much less read French medical literature? Dr. Bigelow then lists several case studies, including a patient who apparently received an overdose of ether. The patient's heart rate was noted to drop while his pulse became weaker and his hands grew cold. As there was little knowledge about how to revive patients who received too much ether, they revived the patient the only way they knew how--they treated him like an unconscious drunk. The doctors put a cold towel on his head, sprayed water into his ears, and held ammonia under his nose. When that failed to revive the patient, they hoisted the patient up and walked him around the room. Eventually the ether wore off and the patient woke up after about an hour. You can't make this stuff up. A modern hospital's ethics committee would have a stroke if such incidents were happening today.

By all means you should download this article and read about the birth of anesthesia. Then you can appreciate how wondrous anesthesia has humanized medicine, without which we would truly still be in the stone age of medicine. It truly deserves to be considered the most important article in the illustrious history of the New England Journal of Medicine.

Dr. Andrew Harris Reelected To Congress

Congratulations to Dr. Harris of Maryland for getting reelected into Congress. He won in his district with an overwhelming 63% of the votes. That is a bigger win than his first election two years ago. As the first and only anesthesiologist to serve in Congress, we are watching his career with special interest. And as a fellow Republican, I also have to congratulate him on being the token conservative in the blue state of Maryland. Now if you can do something over the next two year about that pesky fiscal cliff, Medicare cuts to physicians of 29% in January, unfair anesthesia reimbursements by Medicare, the IAPB, and the socialization of American medicine we would all be truly grateful.

Monday, November 5, 2012

ECG Computers Are Not Infallible

We are always told to read our own electrocardiograms. Though each ECG printout has a reading at the top as interpreted by a machine, we're advised to read it with our own critical eyes and make our own judgements. However, it is all too easy to quickly look at that computer interpretation while we are scrambling to get the next patient into the operating room instead of poring through every single lead on the page. Sure the computer interprets "antero-septal infarct, age undetermined" so often that we don't even bother to check if it is correct. As long as there a reasonable correlation between the reading and the the wave forms, we feel adequately informed.

The ECG above however is so egregiously off that I felt compelled to use it as Example A as to why we shouldn't rely on machines to do our readings for us and make clinical judgements based on them. As you can see, the computer read this ECG as "Sinus tachycardia with 2nd degree A-V block with 2:1 A-V conduction". That would be a pretty impressive ECG, almost like the kind they use to test us during ACLS. But even a cursory glance shows how off base the reading is. First of all, it's nowhere near being sinus tachycardia. As the printout shows a little to the left, the heart rate is only 61 beats per minutes. Then of course there is no evidence of a 2nd degree A-V block. These are all just overzealous interpretations made by the ECG computer. That is why an actual human interpretation is still essential in making clinical judgements in medicine. Even if it's just a disgruntled cardiologist making $20 for using his years of training and expertise to provide this critical life saving service.

Sunday, November 4, 2012

Obama Lied. Anyone Surprised?

During the tumultuous debates leading up to passage of Obamacare, President Obama promised Americans that if they are happy with their employer sponsored health insurance they will be able to keep it. Well somebody forgot to inform the administration about the laws of economics.

Today's Wall Street Journal article reveals that many corporations are now planning to hire part time instead of full time workers precisely because of the effects of Obamacare. They cite companies like Darden Restaurants, owner of Red Lobster and Olive Garden, who have decided that replacing full time workers with part timers will be much more economical. The reason is that companies have to pay a penalty of $2,000 for each employee who works more than 30 hours but isn't offered health insurance. The penalty goes up to $3,000 for each employee if the company health insurance is considered inadequate under the health care law.

Anna's Linens, a chain of stores that sells bedsheets and towels, began cutting the number of hours their full time workers could have each week, rendering them to part time status. Their CEO, Alan Gladstone, says that offering the comprehensive insurance coverage the new law requires for all 1,100 of their sales associates will be too expensive and the law prohibits companies from offering sparser but cheaper insurance. Their only alternative would be to raise prices, which would drive customers away.

Notice the insidious nature of these cuts. Many of these employers are in the service industry with razor thin margins. The employees who will be affected are usually the young, working at their first jobs. In this economy they are lucky to have a good job with any kind of health benefits. Now with Obamacare, that first step up the ladder to responsible citizenship has been pulled up and away. Without that first full time job leading to future career advancement, many of these kids will wind up in dead end part time employment, eventually dependent on the government for handouts. So Mr. Obama, we don't want four more years of laws that could lead to European levels of youth unemployment. If you win the election this week, I hope you have the tolerance to accept criticisms of this imperfect law, as no law is perfect as written the first time, and make meaningful changes to protect vulnerable employees. If you lose, well there will be few tears shed among the medical and business communities.

Thursday, November 1, 2012

The Infuriatingly Incompetent Inpatient Intravenous

Our surgery schedules can get pretty hectic at times. With impatient surgeons pacing in the hallways and tightly packed starting times, a fast turnover of the operating room is essential. That's why it's a relief when I see that my next patient will be an inpatient. Half of the time I spend on my preop interview with a patient can be eaten up by starting an intravenous. Between spiking an IV bag, collecting the IV supplies, and starting the IV on the patient, this process can easily take ten minutes, longer if the patient has difficult veins.

With an inpatient though, the IV is supposed to be already in place. Thus it should be a breeze to just walk into the room, chat with the patient for a few minutes, then roll him into the operating room. Simple as that. Except it is usually not that easy. Unfortunately, for some reason, many of our inpatients don't come to the OR with a functioning IV. Often the patient comes down without any IV fluids running, just a heplock. When I hang an IV bag in preop and hook it up to the heplock, the bag won't drip freely. If I try to flush the line, nothing will go in. The IV has clotted, which it is prone to do if there are no fluids running to keep it open. It is especially true with the tiny IV's many of our patients seem to receive on the floor, like 22 or 24 GA sizes.

What's worse are the patients who come from the floor with an IV pump dripping some medication into the catheter at a glacial pace, like 10 cc/hr. You are deceived into thinking the IV is working. However, when I try to check the integrity of the IV by flushing a small syringe of fluid, the patient complains of pain. I check the IV site and realize the little bolus of fluid revealed the ugly truth about that IV, it is not actually in the vein. The slow rate of the IV pump masked the fact that the medication has extravasated into the tissue but was not felt by the patient.

Sometimes inpatients come down with no IV's at all. I always found it curious that a person who is sick enough to be admitted into the hospital would have no venous access for medications, or heaven forbid, an emergency resuscitation. Our hemodialysis patients usually fall into this category. They have difficult veins to begin with and they are prone to fluid overload. Thus many of them don't get IV's while they are in the hospital. Until they finally come down to the operating room for a procedure and guess who has to start one.

These inpatient IV mishaps occur surprisingly often. I would guess it is at least a third of the time our inpatients arrive in preop without a working catheter. It happens so often that I'm always pleasantly surprised when an inpatient comes down with one that actually works.

Monday, October 29, 2012

CNA vs. CMA. Political Activism vs. Patient Advocacy

We are in the home stretch of the 2012 election. Every time I turn on the TV or listen to the radio I hear another political ad telling me to vote yes for something or no for something else. At the end of the commercials there are always a list of sponsors who paid good money to put this drivel on the air.

Curiously, many of the ads list as a sponsor the California Nurses Association. Their endorsements in the election include such non-nursing issues as how car insurance premiums are calculated and how out of state corporations are taxed in California. I wondered, why in the world would the nice nurses at my hospital care about such topics? We discuss subjects such as patient safety in the operating room and improving hospital efficiency, but never about changing the definition of California's three strikes law.

Finally I decided to go to the source of this political activism, the website for the CNA. I was immediately struck by how political the CNA is. Throughout the home page are advice on how to vote next week. There is a link that takes you to a page that contains a nice little cutout you can take to the polling booth to show you who to vote for and how to vote on each California proposition. In addition to all the voting directives, the home page also contains pictures of nurses holding picket signs and kudos to nurses who were able to negotiate higher paying contracts. There is virtually nothing on the home page about improving patient health, as one would expect from a website run by nurses.

By contrast, when I go to the California Medical Association website, there is almost nothing on the home page that directs physicians how to vote in the election. As a matter of fact, you have to scroll down a bit before you even see any news about political activism, a little tidbit about how the CMA supports California's climate change law. (As an aside, I think the CMA is trying to kiss some legislators' asses by endorsing this measure. California is already losing major corporations to other states because of onerous and over the top taxes and regulations. This ill conceived climate change law will do nothing to help global warming around the world but will make companies think twice before opening another factory here in the state. When good companies don't come here, their well insured employees don't either. Does the CMA think we doctors prefer to treat MediCal patients instead of privately insured ones? There must have been a medical marijuana shop nearby blowing their fumes into the CMA's conference room when they endorsed this law. This message fully endorsed and sponsored by ZMD.)

Anyway, I go back to the CNA's website to see what's going on. To get to the bottom of the story, you have to click on the About link. Then right there, in the first sentence, is the answer. "Founded in 1903, the California Nurses Association/National Nurses Organizing Committee/AFL-CIO is a premier organization of registered nurses..." So the CNA isn't really an organization for patient teaching and nurses training. It is a political union no different from the Service Employees International Union or the United Autoworkers Union. It's no wonder I have an almost totally opposite viewpoint of how I will vote next week. They have hijacked the good name of nurses to promote their political causes. They are using the trust patients have of nurses and abusing it for their own motives. For shame.

The CNA should stop deceiving people about what kind of organization they are. Virtually none of our nurses are the activists the CNA would like the public to believe. They work long hours, do jobs we doctors wouldn't want thrust upon us, and take crap from patients and their families all day long. Yet they are still able to show compassion and respect that many of those patients don't really deserve but still receive. To me, that's what the nurses are all about, not how they will vote on genetically modified food labeling. I bet the CNA would be much less successful in persuading voters if they really knew that they are just another arm of the AFL-CIO.

Thursday, October 25, 2012

The Easy Way To Decide What Kind Of Doctor To Be--Take A Test

It is an eternal fear and frustration faced by all medical students: what kind of doctor should I be. For me it was both gut wrenching and emotionally exhausting. Though I had some inkling that I wanted to be an anesthesiologist while in medical school, I was led astray that took years of soul searching before returning to my true love and destiny. Little did I know that, though it might not have existed at the time, there is an online test to help students navigate through these treacherous waters, the Medical Specialty Aptitude Test.

Hosted by the University of Virginia School of Medicine, this test has been around for awhile. You can surf through various medical blogs and it will keep popping up time and time again. It is a nice resource that every generation of medical students, especially the current technologically astute classes, keeps coming back to. The test consists of 130 questions you answer based on how strongly you agree or disagree with a statement. Many of the questions seem to repeat themselves, such as variations on if you're a thinker or a doer. How much do you like working with people? Do you like to see immediate results? Only a few questions were truly unique, like do you enjoy research? Or are you mechanically adept?

Click to enlarge
The test says it should take about 15 minutes to complete but I did it in less than five. I tried not to think too hard about the questions and answered what came to my head first. So here are the results. As you can see I knew myself in medical school better than I thought. The specialty that I matched best with according to the MSAT is in fact General Surgery. Surprise, surprise. In fact, of the top ten choices, five are in the surgical field. But my instincts weren't entirely baseless. Anesthesiology ranks right near the top at number four. This confirms my feelings that I still love being in the operating room. It's just the lifestyle of general surgery that I detest.

What's also interesting about my results are what's at the bottom of the list. According to the test, and the last two got cut off on this screen shot, the specialties I would be least likely to succeed and find solace in, are: Family Practice, General Internal Medicine, and Pediatrics. They were all fields that I had absolutely no intention of entering.

One specialty that I'm surprised by the ranking is Psychiatry. As I mentioned in a previous post, I loved psychiatry as a student. But here, the test ranks it fourth from last. As many students know, a good attending can make a clinical experience better than what it really is. My psych attending was excellent and made me seriously consider it as a career. Ultimately it looks like I made the right decision by not going into it.

Right now medical students all around the country are getting ready to apply for residencies to fields they hope they will like but really don't understand. It has always been a guessing game based on clinical experience, mentor's advice, and gut instinct. Here is one more resource that can serve as an aid in this life changing decision.