Saturday, November 30, 2013

I Knew The ASA Is Just Another Money Making Enterprise

The American Society of Anesthesiologists bills itself as a standard bearer for anesthesiologists. With its lofty, and oft repeated, statements about patient safety and anesthesia advocacy, the organization comes across as saintly as the Vatican. So it's a shame they will demean themselves by running a stupid Black Friday sale.

I was dismayed when I got an email from the ASA on Black Friday hailing their "hottest sale of the year". Upon viewing the merchandise the group was marking down, it is obvious the selection is full of stuff nobody wants. An eight year old ACE booklet for $30? I guess it is a deal when it used to cost over $100 when new. But how many people really need a CME program from 2005? Medical information has expiration dates. That's why we spend billions of dollars on new research every year. These old CME booklets will not advance an anesthesiologist's knowledge base. More mature and stable information hopefully should have been retained from residency.

In fact, if the ASA really cared about physician advocacy, it should donate these old programs to anesthesia residencies all around the country. Any leftover books more than four years old should be handed out by the ASA for free. This will get the information to individuals who need it the most, our future anesthesiologists. The group should not be hawking its leftovers from the back of their warehouse to make a few extra bucks. But then again I guess they need the money to finish their sparkling new headquarters.

Thursday, November 21, 2013

The ABA Made Me Do It

The American Society of Anesthesiologists recently published a list of procedures and practices that they feel have been overly used and abused. Among the items that the organization advises doctors to minimize is the compulsion to draw routine blood tests on young healthy patients, blood transfusions for patients who are young and hemodynamically stable, and the use of cardiac stress tests or pulmonary artery catheterization in low risk patients for procedures that will produce minimal cardiac disturbances.

This all sounds pretty commonsensical. I've had many conversations with our surgeons who insist on getting a full preop workup on young patients prior to a relatively benign operation. Just the other night, I received a young patient from the ER for a laparoscopic appendectomy. He was less than 40 years old. His H+P consisted of "No previous medical history" and "No previous surgical history". Yet the ER had drawn a complete metabolic panel, coag studies, and performed an ECG. Why do surgeons continue to request all these tests when it's so obvious that most are unnecessary and a waste of money?

The simple answer is that surgeons hate to have their cases delayed or cancelled because the anesthesiologist wants one more test before clearing the patient for a procedure. By painful and frustrating experience, almost all surgeons become habituated to overtesting their patients just so they can be sure that the anesthesiologist doesn't have any excuses to cancel a case and ruin everybody's day.

This leads to the question of why some anesthesiologists want so many studies before they will take a patient to the operating room. While I don't have direct knowledge of why some people do what they do, I submit that a fundamental reason for this action is because we were all horribly traumatized by the American Board of Anesthesiology during our oral examinations prior to receiving our board certification. Virtually every anesthesiologist remembers the horror story of that experience. You study for months at a time, spend thousands of dollars on board prep courses, then fly to a city far away to get grilled by four distinguished strangers for nearly one hour straight on esoteric subjects you hope you will never encounter in real life.

As part of this examination, you are asked by the executioners, er I mean examiners, what kind of lab work you want before allowing a patient into the operating room to continue the exam scenario. Almost automatically we all want to have every blood work and cardiac exam possible. It is so much easier to get every lab done before taking the patient to the OR than to discover that you missed a crucial piece of information once the patient goes under the knife. Heaven forbid that the patient starts bleeding out on the OR table because you didn't think the patient needed a PT/PTT and it turned out she has a Factor XI deficiency. Now you're stuck with an unstable patient in the OR with no clue as to why the patient is oozing from every cut surface in the body, and most likely you also didn't bother getting a Type and Cross to the blood bank too. FAIL.

You'll have nobody to blame but yourself if on the physical exam in another hypothetical preop you hear a heart murmur and the patient says he's had mitral valve prolapse for years but is asymptomatic and you don't do anything about it. Then during surgery the patient becomes unstable because in reality he has severe mitral regurgitation and pulmonary hypertension. At that point you are scrambling to save your skin by calling for an emergency TEE instead having an echo done before surgery and hoping you still have a rat's ass of a chance of passing this exam, which you probably don't.

What about all the expenses and potential complications of performing so many tests on patients who most likely don't need them? Well, in these simulations, cost is never a factor. You may have to justify the need for a test based on your examinations, but money is never an excuse. As a matter of fact, if you omit a test because you say the cost doesn't justify the benefits, you will unerringly be led down a path where you absolutely should have performed that preop test but now it's too late and the patient died on the table. And it will be ALL YOUR FAULT, you penny pinching board failing loser.

So it is understandable why some anesthesiologists continue to be haunted by the what ifs in their daily practice. After being scarred for life by the ABA, it just makes sense that most anesthesiologists will want multiple preop tests performed with little regard for necessity. It is simply better to be safe than sorry. If anybody complains about the expense, tell them to take it up with the ABA.

Wednesday, November 20, 2013

Simple Test To Assess Physiologic Age

As the patients we evaluate for surgery get ever sicker, we are always searching for better ways to assess a patient's health. Of course there are all sorts of expensive tests we can order to give us hard numbers and reassure us of our anesthetic plans. However in this age of cost cutting and insurance oversight, perhaps there are cheaper tests that will give us equivalent results.

A few years ago I wrote about an article in the ASA Newsletter that described a couple of bedside techniques to help decide if a patient is safe to undergo surgery. They both have the advantage of requiring nothing more than a blood pressure and a pulse. Nothing simpler or cheaper than that.

Now there is another simple test that can be performed quickly and cheaply in preop. Written up in the Wells blog of the New York Times, this new test was developed in Norway and rapidly assesses the oxygen delivery capacity of a patient. Oxygen delivery is one way of determining a patient's cardiovascular health and physiologic age. The researchers were able to whittle all the different physiologic measurements of their 5,000 test subjects down to a test with only seven questions that can reliably decide oxygen delivery. Three of the questions ask about the exercise habits of the subject. Other questions include sex of the person, age, waist size, and baseline pulse rate. After trying out this test, it seems that the quantity and quality of exercise made very little difference in my calculated physiologic age. Whether I worked out less than or greater than thirty minutes each time made no change in the final calculation. But varying my waist size or pulse rate made much more meaningful changes. This makes sense since most people can achieve a smaller waist size or slower heart rate by exercising regularly.

So next time you see a patient in preop who you want to delay a case to get one more test prior to clearance, try some of these simple and noninvasive methods. This may save the patient from another expense and prevent your reputation from taking a hit as the anesthesiologist who likes to cancel cases.

Tuesday, November 19, 2013

Anesthesiologists Are Tethered

Anesthesiology is great. Anesthesiologists make a lot of money and have an envious lifestyle. Isn't that why it is such an aspiring field for medical students? However, one aspect of anesthesiology that students and residents may not be fully aware of is that we are strictly tethered to the hospital. Almost all anesthesiologists, if we don't spend our call nights in the hospital, have to be able to get there from home within thirty minutes. The reason for this is that we may have to come in for a trauma or an emergency obstetric case. In such situations, minutes can mean the difference between life and death. This restriction can severely affect our quality of life and spending choices.

The TV show "House Hunters" illustrate this issue. One episode was about Joey, an anesthesiologist in Wilmington, NC. The doctor's search for his new home were restricted by having to live within a few minutes of his hospital. This may not be a problem if one lives in a small town. I grew up in a rural hamlet in the Midwest. Driving thirty minutes outside of town led to cow tipping territory already.

But if somebody wants to live in a traffic plagued city like Los Angeles, living thirty minutes from the hospital may put one only about five miles away. Thus compromises have to be made--life plans may need to be altered. In LA, anesthesiologists who can afford to live near the nicer hospitals on the Westside, like in Beverly Hills or Santa Monica, may have to squeeze into smaller homes. They may have to pay for their kids to go to expensive private schools. There may not be more than a few square feet of lawn for children to play in. If they want to have a nicer home with a bigger yard and better public schools, they may actually have to transfer to a different hospital to stay within the thirty minute radius.

So yes, anesthesiologists have a nice lifestyle. Just remember that the anesthesia lifestyle may include a view of the hospital from your bedroom window.

Monday, November 18, 2013

The Most Important Thing Not Being Taught To Anesthesia Residents

This month's issue of the ASA Newsletter focuses on a subject that is often overlooked and belittled by academic anesthesiologists as they preside in their ivory towers. The topic of the month is the increasing importance of non O.R. anesthesia in our field. NORA is any anesthesia that is given outside the usual hospital OR's, such as the GI suite, Cath lab, Interventional Radiology, MRI, etc. You name it, somebody wants anesthesia somewhere that doesn't have all the niceties and comforts of a regular operating room.

NORA is now approaching 25% of all anesthetics being given in this country. If you also count anesthetics that are given in ambulatory surgery centers instead of hospital operating rooms, that figure is approaching 50%. In other words, there are thousands of anesthesiologists out there practicing outside the hospital operating rooms and the numbers are likely to increase for years to come. Yet I find that our anesthesiology residents have incredibly little training in how to give anesthesia outside their comfort zones of the environmentally protected OR's.

Yes every anesthesia resident wants to get their hands dirty on the intellectually challenging cases like liver transplants and aortic valve replacements. When there is an awake craniotomy to be performed, everybody wishes he was on the Neuro rotation that day. We all love to be involved in cases that will make for scintillating party conversations. But let's face it, for a large percentage of residents, they will not be doing these kinds of cases ever again once they finish residency. They will be faced with giving anesthetics in a setting where they may not have full control of the airway, where the support system of the facility is minimal or none, and the equipment may be outdated or BYOB (Bring Your Own Blade).

Add to that is the fact that MAC cases in NORA's are perhaps some of the most difficult cases anesthesiologists are likely to face. Sure most anesthesiologists scoff at giving propofol for MAC as being far beneath their abilities. But I submit that MACs will tax the intellects of our most accomplished anesthesiologists. I remember the first day I had to go to the GI suite to give anesthesia after my residency. Frankly, I drew a blank as to what to give. I knew all about how to intubate patients with difficult airways and pass Swans in heart patients, but in my entire residency I never once gave anesthesia in the GI suite.

How hard can giving propofol in the GI be? How about confronting morbidly obese patients with pulmonary hypertension with pressures in the 70's, sleep apnea, diabetes, and severe aortic stenosis who needs an EGD for anemia with a Hct of 23? If this patient was having a prolonged procedure in the OR, it would be a no brainer to intubate the patient, start an arterial line, and maybe have a few drips prepared. But you can't do any of that for an EGD where the procedure could last anywhere from 3 minutes to 30 minutes. You need the ability to give maximal sedation for the endoscopic intubation that will prevent the patient from coughing and bucking without having the patient's BP bottom out or heart rate shoot sky high and it needs to wear off within a few minutes so that the next case can proceed on schedule. An anesthesiologist wouldn't survive long in the GI suite if she intubated every patient who came in with morbid obesity.

Other challenging environments include the Cath lab where the cardiologists demand sedation in patients with ejection fractions of 15% and BP's in the 80's so that they can insert an internal cardiac defibrillator. Will the old standard of propofol sedation really be the best drug to give in this situation? Many anesthesia residents will never know until they are confronted with this scenario in private practice. How about giving sedation to a patient in MRI who is morbidly obese, with severe gastric reflux, orthopnea, sleep apnea, and wants to be asleep for the procedure because she has severe claustrophobia? In my residency, I didn't have any training in any of these locations. We were all so busy learning how to do blocks on shoulder patients and understanding the intricacies of inserting a right sided double lumen endotracheal tube that taking time away to learn how to give MAC sedation felt like a waste of my busy residency hours.

But as more and more procedures are moved to outpatient settings where speedy sedation and recovery are of the essence, anesthesia residents should do themselves a favor and ask for more education on NORA. The fact is that almost all of them will be doing some NORA MAC cases at some point in their careers and many will be doing only NORA MAC cases. They should be familiarizing themselves in sedation techniques while they still are protected by experienced faculty. Don't wait until the first week in practice to realize that you have no idea how to sedate a prone patient for ERCP with a big honking scope in the mouth and is refluxing bile all over the bed. And anesthesia residencies would be wise to prepare our residents for these seemingly simple but extremely demanding anesthetics.

Thursday, October 31, 2013

The Most Expensive Jack O'Lantern You'll Ever Buy

Happy Halloween!

The most expensive and fastest jack o'lantern you'll ever buy. A McLaren MP4-12C putting its bright orange paintwork to good use.

Sunday, October 27, 2013

"I was all for Obamacare until I found out I was paying for it."

That is the lament of one shocked insurance buyer featured in a page one article in the LA Times today. The Obamacare advocacy newspaper is just now coming around to reporting on the financial penalties imposed on people due to the new insurance plans. As it turns out, President Obama's statement that people can keep their health insurance plans if they like it was not passed on to the insurance companies who actually have to sell their plans.

The ACA has forced insurance companies to cancel plans by the thousands because they don't comply with the requirements of the new law. Things like mammograms, contraceptives, and mental health coverage are suddenly being thrust upon people whether they need it or not. Therefore the companies cancel their old plans and force consumers to buy the new ACA compliant plans that may cost them 50% more than what they pay now. Naturally this comes as quite a sticker shock to gullible consumers who believed everything their government told them.

Another one of the President's lies that has now been exposed is that you can keep your doctor if you want to. In order to prevent the premiums from rising even higher, the health insurance industry has significantly narrowed the networks of hospitals and doctors that patients can use under the new plans.

You say that your company provides health insurance for you so you can't empathize with the poor schlubs who have to buy their own health insurance on the new exchanges? Well guess what--that corporate protection might not last much longer. Major corporations are realizing that it is easier to dump their employees onto the insurance exchanges with a small subsidy than it is to keep providing insurance ad infinitum. Or if fate is particularly frowning upon you this year, they may decide to cut back on your hours to part time status so that they have no obligation to provide you with any insurance at all. That's all perfectly legal according to President Obama.

All these changes should really be called the new Obamacare tax that has been subversively thrust upon the American people. They may not call it a tax, and the Supreme Court tried very hard not to defeat Obamacare based on tax clauses, but if you have to pay more money due to a government mandate, it is a tax. During the Congressional debates prior to its passage, there were impassioned arguments from our representatives that it's just not fair the top 1% are taking all their wealth and leaving the other 99% behind. They have to pay for their financial success, which obviously couldn't come from hard work and sacrifice. So let's just raise their taxes to help pay for health insurance for everybody. Everybody else can get free or subsidized health insurance and it won't cost them one bit. Ha ha! The voters have been fooled again.

Everybody is all for universal health insurance coverage, until they have to pay for it as the LA Times found out. While we haven't raised our taxes to the levels found in Europe that are necessary to provide health coverage for everybody, these forced payments on higher insurance premiums for lesser coverage is just another name for a new government tax. But all these people who voted overwhelmingly for Obama twice knew what they were getting when they elected a tax and spend liberal Democrat to the presidency, right?

Saturday, October 26, 2013

Don't Forget To Leave Behind Your Constitutional Rights When You Pick Up Your Medical Degree

Recently, an order was issued from the Los Angeles County Department of Public Health. Written by Dr. Jonathan Fielding, the department's Health Officer, it imposed on all healthcare providers in the county this edict:

Pursuant to my authority under §120175 of the California Health and Safety Code, I hereby order every licensed acute care hospital, skilled nursing facility, and intermediate care facility within the County of Los Angeles public health jurisdiction to implement a program under which healthcare personnel at such facility receive an annual influenza vaccination for the current season or wear a mask for the duration of the influenza season while in contact with patients or working in patient-care areas.
In other words, get a flu vaccine or wear the scarlet letter equivalent of a mask over your face. There is no leeway or any sort of objection to get around this new rule in L.A. While I am all for preventing the spread of the flu, this seems to blatantly trample on my rights as a citizen of this great United States. Get a flu vaccine or be ostracized at my place of employment? Something doesn't feel right here. Why is it that while parents can legally refuse to have their children vaccinated against childhood illnesses, and thus potentially start an epidemic at my children's school, I have no say in whether I want to get the flu vaccine or not? Shouldn't children who don't get vaccinated as per government recommendations wear a mask at school to keep them from spreading their diseases to other kids? Why isn't the equal protection clause of the U.S. Constitution being observed?

Besides, the flu vaccine is no panacea in keeping one from getting the flu. Its effectiveness is dependent on the recipient and whether the vaccine actually contains the flu strain that is currently the most widespread. Just because I am forced to get a shot doesn't mean I still won't get the flu.
Of course doctors should be used to being brushed aside and taken for granted by the government by now. New laws and regulations are issued all the time regarding how we should practice our profession. The most brazen of course is the EMTALA law, requiring doctors to treat all patients regardless of ability to pay.  While admiral in its purpose, it still places doctors into a professional servitude which the feds wouldn't dare impose on anybody else. Would the government force lawyers to work with a client who couldn't possibly pay their hourly rates? In this litigious society having legal representation is practically a necessity but if you have no money, you are not going to get good representation, or even any representation. 

Somehow physicians have come to accept their plight as the cost of doing business. We just roll over while other people make rules for us. I have not heard anyone at the LA County Medical Association object to this ruling. No word from the California Medical Association either. They're too busy throwing parties for themselves to empathize with how doctors well being are being infringed upon by the government. 

So I will be trudging to my hospital's employee health department and getting my flu vaccine soon. It doesn't appear that I have a choice. Maybe I should bring a tea bag with me as a sign of my conscientious objector to this travesty of justice.

Monday, October 21, 2013

Where The Battle Has Already Been Lost

We recently had some traveling nurses come work at our hospital. Their most recent assignments had been at some East Coast medical center. They remarked with astonishment that we have actual anesthesiologists working inside the operating rooms.

"Why do you sound so surprised?" I asked them. They informed me that at the prior hospital back east that they've worked in, CRNA's were the ONLY ones in the operating rooms administering anesthesia. What were the anesthesiologists doing outside while the operations were going on? Seemed like they were in charge of getting the next patient ready for the case, having the anesthesia consents signed, and writing post op notes on the floor. "Didn't they ever come into the OR to do cases?" I further inquired. No, they said. And the surgeons preferred to have the nurses giving the anesthesia at their institution.

I was dumbfounded. And depressed. Something has gone terribly wrong with the way that anesthesiology group has decided to practice at that hospital. This was coming from a state that had not yet opted out of physician supervision of CRNA's. But for all intents and purposes the CRNA's were running the show in their operating rooms. Imagine that you've spent hundreds of thousands of dollars getting your medical education. Spent years out of your life that you will never get back studying to become an anesthesiologist. Then at the end, you are nothing more than a paper pusher and face greeter. That appears to be the functions of their anesthesiologists. 

The longer this situation continues, the worse it will be for those doctors. As the nurses pointed out, the surgeons actually start preferring to work with the CRNA's. The less exposure the surgeons have to the expertise of their anesthesiologists, the less they can trust them or respect their hard earned anesthesia experience. They won't have gone through the difficult cases together, fought the same battles, or share the same war stories. Instead the anesthesiologists over there are on the outside looking in.

Now maybe the anesthesiologists at that hospital prefer to work in this fashion. Perhaps they like not stressing in the operating rooms. It could be that they like to go get their coffee and bathroom breaks anytime they wanted instead of rushing between cases. Maybe their accountants told them that they can make more money hiring CRNA's to work than to bring in more anesthesiologists. But if anesthesiologists start taking this attitude, then it becomes easier for hospitals, and states, to say they want their CRNA's to work without the oversight of anesthesiologists protecting the patients. If anesthesiologists are reduced to little more than legal secretaries and nurse practitioners, then anesthesiology as a relevant clinical field of medicine will be irretrievably lost.

Sunday, October 20, 2013

Anesthesiologists' Last Stand?

Last week, Rep. Andy Harris, M.D., the only anesthesiologist serving in Congress, sent a letter to the California Society of Anesthesiologists apologizing for not being able to attend the ASA conference in San Francisco due to the government shut down at the time. In it, he also addressed the issue of the insidious changes that are occurring at the VA Administration in regards to increasing the scope of practice of CRNA's that are being considered at VA hospitals. I have copied the letter in its entirety below.

To those of you who are attending the ASA meeting in San Francisco - I am sorry I have to remain in Washington this week and won't be able to attend as I had planned.

I did want to update you on a very important issue to anesthesiologists addressed here in Washington last week.

The Department of Veteran Affairs recently developed a new draft of the VA Nursing Handbook which dramatically expands scope of practice for nurses. This change would require nurses to practice independently. Currently, the VA facilities operate under the applicable state scope of practice laws.

Last week, I requested to sit in on a hearing of the Veteran Affairs Committee's Health subcommittee where the VA Principal Deputy Undersecretary for Health Dr. Robert Jesse was testifying. I directly confronted Dr. Jesse about these dramatic changes to the nursing handbook. You can watch the exchange by clicking here (or copy and paste this link into your web browser).

The main focus of the over two hour hearing was on the skyrocketing use of prescription painkillers to treat veterans. Those who testified discussed how the VA is failing to adequately treat the pain our soldiers are returning from battle with and failing to prevent our soldiers from becoming addicted to painkillers. The drafted dramatic scope of practice expansion for nurses would only make this problem worse as those with little to no training in pain management would be in charge of treating these wounded warriors. Those who sacrificed for our country deserve better.

During the questioning, Dr. Jesse committed to me that before any changes to the Nursing Handbook are finalized, the VA will have a comment period and will listen to the concerns of the ASA, AAFP, and AMA. I will continue to make sure our concerns are addressed. In addition, the VA Health subcommittee's chairman, Dr. Benishek, and Democratic ranking member Ms. Brownley have written to the VA and expressed concerns about these changes.

If you have any concerns or need to reach me, please feel free to email me at

Andy Harris, M.D.

The danger here, of course, is that the federal government will lead the charge in allowing CRNA's to practice without the supervision of a physician.  Right now, each VA hospital lets the nurse anesthetist practice according to the laws of the state that it resides in, whether the state has allowed CRNA's to opt out of physician supervision or not. If the federal government decides that all VA hospitals in every state should let CRNA's practice without supervision, then the chances are that this will open the door for more states to opt out.

The threat posed by this seemingly minor rules change in the VA Nursing Handbook should not be underestimated. Don't our veterans, the ones who have sacrificed their lives to protect the interests of our country, deserve to have the best anesthesia providers available to them? Do we really want the heroic men and women of our armed forces to be treated by somebody who is just counting down the clock to their 2:00 PM quitting time so they can hustle to their cars ahead of the secretarial and janitorial staff?

If you understand the grave risks the Veterans Administration is posing to anesthesiologists, don't hesitate to contact your state anesthesiology society and your local congressional representative ASAP. Giving money to the ASAPAC or your state society PAC wouldn't hurt either. Congress shouldn't hear only one side of the story from the politically powerful AANA. We need to do everything in our power to prevent these changes from happening at VA Hospitals. If this isn't stopped, it will be a slippery slope to universal control of operating rooms by CRNA's.

What happens when anesthesiologists abdicate their proper role as the patient's safety advocate in the operating room? Read here to find out.