An Anesthesiologist's Guide To Medical History

If you like reading history as much as I do, you have to get yourself a current issue of the Anesthesiology News (registration required) for a fascinating article on the history of anesthesiology. Titled "When Settled Isn't Settled: An Anesthesiologist's Guide to Medical History," it is written by regular commentator Dr. Steven Kron. The piece lists his personal "10 Best Anesthesia Paradigm Shifts." This is the kind of information that is never taught to busy students and residents. It's not until they have the luxury of free time do they finally get around to understanding how anesthesiology has gotten to the preeminence it holds today in patient safety.

Many of you may already know this, but I didn't know that ECG monitoring wasn't even considered a necessity as late as the 1970's. This was eighty years after the invention of the device by Einthoven in 1895. Nowadays I wouldn't even start a case until I have a decent ECG reading on my monitor.

The closed circle system found in all operating rooms was invented in 1924. It was developed by the father and son team of Heinrich and Bernhard Drager. That helps explain the source of the Drager name on anesthesia machines that are ubiquitous in operating rooms these days.

Health insurance wasn't even a purchasable product until well into the 20th century. Before that, there was sickness insurance which insured against lost income during illness but it didn't pay for physicians or treatments. At that time doctors had few remedies for treating patient so there was thought to be no need to pay for our work when it was God who decided who lived and who died. Then in 1929, a group of Dallas teacher worked with Baylor Hospital in Texas to pay $6 for 21 days of hospital care (!). This was the beginning of the current healthcare morass we face today.

There is a lot more fun stuff to be found in the article. Things such as the history of the hollow needle and the invention of the anesthesia record. You'll be astonished how much of our anesthesia practice we now take for granted but were revolutionary when first introduced into the practice of medicine.

The LAUSD's IPad Scandal

A few months ago, I wrote about all the new iPads the LA school district is handing out to its students. Thanks to a voter approved tax increase, there is suddenly money for the politicians to shower on their constituents to buy future votes. Never mind that before the election the new tax dollars were marketed as necessary evils to shore up ancient school buildings and infrastructure. After the election, the school district decided that it was far sexier and crowd pleasing to buy iPads for every student in the school district instead of fixing old plumbing.

Many people, including myself, were wary of handing out expensive electronics to every single student. Improving student education can't be as simple as handing out iPads to all of them then expect their achievement scores to shoot higher. Sure enough, within days of passing out the devices, the district came to the sudden realization the iPads really aren't that great for writing papers. There is no doubt they are wonderful for presenting textbooks with eye catching animation and searching the internet for information, but when it comes to writing, you know, one of the three R's fundamental to education, the iPads really suck. So the schools decided they needed to spend millions of dollars more to buy keyboards for those iPads. So a $700 iPad now needed more money to make it useful when a simple laptop can be had for less than $500. But an ultrabook is certainly not as sexy as an iPad.

The crisis worsened this week when the school district realized that many students had already figured out how to hack into their iPads. The iPads were supposed to be secured so that it will only present the electronic textbooks that the students use in class. They weren't supposed to be able to search outside the school's intranet. Well that firewall lasted all of about a week. The kids, again many from lower economic classes, quickly figured how to break the security system so that they were using their tablets for Facebook, YouTube, and anything else on the internet. The breach was as easy as deleting the student's own profile on his tablet and logging in as a guest. Voila. Free web surfing for all with no restrictions. Now the school district is temporarily putting on hold the distribution of more iPads as it considers spending even more money to beef up the security.

Finally, the school board belatedly realized that iPads posed a safety risk to their students. With every student carrying the tablet home every night to do their homework, hundreds of thousands of iPads are floating through the streets of Los Angeles, all of them potential targets for crime. The school hasn't yet decided how to protect their precious purchases or the lives of the students. While they would like the students to be responsible for their own devices, they also don't want them to resist a robber who could physically harm them trying to steal the tablets. Already over 70 iPads have been reported missing.

The district thought about having the parents sign contracts stating they would be responsible for any lost or damaged iPads but again many of the families are poor so the contracts would be meaningless since they wouldn't be able to pay. The district also can't withhold iPads after one is damaged or stolen because there are no more textbooks. If a student doesn't have one, he can't do his homework and keep up with his peers. So the school has to issue a replacement iPad to any student who lost his.

It's unbelievable that these issues were not addressed before the LAUSD signed a $1 billion contract with Apple to supply iPads to all the students. Can they stop the program and pay a penalty for breach of contract? They probably could but they won't. First, they would need time to bring books back into the classroom. The students and families may also be reluctant to give up their electronic toys now that they've had a chance to use them. The district board members probably wouldn't want to admit defeat and lose potential votes in future elections by affirming voters' suspicions of their spendthrift ways. My feeling is they will probably double down on the money to make sure this program works at least until the next election. Am I cynical? You betcha. With the incompetence of the LAUSD on full display, it looks like everybody should be leery of politicians who promise the moon if only we can give them more money.

Medical Heroics In A Steak Restaurant

The knife that saved a life.

Everybody wants to have a doctor in the family. If that isn't possible, it's always nice if you can be in a room full of them when an emergency occurs. A couple of days ago, a customer by the name of Pauline Larwood was enjoying her dinner at The Mark in Bakersfield, CA when she started choking. Lucky for her she happened to be in a restaurant filled with physicians who were in town for a conference on Valley Fever.

When the Heimlich maneuver failed to dislodge her food bolus, she started turning blue. At that point, Dr. Royce Johnson, professor of medicine at UCLA and chief of infectious disease at Kern Medical Center, took charge. He grabbed a large pocket knife from another patron and proceeded to perform an emergency cricothyrotomy right there at the dinner table. Dr. Paul Krogstad, professor of pediatrics and pharmacology also at UCLA, then broke a pen in half and inserted it into the new airway. Dr. Johnson then started to ventilate Ms. Larwood by blowing through the pen as she was transferred by ambulance to the hospital.

Amazing. Most doctors have a vague understanding of how to make a cricothyrotomy but to actually be in a position where one is required in order to save a life is a scenario no doctor wants to be placed. For Ms. Larwood, she happened to be in the right place at the right time. Congratulations to the doctors for a job well done.

I Paid The ASA $360 For A Web Search. I Want My Money Back!

By now all you readers know about my disdain for the MOCA process for board recertification. But just because I don't like it doesn't mean I can just ignore it. I still have to comply with its rules to make sure I have a practice in ten years. In addition, California requires that I have at least fifty hours of CME every two years to maintain my medical license. Therefore, I use the ASA's Anesthesiology Continuing Education program (ACE) to keep up my CME hours.

I've been using ACE ever since I finished residency. It consists of two sets of question booklets, one issued in the spring, the other in the fall. It helps me reacquaint myself with all the information that I learned during training so many years ago. With it, I can receive sixty hours of credit each year. As a bonus, when I submit my answers back to the ASA, they automatically submit the hours I claimed for education to the ABA so I don't have to enter it manually into my MOCA portal. The price this year is $360 for ASA members ($830 for nonmembers) but has been going up steeply recently.

One good feature about ACE is that at the end of every question and answer, the author of that question lists the sources from which they obtained the information. While most of the sources are from reputable journals, I was disappointed that several questions in the latest booklet listed their sources as the medical wiki site UpToDate. Really? For those who aren't familiar with UpToDate, it is like Wikipedia for medical information. You see many of the medical students and residents using it to brush up on their knowledge of a particular subject before or after rounds. It certainly beats carrying all those pocket books that we used to cram into our lab coats, adding about twenty pounds to our weight.

However, for $360, I expect the ASA to use better references for their answers. Why should I pay that much money when I can do a simple web search myself to get the answers? Perhaps I'm asking for too much. Maybe it costs too much money to pay all those contributors to actually find the source article from which they derived their questions. Maybe the ASA needs to save their money for the new headquarters they are erecting in honor of themselves. Maybe the authors are so used to using UpToDate in their everyday practice that they have forgotten how to actually read a medical journal. Whatever the reason, I am sorely dissatisfied with the quality of this year's ACE. It is probably too late to change the questions for the fall booklet but maybe there is hope for 2014. Otherwise I can buy a lot of CME for that kind of money somewhere else.

Signs The Surgical Patient Isn't Doing Well

Surgeons regularly inquire over the ether screen about how the patient is doing during a case. This is very annoying to the anesthesiologist. It makes us feel like the surgeon is intruding on our turf. As a result, nine out of ten times they'll hear the standard reply, "Fine."

A far more accurate way to ascertain how the patient is faring during an operation is to take a quick glance at the head of the operating table. The anesthesiologist's actions and demeanor will tell the surgeon all he needs to know about the state of the patient.

Here is a list of ten signs the surgeon can use to decipher if the patient is really fine or things are not going as well as planned, starting from the least worrisome to the most. Each line is followed by an explanation for the action.

1. The anesthesiologist is sitting down and reading his Kindle.
The case is going so smoothly that the EMR can do all the work of charting the case.

2. The anesthesiologist is sitting but watching the patient monitor intently.
Vital signs are starting to fluctuate at the outer limits of comfort level for the anesthesiologist.

3. The anesthesiologist is standing and watching the monitor intently.
Because standing to watch fluctuating vital signs makes the anesthesiologist feel better even if it doesn't improve the outcome.

4. The anesthesiologist is looking over the ether screen.
He's wondering how soon the case will wrap up so he can get this patient off the table before something really bad happens.

5. The anesthesiologist is asking the surgeon how the case is going.
He's not trying to hide his desperation to get the patient off the OR table anymore.

6. The anesthesiologist is drawing up and pushing multiple syringes of drugs.
Pressors. Need more pressors.

7. The anesthesiologist is making phone calls and talking with an urgent tone of voice.
Time to call in the cavalry.

8. There are more people working above the ether screen than below.
Can never have enough hands to assemble drips and start lines.

9. The anesthesiologist is calling for the crash cart.
The fat lady is about to sing.

10. The anesthesiologist turns off the anesthesia machine.
Opportunity to document zero anesthesia complications during case.

So if any surgeons are reading this post, please follow its advice. Don't aggravate tensions in the room by constantly asking the anesthesiologist for a status update of the patient. With a keen eye, the anesthesiologist's actions will tell you everything you need to know.

When The Shoe Is On The Other Foot

I received an urgent missive in my email from a colleague the other day. She wanted to warn all the anesthesiologists about the impending calamity about to befall doctors. It appears that there is a movement afoot that may require all physicians to periodically retake examinations to maintain their board certificates. The horror! She mass emailed this to the entire department not realizing that many of her younger partners already have to do this. I find her anxiety and panic quite amusing and not without a touch of schadenfreude.

For over a decade there have been two classes of physicians: those who received a lifetime board certificate after residency and those who have a temporary time limited certificate. Through no fault of our own, maybe our parents', many of us were born too late to receive medical training that allowed us to receive the lifetime certificates before they were phased out. Instead we have to pass through an onerous ten year cycle of CME courses, peer reviews, and simulation exams to continue to practice medicine. All these tests cost thousands of dollars, a burden not carried by the older doctors. How this discrimination passed the equal protection clause of the U.S. Constitution is beyond me.

Now the shoe is on the other foot. All the lame rationalizations that the medial societies have forwarded for requiring periodic recertification exams have come back to haunt them. After all the proselytizing about physicians keeping up with current medical knowledge and protecting patient health, the politicians have taken notice and decided that maybe it is a good idea to have a Maintenance of Certification (MOC) process for all doctors. In fact they think it is such a great idea that several states have attempted to tie MOC to state medical licensure.

To no ones' surprise, suddenly doctors around the country are saying that MOC is not really necessary to treat patients well after all. They have been practicing medicine for decades and not once have they felt the need to recertify and update their knowledge base. Besides, lawyers don't have to retake their bar exams every ten years. Why should doctors have to take tests every decade to keep practicing?

The irony here is beyond belief. Suddenly what's good for one group of doctors doesn't apply when all doctors come under the same scrutiny. Change Board Recertification is a website dedicated to bringing about an end to the MOC process. All the excuses for abolishing MOC are here: that MOC hasn't been proven to improve patient care, that it is just a bunch of busy work that wastes a doctor's time and money, and that MOC is actually a method for the different medical societies to enrich themselves with fees from CME courses and mandatory exams. Yes we've heard all of this before. But somehow, the excuses take on more legitimacy when the rules are being applied to all.

If we can't get rid of MOC in its entirety, I wouldn't mind the state legislatures passing laws requiring ALL doctors go through the process. If the older doctors really felt that MOC is a positive experience for doctors and patients, then they should all do it. Unless of course it really is a sham and now they have to admit it or suck it up and starting writing checks every year to attend CME classes to keep their practices. I guess those lifetime guarantees on those certificates are about as good as the the one that came with my set of Ginzu knives I ordered from the late night infomercial.

Stupid Anesthesia Tricks

From the "WTF was the anesthesiologist thinking?" department. An anesthesiologist decorated a patient's face with colored stickers while the patient was asleep. He then had a nurse's aide take a picture with his cell phone. The photo may or may not have then been posted online depending on who was asked.

In October 2011, Dr. Patrick Yang, an anesthesiologist at Torrance Memorial Medical Center was giving sedation to Veronica Valdez, an employee of the hospital, for a hand procedure. Before the patient woke up, he placed black mustache stickers and yellow tear drop stickers on her face and had Patricia Gomez, the aide, take a picture. Later, when the patient was awake the aide showed her the photo.

As you can imagine, Ms. Valdez was none too pleased. She filed a civil lawsuit for breach of privacy and emotional distress. Ms. Gomez claims she deleted the picture right after showing it to Ms. Valdez. Several people have testified in court that they saw the picture on the internet. Ms. Valdez resigned from the hospital after working there 13 years because she felt completely humiliated. Dr. Yang was suspended from his practice for two weeks but is still currently working there. Ms. Gomez was also suspended briefly before returning to work. The lawsuit is still ongoing.

While the gross violation of patient privacy is bad enough, I bet that Dr. Yang felt comfortable taking this picture because he knew Ms. Valdez well. He would know better than to do this stupid act on a total stranger he had just met in preop for ten minutes before surgery. Both people had been working at the hospital for over a decade. Whenever a hospital employee has surgery, he or she usually chooses the surgeon and anesthesiologist they know best and arrange to have the procedure done by them. As an anesthesiologist, whenever I am asked by a hospital employee to personally administer to them the anesthetic, I feel extremely honored and gratified and feel tremendous pressure to do my best job possible. So besides being a breach of privacy, this also most likely led to a loss of friendship and respect between Ms. Valdez and Dr. Yang.

As a doctor you live and die by your reputation. That really is the only thing patients know about you. They could care less that you were AOA president or served as secretary of the state medical society. If they hear good things about your work, they will choose you. Nothing in your C.V. will matter more than what people say about your competence on the job. What a shame two hospital careers have been marred by this imbecilic action.

Just as an aside, where was the surgeon when all this was happening?

Why We Hate Government Run Healthcare

Do you know why doctors despise Obamacare? Not because it will provide health insurance to more people in the country, which we can all get behind. Not because of potentially disastrously low reimbursements, which I'm sure we will all work around eventually. Actually it is because of the hassle of complying with the byzantine rules the government has formulated to receive the money in the first place that draws the greatest ire.

Take for instance this urgent email I received from the ASA. The organization is asking for all anesthesiologists to respond ASAP to changes being considered by Medicare for how anesthesiologists should be reimbursed. I'll reprint it below for you to understand what I'm talking about.

Many ASA members use the “claims-based” method of reporting PQRS measures since it permits successful reporting when there are fewer than three measures applicable to an eligible professional (EP). At present, the Centers for Medicare and Medicaid Services (CMS) has criteria in place for physician anesthesiologists to successfully report quality measures; however, the proposed rule for the 2014 Medicare Physician Fee Schedule seeks to alter the criteria in a way that will place physician anesthesiologists at a great disadvantage.

CMS is moving toward elimination of the claims-based reporting mechanism and is seeking comment as to whether that mechanism should be eliminated in 2017. Some of the actions described in the proposed rule would sharply curtail claims-based reporting even sooner. Specifically, of the more than 40 proposed new measures CMS intends to add to the 2014 PQRS, none allow reporting via claims.

 

Additionally, CMS proposes to increase the required number of measures that must be reported from the current three (3) measures to nine (9). These nine measures must cover at least three of the National Quality Strategy (NQS) domains: Patient and Family Engagement; Patient Safety; Care Coordination; Population and Public Health; Efficient Use of Healthcare Resources; and Clinical Processes/Effectiveness.

 

Currently, there are a maximum of three measures applicable to most physician anesthesiologists. They all are within a single domain. Accordingly, if Medicare’s proposed rule is finalized, anesthesiologists will be unable to satisfactorily meet reporting requirements.

This change would have a significant impact on anesthesiologist’s practice because 2014 is the performance period for your 2014 PQRS incentive and for the 2016 PQRS penalty adjustment.

See what I'm saying? Does anybody outside of political action committees and government lobbyists even know what that means? Just for your information, PQRS isn't a teaching moment on an episode of Sesame Street. It stands for, wait while I look it up, Physician Quality Report System. Click on the link if you want your mind melted by more alphabet soup of arcane government red tape.

The older doctors lament the days when they could just turn in their bills to insurance companies or Medicare and a check would arrive a few weeks later, no questions asked. But unfortunately, through a combination of greed, fraud, and fiscal austerity, the era of blank checks are over. Now we younger doctors are the ones to face the consequences as payers seek ever more creative ways to save money by not paying doctors. Is it any wonder doctors prefer to sell their practices and work for giant healthcare organizations as paid employees? You need to have an army of lawyers to understand all the new rules that are being created under modern healthcare. No independent doctor can afford that can of overhead to stay in compliance and get paid. Welcome to the future.

Scariest CBC I've Ever Seen

This is the scariest CBC result I have ever seen. I didn't think it was even possible for somebody to be alive with a hemoglobin that low. Usually they would have succumbed to the lack of oxygen carrying capacity in the blood before this.

The labs were from a patient who came in with GI bleed. Before you say that the blood sample was drawn from a vein above an IV site, which can dilute the blood and give you dramatically low readings, the patient was transfused three units of PRBC and his hemoglobin almost reached 6. Still less than half of a normal hemoglobin level but at least somewhat above fingernail biting, sphinter releasing stage. So this result is true.

I'm frequently amazed by how much redundant functional capacity our bodies contain to overcome adverse events. Anemia, renal insufficiency, liver failure. The list goes on and on. We are endowed with so much more than what we need to survive it's a wonder anybody ever gets sick or dies. Virtually all our organs have to have reductions of at least 50% before we start feeling the consequences. People do well with only one kidney or one lung. You need to remove at least two thirds of the small bowel to suffer malabsorption. And you can live very well, if uncomfortably, with no colon at all. You need to lose about half of your cardiac output before you start getting symptoms of failure. And you can definitely survive without any brain function, though by then you're not really considered "human" anymore and are considered brain dead.

So whatever your beliefs, thank your maker for how resilient the human body is. We wouldn't have the capacity to destroy our planet if it wasn't for our ability to survive through virtually any adversity.

Anesthesiologists Do Well By Doing Good

Anesthesiologists seem to have the best of both worlds. We contribute significantly to the welfare of humanity while at the same time we are paid very well for that privilege. That at least is the findings from a survey conducted by Payscale.com.  The site asked respondents if they felt their jobs made the world a better place. They then correlated the answers with income data. The information was then compiled into a list of the top 25 most meaningful jobs that pay well.

Our profession came out near the top at number three. Eighty-eight percent of anesthesiologists felt that they made the world a better place. That's not surprising considering that our job is to alleviate pain and suffering. Who wouldn't consider that making the world better? At the same time the average salary of anesthesiologists is $283,600. Not a bad chunk of change for improving people's lives.

As a matter of fact the top five on Payscale.com's list are all physicians. Number one is neurosurgery, with an average salary of $381,500 and a positive survey response of 97%. The second place profession is cardiothoracic surgery, with a salary of $353,900 and a response of 91%. Rounding out the top five are dermatology, because who doesn't appreciate a more beautiful complexion, and OB/GYN, because we all love healthy newborn babies.

So consider this another feather in the cap for anesthesiology. While it's admirable to volunteer to help the world's poor like Mother Teresa or the Peace Corps, that's just not realistic for most of us who have families to support. Like them, anesthesiologists also contribute to the general welfare of society but with the added incentive of a substantial income. In addition, of the top three, anesthesiology has the shortest residency training period and the best lifestyle. Is it any wonder anesthesiology is one of the best jobs in America?