Friday, October 11, 2013

Liberal Europeans Hijack The American Justice System With Propofol

Last week I received an urgent email from the American Society of Anesthesiologists. In the letter, they warn about the possibility of an acute shortage of propofol in the United States due to the actions of one small state in the country. To be specific, the Missouri Department of Corrections was planning on performing two executions on convicted criminals in the coming weeks using propofol as their drug of choice.

Apparently this has set off a worldwide controversy. The European Union has laws prohibiting the export of products that could be used for capital punishment. Unfortunately for us, nearly 90% of all the propofol used here are manufactured by the German company Fresenius Kabi. Fresenius had delivered the propofol to the American distributor Morris & Dickson which then supplied the drug to Missouri. The EU has demanded that the propofol be returned to Morris & Dickson or they would cut off the export of propofol, thereby depriving us of this essential anesthetic, patient necessity be damned.

Did Missouri stand up for its right to treat its hard core criminals as their laws and juries see fit? Sadly, no. The state government knuckled under the demands of the EU and has returned the propofol back to the distributor. The Missouri DOC says that it has enough American made propofol still in stock that can still be used for the executions. But now Governor Jay Nixon has postponed the executions indefinitely until another method can be worked out.

It is outrageous how the EU has blackmailed America into treating our prisoners to their liking. Their faux compassion is especially galling when one considers that the EU looked the other way when products were shipped to Syria to help make chemical weapons that killed thousands of people. They sell billions of dollars worth of military equipment around the world that will be used to kill thousands, perhaps even millions, more people. Now they have the temerity to dictate to us how we should treat our prisoners who have been convicted of murder by juries of their peers? Hypocrisy doesn't even begin to describe this outrage. Sadly for our justice system, one of the three pillars of the American Constitution, they got away with it.

Monday, October 7, 2013

Have You Read Your Package Inserts Lately?

This is just a quick update on a story I wrote a while back. A couple of years ago I wrote about a medical malpractice case in Connecticut involving the use of an LMA in a morbidly obese patient. It turned out to be not such a great idea as the patient suffered a severe aspiration and was left in a coma for 26 days and suffered long term medical complications. The anesthesia group wound up paying $10.5 million dollars to the plaintiffs for this incident.

Since the wheels of justice grinds ever so slowly, you probably wouldn't be surprised that this case has still been winding its way through the state court system for the past two years. A few weeks ago, the state's Court of Appeals upheld the judgement against the anesthesia group. This article has a lot more detail on the case and what happened during the trial.

What is so surprising is how much credence the courts gave the LMA package insert as evidence of a substandard level of care given by the anesthesia providers. One of the contraindications for using an LMA according to the manufacturer's insert was morbid obesity. This was taken by the plaintiff's lawyer and the court as setting a standard of care. Despite the defendant's expert witness stating that the use of an LMA was appropriate in obese patients when properly used, the jury obviously did not agree and rendered the multimillion dollar judgement against the anesthesia group.

This opens up a whole Pandora's box for doctors everywhere, not just anesthesiologists. As we all know, package inserts of medical devices and pharmaceuticals are written in tiny type with every possible risk and complication that's ever been recorded listed. This is more for preventing legal liability on the part of the manufacturer than as guidelines on how to use the product. However, if the courts start considering this as evidence of standard of care, there may be no complication too small for plaintiffs to consider medical malpractice.

How many anesthesiologists have read through those little pieces of paper and memorized the potential complications of propofol, or succinylcholine, or sevoflurane? What about the package insert of that IV catheter you're about to insert into the patient? Or the possibility of harming the patient with use of the IV pump? The risks are endless since those inserts are written by lawyers to cover their own butts. Should we start practicing medicine based on the legalese of some company lawyer? If the trial lawyers start using them as evidence of medical malpractice because we don't adhere to the letter on a product's proper use, and the judges agree with them, then we might as well just start writing out blank checks.

Thursday, October 3, 2013

Anesthesia vs. Patient

How difficult is it to get truthful answers from patients? Watch this funny video to see what anesthesiologists have to go through sometimes to get information from our patients. It's funny because it's true. Is it as funny as the classic Orthopedics vs. Anesthesia? You'll have to judge for yourself.

Blame The Anesthesiologist

Hospital administrators and government officials are always trying to eliminate medical errors. It is a worthy attempt as some estimates put deaths due to errors in the hundreds of thousands per year. Unfortunately, no matter how many rules and backstops are put in place, medical errors will still happen. This is because doctors and nurses are all human and humans make mistakes. You can't sign a law banning human error. But there will always be attempts to point the finger at someone when it happens.

A case in point was published by the California Department of Public Health in its quarterly release of hospitals penalized for gross medical errors. The incident at St. Jude Medical Center in Orange County highlights the limitations of multiple precautionary measures in preventing medical mistakes.

A patient was admitted to the hospital in 2012 for a nephrectomy due to a renal mass suspicious for cancer. The surgeon's H+P documented the mass was in the right kidney. When talking to the patient, he complained of pain in his right flank. The surgeon marked the patient's right side in preop to indicate the correct side for the operation. The operating room nurse even called the surgeon's office before surgery to confirm the proper procedure and side. The anesthesiologist also confirmed a right sided nephrectomy after interviewing the patient. The consent for the operation listed the right side was the correct side. The patient then went into the operating room. A Time Out was called before the operation commenced and everybody agreed that it was the right side that was being removed. The procedure went smoothly.

Shortly afterwards, the pathologist notified the surgeon that the kidney that was sent to the lab was completely normal. Startled, the surgeon reviewed the CT scan, which was left at his office the day of the operation. The CT showed that the cancer was in the LEFT kidney. Since the imaging study was performed at a different hospital, it was not available to be reviewed in the operating hospital's computer system, which one of the nurses attempted to do before the operation. Oops.

During the process of identifying the cause of the wrong sided operation, the state's interviewers asked the anesthesiologist if he should have been more thorough in confirming the correct side of the operation. According to the report, "He looked at labs and general medical health. MD 2 (anesthesiologist) stated he would not meet with the surgeon and review CAT scan results and typically did not review test results (x-rays) as it was not a standard of care."

That sounds about right. I don't know of any anesthesiologist who routinely reviews diagnostic studies before an operation. We just take it as faith that the correct operation is being performed since the surgeon, primary care doctor, nurse, and patient have usually unanimously agreed upon the procedure. Why should the anesthesiologist take the time the review the studies one last time? We would just be blamed for unnecessarily delaying the case.

But that's not how the CA Dept. of Public Health sees it. One of their recommendations after their investigation was completed was this:

Prior to commencing surgery, the person responsible for administering anesthesia, or the surgeon if a general anesthetic is not to be administered, shall verify the patient's identity, the site and side of the body to be operated on, and ascertain that a record of the following appears in the patient's medical record.

What the heck? So now we have to be the mother hen and watch over the surgeons because they might not be doing their jobs properly? We already have enough headaches making sure the proper preop workup has been completed prior to surgery. Anesthesiologists are already considered nags for insisting on a cardiac stress test or requesting a pulmonary function test. Now if we don't review all the diagnostic exams we are possibly liable for the surgeon's mistakes? I better get a pay raise if that is considered one of my duties, and the title Captain of the Ship.

The hospital was fined $100,000 for this infraction.

Wednesday, October 2, 2013

Proof That Jurors Shouldn't Decide Medical Malpractice Cases

Doctors have long contended that medical malpractice cases shouldn't be decided by juries composed of the general public. These jurors just aren't knowledgeable enough about medicine to make an intelligent decision about proper medical conduct. Instead they are easily swayed by crafty lawyers who prey on their emotions. As an alternative medical cases should be overseen by judges who have been specially trained in handling medical cases.

The just concluded Michael Jackson, or more specifically the Jackson family, trial against his concert promoter AEG offers more proof for this common sense approach. The family sued AEG for at least $1 billion because they contend the company hired Michael's disgraced personal physician, Dr. Conrad Murray, which led to his death by propofol oversedation in the singer's private bedroom. If the company knew that the doctor was incompetent and only hired him to help get Michael on stage to perform for his comeback tour with no regard for his well being, then AEG could be found liable for his death. Since this was only a civil trial, only nine out of twelve jurors had to agree.

As it turned out today, the jury did agree that AEG hired Dr. Murray. However, when it came time to answer the question of whether the doctor was "unfit or incompetent to perform the work for which he was hired," the jurors said that he was competent to work as a doctor. Excuse me? This is the assessment of a doctor whose medical judgement is so poor that he gave a surgical anesthetic to a patient in a private home with no monitoring of any kind? This jury gave the doctor a pass even though the cardiologist didn't even know how to do a proper CPR when his patient needed it?

Says Gregg Barden, the jury foreman, "Conrad Murray had a license; he graduated from an accredited college." Another juror, Kevin Smith, stated, "Murray was fit and competent for the job he was hired for...Michael Jackson thought he was competent enough." So these impartial citizens all thought Dr. Murray's lack of medical skills and the resulting death of his one patient was not enough to deem him an unqualified physician. Maybe we can use this trial as evidence that medical cases need to be moved out of the reach of jurors and into special medical courtrooms. Maybe Mr. Jackson's death won't be in vain after all.

Saturday, September 28, 2013

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.

Friday, September 27, 2013

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.

Wednesday, September 25, 2013

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.

Thursday, September 19, 2013

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.

Sunday, September 8, 2013

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.