Friday, April 12, 2013

The Yacker Tracker Yanked

Somehow this didn't really come as a surprise at all. Our recovery room recently purchased a Yacker Tracker to monitor the noise levels that were drawing complaints from patients and families. The device is supposed to alarm if the room reached a certain loudness so that everybody would know when to pipe down.

Predictably, like other ill advised medical purchases designed to improve patient care, this one didn't really pan out. As you can see, the Yacker Tracker has now been ignominiously relegated to the closet, piled up with the discarded chairs and other furniture that nobody wants or needs.

This is so typical of the waste that we see all the time in medicine. Somebody will get the bright idea to buy a new piece of equipment because they went to a conference that extolled the virtues of the latest and greatest technology. Or there will be some issue that can only be solved by acquiring more costly paraphernalia. After spending scarce dollars on this stuff, people realize it is no better than what we had before. In this case, my high school librarian could have done a better job of keeping a room quiet. The money has been spent but the problem has not been resolved. If this is typical of how medical dollars are wasted around the country are we surprised how little the trillions of dollars we spend on healthcare get us?

Thursday, April 11, 2013

Drinking Before Surgery

It is one of the cardinal rules of surgical preparation; NOTHING by mouth after midnight, or NPO after MN. That is one of the easiest and most clear cut ways for an anesthesiologist to cancel a case. The surgeon will rarely argue with an anesthesiologist on this point. Some anesthesiologists adhere to this rule so strictly that they will cancel a procedure if the patient is even found chewing gum before surgery.

The reason we discourage patients from eating or drinking anything before receiving anesthesia is that we don't want any contents in the stomach during the procedure. If the stomach is full of food or liquids, there is a risk that the patient will vomit the half digested gastric bolus while under sedation and aspirate it into the lungs. This could lead to severe aspiration pneumonia and possibly death. The doctors and the hospital frown upon unexpected operating room deaths.

But now NPO after MN maybe getting a closer scrutiny. The American Society of Anesthesiologists has for years recommended that cases can proceed if the patient has only clear liquids up to two hours before surgery. Clears means anything that one can see through. Water is obviously considered clears. So is apple juice, grape juice, and, surprisingly, black coffee. Milk, orange juice, and coffee with cream are not clear liquids.

Now a study has been released that may actually encourage doctors to recommend patients have a drink before an operation. As Anesthesiology News reported, researchers at Texas Tech University Health Sciences Center had one group of patients drink a carbohydrate rich clear drink two hours before surgery and another group remain fasting after midnight. Not surprisingly, the group who got to drink before surgery felt less thirsty before their operation. But they also felt significantly less anxiety and greater comfort overall. The researchers concluded that perhaps patients should be allowed to drink clear liquids before they have their surgeries.

First of all I think that is a fine idea that should be further explored. While I would hesitate to let a patient drink as much as these study patients did, 360 mL of fluid which is a little more than one can of soda, I think a couple of gulps wouldn't hurt. We frequently ask our patients to take their medications with small sips of water before coming to the hospital and I don't know of anybody who has aspirated because of that.

Instead of using some specialized "carbohydrate rich beverage" that the researchers used (Clearfast and BevMD) which sounds very expensive, how about just letting patients get a small bottle of Gatorade or other sports drink? It is cheap and readily available. They also contain the electrolytes that are missing from plain drinking water.

Let's face it, NPO after MN is rather barbaric. No elective surgery starts at 2:00 AM. It is especially cruel if the patient's operation isn't scheduled until the early afternoon like 1:00 PM. Is the patient supposed to go without food or water for that long? They can do it but it is not comfortable. Plus by the time the patients comes to preop, they are so dehydrated that it makes starting an IV more difficult. The only reason we tell patients not to eat or drink anything after midnight, even for late starting procedures, is that just in case an early procedure gets cancelled, we can move another patient up without worrying about whether he had just drank something. The last thing the hospital wants is for an expensive operating room to sit empty while we wait for the two hour window to pass.

So let's do patients a favor and consider letting them drink a refreshment up to two hours before surgery. They will feel better when they come to preop. If they are happy, they will make your life better too.

Wednesday, April 10, 2013

Better Late Than Never

I finally did it. After writing this blog for nearly four years at last I have started a Facebook page. You can find it here or search under Great Z's and it should be the first choice that pops up. Right now there is literally nothing yet on the FB page other than a quick introduction. I eventually hope to mirror the content of the blog and the FB site so that readers can find me no matter which social media they prefer to use.

Why haven't I done this earlier? The quick answer is that I just never had time. It is hard enough to write steadily to make a blog worthwhile to read in the little amount of spare time that I have. I didn't feel like I wanted to burden myself by having a second site that required even more of my time. However, I realized that some writings are more appropriate for a long blog post and some are better as quick FB comments. I hope this dual format will make it more liberating for me to write on various topics.

As they say, I hope you like me on Facebook. And please share it with all your 5,158 friends.

Monday, April 8, 2013

I Knew You Were In Trouble When You Rolled In

To the music of  "Trouble" by Taylor Swift

Once upon a time many years ago.
I was in the lounge watching "24".
Trauma called me, trauma called me, trauma called me.
They're bringing a patient up with gunshot to the chest.
Bring all the blood as much as you can.
Set up room 3! Set up room 3! Set up room 3!

You looked long gone when you came to me.
And I realized your life depended on me.

Cause I knew you were in trouble when you rolled in.
Your skin was ashen
Blood poured out your mouth and down your chin.
Gonna lose my lunch, ugh.
I knew you were in trouble when you rolled in.
Your pulse was racing.
Blood poured out your chest and down the bed.
Now you're lying in a pool of clots.

Oh! Oh! Trouble! Trouble! Trouble!
Oh! Oh! Trouble! Trouble! Trouble!

I untangled all your lines. Hooked up the Level One.
I hung up all the O's and the FFP's.
You're fading. You're fading. You're fading.
Now I hear the surgeon shout.
He's cracking wide the chest.
The aortic clamp reaches in. You have gone brady.
And now I see. Now I see. Asystole!

You were nearly gone when you came in.
Now I realize your savior's not me.

I knew you were in trouble when you rolled in.
You're now pulseless.
Crash cart rolls in and we're pounding epi.
Get some bicarb.
I knew you were in trouble when you rolled in.
Squeeze the heart more.
This bloody battle we cannot win.
Now you're lying in the cold hard ground.

Oh! Oh! Trouble! Trouble! Trouble!
Oh! Oh! Trouble! Trouble! Trouble!

Apologies to all the Taylor Swift fans out there.

Sterility In The Operating Room. Hey It's All Relative.

I don't often reply to a comment that people make after reading one of my posts. And I have never before written a whole page to counter what people thought about my writing. But I think this one deserves an exception. An irate reader took me to task for making recommendations for what types of food would be acceptable for consuming in the operating room.

The author of the comment only signed himself or herself as "Anonymous". But he, for simplicity sake, starts off by berating me, and my readers, by writing, "Shame on all of you." He goes on to claim that surgeons and nurses sometimes work for 8 to 12 hours at a time without a break. Therefore anesthesiologist should just tough it out and do the same thing or talk to the administration to hire more anesthesiologists to give us breaks. He chastises us for bringing food into the operating room and possibly jeopardizing the sterility of the surgical field.

Okay, I don't know if Anonymous is a surgeon, a hospital administrator, or a Joint Commission lacky, but his statement that nurses work without a break for half a day is clearly ignorant. I don't know of any operating room nurse who works that long without being given some time out of the room. As a matter of fact, during a single four hour case there may be as many as three or more shifts of nurses moving in and out of the room. Most states have pretty strong rules about how often nurses are supposed to be given relief. And if a hospital is found in violations of overworking their nurses, major lawsuits can ensue.

As for the surgeons not getting breaks, well that is their choice. They can operate twelve hours straight if they wanted to but the truth is that they have options. In a long case, there is always some point where the surgeon can scrub out and take a quick five to ten minute break to go to the bathroom or get something to drink. Rarely is a procedure so intense for the entire period that the surgeon cannot leave for even a few minutes. In addition, the surgeon usually has an assistant in the room that can continue working or at least watch the patient until he comes back.

By contrast the anesthesiologist is almost always working alone. By moral and legal grounds he can never leave the operating room with the anesthetized patient unmonitored. While the surgeon is making a quick run to the restroom, the anesthesiologist is watching the patient diligently to make sure every is going well. It doesn't work the other way around.

Now let's get to the crux of the matter, the reason food is banned from the operating room. Like I said in the original post, food is never, ever, ever permitted in the OR. And the reason for this is the fear that it would somehow contaminate the sterility of the operating field. But is that really the case?

Not a hospital operating room
People have to know that the OR is considered sterile, but the sterility is not as strictly enforced as you might believe. Sure the surgeon and the scrub nurse gown and glove up with the utmost care to ensure absolute cleanliness but it is still far from the true sterility that you might find in say a computer chip manufacturing facility. There, particles measuring micrometers in diameter are efficiently whisked out of the factory to prevent damage to the impossibly tiny tolerances required of modern technology.

By contrast, really the only sterile part of the operating room is the few inches surrounding the patient's open wound and the instruments and hands that reach in. The surgeons gown up mainly to protect their own clothing. Nobody wants to get splattered with disease ridden blood and body fluids. If you wanted to you could operate in your street clothes and I bet the infection rate would not change as long as you wear sterile gloves. As for the mask, think of it as more of a sneeze guard than a true protector of sterility.

For the same reason I find it hard to believe that me eating a little grape under my mask behind the ether screen will somehow contaminate the operating field. I'm usually at least six feet away and frequently BELOW the level of the the open wound while being behind a sterile drape. The surgeons' bushy eyebrows, which are obviously uncovered, are within inches and above the patient's wound. Same goes for the caps they wear on their heads. Those caps are definitely not sterile, nor are the tendrils of hair that often peek out from under the edges of the caps. Should all surgeons shave their heads to prevent dandruff and stray hair from falling out and infecting the patient?

Now I'm not advocating that anesthesiologists should be allowed to bring in gourmet lunches into the operating room. And again pretty much all hospitals frown upon any food or drinks in the OR's. But most see the practicality of allowing some sustenance for the anesthesiologist. As long as one practices common sense and and discretion, a few snacks are usually tolerated. Otherwise cases will just have to be delayed so that the anesthesiologist can go to the cafeteria and eat to prevent his blood glucose levels from collapsing. Which wouldn't really matter to the surgeon or the hospital but it might endanger patient safety, which you know, might not look so good on the local evening news.

Sunday, April 7, 2013

Astroturf On A $2.8 million House. Insane L.A. Real Estate Market Is Back

Just a couple of years ago people were predicting doom and gloom in real estate, particularly in large bubble markets like Los Angeles. Comparisons were being made to the real estate depression that has plagued Japan for over twenty years. Many cried out to the government for relief, which promptly acquiesced and introduced near zero percent interest rates they claim they will maintain as long as necessary.

And you know what, it worked. The housing market has come roaring back. Here in L.A., real estate dropped about 40% from its peak in 2008. But now people who waited for an even bigger decline may be too late. In fact, professional house flippers are already starting to return.

A recent home listing near my neighborhood took me aback for its audacity and bad taste. According to its listing page, this $2.79 million 4,000 square foot monstrosity is a, "Newly custom built home situated at the top of the hill." Yes it certainly looks new, and it does have a killer view out the back yard, but this house is McMansion personified . Though you can't tell from its listing, it is located in the middle of a neighborhood filled with 1950's era ranch style homes that are half its size and price. If your neighbor wanted to borrow a cup of sugar, you could almost reach from your kitchen window directly into their kitchen window.

What made me do a double take was the tackiness of the Astroturf around the house. The owners tried to make this a virtue by describing it as "low maintenance". I think they would have been more successful in selling this fake grass if they had claimed it to be environmentally friendly or even drought resistant. Either way, it is quite jarring to see a multimillion dollar house with a plastic lawn for a yard.

Inside it is all granite tiles and marble columns. There seem to be arches and oversized crown moldings everywhere. The overwrought decorations are meant to justify its extreme price. But the owners better hope they get lucky and find a buy who has the same gaudy tastes in interior design. Anybody who has almost $3 million to spend on a house can buy virtually any house they want. They will not want to spend that much money only to have invest even more dough to rip out all the interior touches that they find objectionable.

So if you were hoping to buy a house in L.A. and was waiting for the market to hit bottom, you may already be too late. Home prices are again reaching levels where even doctors can barely afford to buy one in a decent neighborhood. Though I went through my own personal hell in buying our house a couple of years ago, it looks like I was prescient and got our dream house just in time.

Online Shopping At Work, The Great Benefit Of Having An EMR

When our hospital went to all electronic medical records recently, we had to buy tons of new computers. This ensured that no impatient doctor or nurse ever had to wait for somebody to finish before they can log on and complete their patient charting. We now have multiple computer workstations in every conceivable location short of the bathroom.

But along with this new advance in patient care has come increased temptation. For you see, it is all too simple to start surfing and shopping on our powerful gigabit high speed internet connection. And many staffers do exactly that. You can see it on every ward and in every room. It's easy to find somebody who is logged into their Facebook account updating their status. Or they're shopping for new shoes and bags. Or they're checking out the cheapest tickets to Cancun.

Has all this new technology actually distracted us from our duty to diligently look after our patients?  While the goal of implementing EMR's is to improve patient care and prevent mistakes, I sometimes wonder if  the exact opposite is happening. People seem ever more distracted as they constantly seek out the nearest computer to sate their internet needs which in actuality is insatiable. Whether to check their emails that they last looked up five minutes ago or to find the best deal of the day for a refurbished iPad, non medical use of our computer system is rampant.

The hospital has put in some blocking software to prevent introducing viruses into the system. These mainly affect the foreign country and porn sites, not that I had ever looked of course. But if there were no blocking software I don't think most people would surf there anyway, mainly out of embarrassment of doing so in a public setting. I would think that they could easily block shopping and social media sites. But they don't. Maybe there are just too many for them to try to block in an ever evolving world wide web? Or maybe they are afraid that keeping the staff from misusing the computers will bring down morale? Perhaps they fear that people will just switch to their smart phones instead and start walking into walls since they are staring down at a four inch screen held at chest level.

Whatever the case our EMR is here to stay. And the shopping spree will not be denied.

Saturday, April 6, 2013

The Myth About Anesthesia Sitting Around Time

Surgeons hate delays between operating room cases. They frequently attribute this to the anesthesiologist. They even have a term for this: Anesthesia Sitting Around Time, or ASAT. Some of the less charitable surgeons refer to this as AFAT. I'll let you figure out what the "F" stands for. But they only see half the picture. Let me tell you what really goes on after the surgeon finishes the last stitch and leaves the room.

Once the surgeon finally walks away from the OR table, the scrub tech can then put the dressing on the wound. By now I have already started waking the patient up. If I'm really good, I can extubate the patient almost immediately. However every patient is different, and every anesthesia is different so sometimes it can take a few minutes before the patient is awake enough to have his endotracheal tube removed. Once I have determined that the patient is safely alert and able to protect his airway we can then move him onto a gurney to be transported to the recovery room.

When we are in recovery, I have to give a report to the receiving nurse, including all the relevant patient history, pertinent events during the operation, and his fluid status. Vital signs also are done to ensure the patient is stable before I hand him off. Then I have to write a postop note to document the patient's well being. I then rush back to the operating room to set up my next case. But the janitorial crew hasn't finished cleaning the room yet. And I can't really complete my preparation until they are done. So I do as much as I can before I head over to preop to see my next patient.

If I'm lucky, the next case is on an ASA 1 patient with no complicated medical, surgical, or anesthetic history. The patient will already have an IV in or will have giant garden hose veins. Somebody will hopefully have already put all the important history into the EMR so that I can finish my preop assessment note in twenty seconds. That's the ideal. Often I'll have to prepare an IV bag, start the IV, interview and examine the patient, and write the note, all under five minutes if possible.

Once that is done I head back to the operating room. It is now cleaned and the scrub tech is opening up the surgical instruments. I attach a fresh anesthesia circuit on the machine and put in a clean suction cannister. I announce to the circulating nurse that I'm ready to bring the patient in. I have achieved my goal of getting the patient ready in less than thirty minutes. The nurse says she and the tech have not finished counting the instruments yet so they're not ready.

Okay, fine. I told her I'll meet her in preop when she's done. As I sit in preop waiting for her arrival, another nurse comes to interview the patient. I ask her what happened to the first nurse. Oh, she is giving her a lunch break. This new nurse then notices that the surgeon had not properly filled out the consent form and had not marked the operating site on the patient. Now we need to call the surgeon back to complete those essential prerequisites. In the meantime she needs to go back to the OR to count instruments because she wasn't there when the original nurse counted instruments the first time.

It is now going on forty five minutes since I left the operating room with the last patient. I can see that this is still going to take some time. Therefore I walk down the hallway to the operating room lounge and grab some water and answer nature's call. Suddenly my pager goes off. Preop is calling me. I head back to the room and the surgeon and the nurse are standing there waiting for me. The surgeon mutters something about typical anesthesia delay and stomps back to the OR. Sigh. Sometimes you just can't win for trying.

So you can see, ASAT is really a myth. There is hardly any sitting at all on my part between cases. For people who think anesthesiologist just sit around all day and collect easy paychecks, they obviously have never talked with one.

Thursday, April 4, 2013

Remind Yourself Again Why You Went Into Medicine

Remember how happy you made your parents when you decided to become a doctor? Your mom couldn't wait to tell all her friends that her special offspring was smarter than all their kids because you were going to do something more meaningful, and lucrative, by applying to medical school. She could finally be the queen bee at her tennis club because her child will be an M.D. All the other moms can just go cry in their metropolitans and rue the day their children didn't want to be a medical professional and became a mundane software engineer with a four year degree instead.

Well now who has the last laugh? Business Insider has listed the companies that pay the highest salaries to software engineers. Let me tell you, the money ain't bad. It's fairly comparable to many primary care physicians' incomes. Companies like Juniper Networks, Google, Apple, and Facebook all start their base salaries for software engineers at over $100,000. And that's just the base salaries. It doesn't include stock options, the manna of tech company employees. They are particularly valuable for employees who work at companies that haven't gone public yet like Twitter. Facebook's IPO was estimated to have generated 1,000 new millionaires alone.

Besides the money, tech companies are infamous for lavishing outlandish perks on their employees. Google's workplace is known for giving employees free gourmet food night and day, free gyms, free dry cleaning, even free healthcare with an onsite doctor available to employees. How much of that generosity is enjoyed by the workers who don't have to pay a dime of income tax on those benefits? In the meantime laws have been passed that keep physicians from accepting even stupid gratuities like a box of doughnuts and free pens.

Plus there's just an aura around people who work at one of these corporate leaders. As one Apple employee wrote, "...everyone says 'wow' when you tell them where you work." I know a few people who work at these places and the reaction is always one of admiration and envy. You can't help but wonder how smart they must be in order to be hired by Google or Facebook. When was the last time you had that reaction when you met a doctor?

Well Dr. Z, all that may be true, but as an anesthesiologist you probably make two or three times that much money every year. Yes, the average salary of an anesthesiologist, or gastroenterologist, or orthopedic surgeon is several times that of the software engineer. But the real question is how much income is your peace of mind and free time worth to you? How much money would you place on your anxiety of knowing that any patient who walks through your door is a potential medical malpractice case? How much money would you pay to not have to sit through a deposition because your patient decided to sue you for a broken tooth during intubation. How much money would you give back if you could work an eight or nine hour shift and enjoy every night and weekend with family and friends without worrying about some sick patient in the hospital? Any doctor who has ever been sued will tell you that all those sleepless nights and constant fear and paranoia after getting subpoenaed is not worth the satisfaction of practicing medicine. They would gladly give back all their money if they didn't have to face a malpractice suit ever again.

Remind yourself again why you decided to go into medicine.

Tuesday, April 2, 2013

Those Godless Burned Out Money Loving Anesthesiologists

Here comes another physician survey from the good folks at Medscape. These are the same people who previously found that anesthesiologists as a group are among the happiest physicians in all of medicine. This time they conducted another study to explore the darker underside of medical practice: how much burnout exists within the medical field. The survey is based on responses from over 24,000 doctors that Medscape emailed. For full disclosure, I too participated in this survey but I didn't win that iPad mini they had promised to give to three lucky recipients who returned their email, dammit.

So how did anesthesiologists fare when it comes to feeling stressed? Not so good. While we may be happy, we also feel high levels of stress. In fact, anesthesiologists tied for fourth place as being the most stressed out, along with internists, general surgeons, and OB/GYN. Maybe it's those other burned out doctors that are giving us our stress ulcers. Emergency medicine and critical care came in as the most difficult fields while pediatricians were the most satisfied with their work.

According to this survey, 42% of anesthesiologists feel stressed out, which was defined as, "Loss of enthusiasm for work, feelings of cynicism, and a low sense of personal accomplishment." More women were burned out than men, which may be due to more domestic obligations than their male counterparts. The life stage when anesthesiologists felt the worst are between the ages of 46-55 when 40% of us feel stressed. The younger doctors haven't practiced long enough to be burned out yet and the older ones have probably cut back hours and are looking forward to retirement. As somebody close to that middle cohort I totally agree with this one. This is the period when one has car payments, house payments, childcare and school expenses. It's easy to understand why the middle bracket will feel the most stress.

Maybe exercise will take the sting out of difficulties at work. Yes, but not by much. Fifty-seven percent of the stressed out anesthesiologists exercise at least twice a week as compared to 66% of their happier peers. About 35% of the overburdened doctors work out only once a week compared to 28% of the unstressed docs. So exercise does make some but not a big difference in feelings of work satisfaction. However even if one doesn't exercise much, one should try to watch his weight. Fifty percent of overweight anesthesiologists reported being burned out compared to 39%.

If exercise doesn't take your mind off how crummy your work is, maybe some spirituality might help. In this survey, that didn't pan out either. There were no differences in religious activities between the two groups. Just as many stressed out anesthesiologists participate in religious endeavors as their satisfied peers. However anesthesiologists in general are not that religious. While 88% of Americans report having a religious affiliation, about 30% of anesthesiologists say they have no religion at all.

So here comes the $64,000 question. Does money make you happier? Of course it does. Whoever said money can't buy happiness has never had enough money. Of those anesthesiologists reporting that they feel burned out, 35% said they had minimal savings in their bank accounts. That is nearly twice as many as those who are happy at work. Sixty percent of burned out doctors say they have an adequate amount of money to fall back on while 76% of non stressed doctors say they have adequate savings. Somehow that isn't terribly surprising.

So there you have it. The key to not stressing out at work as an anesthesiologist is to 1) be a man, 2) stay thin, and 3) have lots of money. Easy. Oh, and try to stay away from the nasty stressed out surgeons.