Sunday, October 12, 2014

The Scariest Doctors I Work With

I've worked with angry doctors. I've worked with slow doctors. I've worked with funny doctors. But do you know which physicians worry me the most? No it's not the psychopath surgeon whose mother never taught him how to talk with his inside voice. Nor is it the befuddled old coot of a surgeon who meticulously labors through a case that would take half the time in the hands of a more competent physician. No the procedurists that worry me the most in a procedure room are...first year GI fellows.

Why do these young innocent physicians scare the crap out of me? It really is no fault of their own. Every doctor has a steep learning curve that has to be traversed before they can be the experts they will eventually become. Unfortunately for me, new GI fellows are acquiring their craft by obstructing the part of the patient I am most responsible for safeguarding, the patient's airway.

When these young doctors first grab hold of an endoscope, they literally don't understand the ups and downs of the instrument. They'll fiddle with the myriad of knobs and locks to try to understand how to aim the scope in all directions. They'll play with the various valves and buttons to determine how to suction or insufflate. It makes my sphincters tighten just anticipating what is about to happen.

Then the dreaded procedure begins. The fellow will sort of bend the end of the scope to what he thinks is the approximate curvature of the tongue and the oropharynx. He will pass the scope through the lips then...get completely lost. All he'll see on the monitor is a red or orange monochromatic screen. Unless he pushes really hard into the soft tissue in the mouth in which case he may see white as all blood under the mucosa is pushed away from the end of the instrument.

In the meantime my job is to preserve the patient's airway while sedating her well enough so that she doesn't jump off the table as the neophyte continues his lesson. If the patient starts coughing or moving, I'll get the much despised, "Anesthesia, patient's waking up!" and it will be my responsibility to keep the patient still with more drugs while the fellow continues to meander his way down the mouth.

Eventually he will advance far enough past the tongue to actually see the vocal cords. It is at this point, when the greatest danger to the patient is present, that most of them decide to pause to admire the view, as if they think they are ENT surgeons. They may blow air directly on the cords to keep open the space around the tip of the scope, which of course causes the cords to become irritated and the patient to cough. Once again I'll have to respond to "Anesthesia, patient's waking up!" as if it is my fault. Or worse, the tip of the endoscope may become smeared with saliva and the fellow decides he needs to wash it with a squirt of water, which again leads to coughing, or worse, laryngospasm. All of these reactions the patient is suffering somehow have to be mitigated by me or the doctor won't be able to continue.

Once he's had a good look at the cords, he will then proceed to enter the esophagus. He will try to enter through that tiny little space right below the arytenoids and through the upper esophageal sphincter. Here is where most of them baffle me. They will tell the patient to swallow the scope to open up the sphincter. How quickly they forget that I have to sedate the patient so deeply for them to get to this point that the patient is not able to cooperate to verbal commands. This step may take awhile as there is usually a slight bend in the UES before the scope will enter the esophagus properly. Once they have passed this point I can finally let out a quick sigh of relief as the airway is now at less risk of obstruction once the scope has passed.

I know they have to learn their trade somehow. And after a few thousand endoscopies under their belts, they will be one of the highest paid physicians in the country. But in the meantime I don't think patients understand what risks they are taking when they have GI fellows practicing their procedures on them. Maybe this is one of those times where a model simulation of an endoscopy, like simulations of airway intubation, can be both safe and effective. I'm sure getting tired of pushing more propofol just so the fellow can get the endoscope past the patient's uvula.

Friday, October 10, 2014

Rich People Doing Stupid Things

I've seen some pretty ignorant driving behavior here in Southern California. There are the women who put their mascara on while going down the road at thirty miles per hour, the applicator just millimeters from their eyeballs. Or the girls who decided they just needed to braid their hair with both hands at that moment while steering their vehicles with their knees. Texting while driving is practically ubiquitous these days. But when I saw this car on the freeway I had to do a double take.

People were all driving 50 mph+ when this BMW M6 convertible came zooming past. Now that isn't unusual for a car with an excess of 550 horsepower under the hood. But what shocked me were the three teenage passengers sitting in the back seat. They weren't really sitting in it so much as squatting on it. As you can see their heads and shoulder are way above the headrests. That's probably because this car's knee room is so cramped that they couldn't fit their legs back there. This car is more of a 2+2 touring vehicle, not a family transportation hauler. BMW calls it a 4+1 seating configuration, meaning the person in the middle of the back bench had better be tiny and willing to straddle a huge center tunnel running down the middle of the car.

Of course when you aren't sitting in the seats properly, you can't wear the seat belts either, which none of these three kids were doing. If this car ever got into an accident, those kids would become living breathing flying missiles shooting out of the vehicle at fatal speed. So now you have three children squatting in the back with their heads above the headrests and none of them wearing seat belts in an open top convertible. The potential for disaster is mind boggling. This just goes to show that just because somebody has lots of money, the retail price of this car is almost $120,000, doesn't mean they have much common sense, or any sense. I hope somebody recognizes this car and tells the driver to stop this insanely reckless behavior before innocent people are killed.

Wednesday, October 8, 2014

Binge Drinking Is Another Reason Why Children Shouldn't Copy The Behavior Of Their Sports Heroes

Here's another case of a professional athlete setting a bad example for their young admirers. While the child abuse case of Adrian Peterson and the spousal abuse by Ray Rice are worse, this binge drinking by San Francisco Giants pitcher Madison Bumgarner is potentially more dangerous. Most of us can't contemplate the violent behavior of the aforementioned football stars, but the Giants player's binge drinking will certainly be admired by many young adults, maybe even impressionable high school students. In this video clip, Mr. Bumgarner is seen chugging FIVE cans of beer simultaneously while his teammates cheer him on in the aftermath of their win in the National League Division Series. Is this celebration of a baseball game excessive? Will Mr. Bumgarner want to be remembered as the man who can drink five cans of beer at a time? How will he feel when his own children and other young family members watch this on YouTube, up there on the internet for all time? Will he be embarrassed? Or will he be like the hypocritical pot smoking parents who tell their kids not to do what they see their elders doing?

Excessive alcohol consumption is a serious issue in our country. Its economic cost is estimated to be over $200 billion per year in medical care and lost productivity. Seventy-five percent of that is directly related to binge drinking. Binge drinking is defined in men as taking five or more drinks within a two hour span. In the video, Mr. Bumgarner is doing it all in thirty seconds.

According to the CDC, ninety percent of alcohol consumed by young adults under the age of 21 are done by binge drinking. Think of the fraternity weekend parties, postgame keggers, and Greek nights on campus. But it's not confined to just college campuses. Ten percent of high school drinkers have binge drinked. These are precisely the fans who will be admiring the beer guzzling performance of Mr. Bumgarner.

For the same reason these young fans buy the shoes and other products endorsed by athletes, they will also try to emulate their actions on and off the field. At that youthful age they don't have the judgement to discern what's wrong and what's right. I don't have to go through the long list of potential complications from excessive alcohol use, including injury or death to oneself or others from drunk driving, hepatitis, pancreatitis, unwanted pregnancy and sexually transmitted diseases. This sort of behavior should not be an example of a celebratory display after a hard won game. Spraying each other with champagne is one thing. Drinking alcohol so quickly that it is running out the sides of your mouth and down your clothes should not be condoned by any athlete or their professional organization lest they want their own children to do the same thing.

Everything You've Always Wanted To Know About The Female Sex Organs And Were Afraid To Ask

This extremely clinical description of the female genitalia will surely take any romance out of the mystery of female orgasms. Hmm, required reading for high school sex ed and college fraternities everywhere?

Tuesday, September 23, 2014

Syringe Labeling Rules Run Amok. The Double Wide Propofol Label

We are expecting shortly another facility inspection by The Joint Commission. Cue scary Psycho music. As per routine, our department heads are going around the operating rooms to make surprise inspections in each anesthesiologist's cart. At the top of the list is making sure that we have properly labeled our drug syringes.

But this year the rules have changed, specifically for propofol. In the past, one would slap a propofol label onto the syringe and write down the date and time the drug was drawn up along with the user's initial. Now that is no longer the case. Instead, the new rules want the date it was drawn up, the time twelve hours later when it supposedly will expire, along with the date of the expiration time and the user's initial. Consequently, in order to have space for all that information, our propofol labels has gone double wide compared to the other drug labels.

I asked my department why twelve hours when I've always been told that propofol should not be used six hours after it is taken out of the bottle. Their reply is that due to the ongoing propofol shortage, our pharmacy has determined that propofol is acceptable to use for up to twelve hours. What? With just a simple decree by committee, longstanding rules for drug use can be changed without further research and FDA approval? It makes me wonder how many other "rules" in medicine are not based on any scientific processes and were developed by a bunch of people sitting around a conference table.

Frankly this whole syringe labeling exercise is a total waste of time. Half my routine during morning setup involves sticking these small labels on small syringes and writing in teeny tiny letters on slippery rounded surfaces. It's not as easy as it sounds. Not all pens will write on these paper labels. And how many of us routinely write on a non-flat surface? The lettering wind up being so small and distorted that they are hardly legible. How is this helping patient safety? Doing this on dozens of small syringes a day wastes a good portion of my time before each case.

I never understood why we even label syringes. I have a colleague at an ambulatory surgery center who claims he has not labeled a syringe in a decade. He uses only four different drugs for all his cases. With a clever combination of different size syringes and needles, he knows exactly what each syringe holds without even thinking about it. He scoffs at our insane rules for syringe identification.

Besides, who really needs to know the content of a syringe? Yes almost all drugs look like water in the syringe so it's helpful to know what's in it. But as far as dating and timing the drug, who really needs that. If I find a filled syringe sitting around that I didn't make, of course I wouldn't want to use it. It would go instantly into the drug trash bin. If I drew up the drug and forgot to put a label on it and subsequently forgot what I put into the syringe, again it goes straight to the medication trash. If I'm the one using the syringe, why should I put my own initials and date and time for when it was first made? I know all that information already. Who are the labels really supposed to help?

But The Joint Commission is on its way. And since they have a near monopoly on this whole hospital accreditation scam and could potentially shut us down, we just have to grit our teeth and follow their rules, no matter how nonsensical they are.

Sunday, September 21, 2014

You Give Docs A Bad Name

Audacity hardy begins to describe this physician. In the latest article from the New York Times on who is to blame for the U.S.'s enormous healthcare costs (they usually blame the MD's), the paper writes about unexpected medical expenses following a hospital stay. This time, they document the difficulties of a young man who just had neck fusion surgery.

Even before they talked about the outrageous bill that blindsided this patient, they itemize the enormous costs of having surgery that were anticipated in advance: $56,000 from the hospital, $133,000 from the orthopedic surgeon, a relatively measly $4,300 from the anesthesiologist. I think most Americans would be shocked by these expenses, much less the rest of the single payer world. The man knew that his insurance company will only pay the prenegotiated reimbursements since these were all within his network. But then, much later, her received a bill for $117,000 from an assistant surgeon that he never recalled meeting.

The primary surgeon, Dr. Nathaniel Tindel, was eventually reimbursed $6,200 by the insurance company. The assistant, a neurosurgeon by the name of Dr. Harrison Mu, was out of the insurance network. Therefore he could bill for whatever he felt was his going rate. This despite the fact that he was duplicating the work that was already performed by Dr. Tindel. Dr. Tindel billed the insurance company $74,000 for removing two vertebral disks and $50,000 for inserting the hardware. Dr. Mu billed for the exact same procedures at a rate of $67,000 and $50,000, respectively.This sounds suspiciously like double dipping to me. Not a bad payday for about two hours of operating time.

I've seen these situations in the OR's before.When the economic times were tough a couple of years back, we had plastic surgeons scrub in and just stand around holding retractors until they were needed for skin closure. I'm sure they billed a pretty penny for that beautiful pencil thin scar. You have to wonder about any possible financial arrangements that were made between the primary surgeon and the assistant. After all, why share the work with another doctor if it is much cheaper to just use the PA or resident?

Another highly questionable aspect of this situation is that the patient denied ever meeting Dr. Mu. Was Dr. Mu's name on the surgical consent? Around here, if the name is not on the consent, the doctor does not touch the patient, period. That even applies to the surgical residents and fellows in the operating room. Anything else could be construed as an assault by the doctor on the patient.

The paper tries to justify Dr. Mu's actions based on his normal hospital practice, which is in Jamaica Hospital Medical Center in Queens. According to state records, his practice mostly involves trauma patients on Medicaid, which probably pays him about one percent of what he billed in this spine case. Therefore, even though Dr. Mu is the chief of neurosurgery at Jamaica Hospital, he has to find time to moonlight at other places to make ends meet.

In the end, the insurance company coughed up a $117,000 check for Dr. Mu. The patient, who was reluctant to pass the check along to the surgeon for fear of setting a bad example, ultimately mailed it to him rather than getting into a legal tangle with the doctor. And Dr. Mu will now be forever known to the world as the neurosurgeon who makes Gordon Gekko look like Mother Teresa.

Tuesday, September 16, 2014

The Contradictions Of Voter ID Laws And Obamacare

The latest headlines about the travails of Obamacare concern the fact that hundreds of thousands of people will lose their newly acquired government healthcare insurance because they are unable to prove their eligibility by producing paperwork showing their citizenship or residence in this country. These undocumented insurance recipients will likely lose their plans or have to pay back to the IRS the subsidies they have been getting from the government to buy into the program.

I can't help but contrast this aggressive bureaucracy with the controversy surrounding voter ID laws. These laws were enacted to make sure that people who want to vote in elections can prove that they are really who they are and where they live. Yet this simple requirement has been struck down by liberal courts all over the country.

I find it difficult to believe that people can be so isolated from society that they can't produce one single piece of paper to prove their identity. You need a photo ID to do almost anything these days. Use a credit card? Show me your ID. Want to buy that six pack of Bud along with that carton of Marlboro's? Show me your ID. You want to receive free government handouts? ID please.

Ironically these special interests who want to allow virtually anybody to vote without identification are the same ones who endorsed Obamacare in the first place. Are they going to abolish this requirement for proof of identification to receive health insurance? Unlikely because they know that massive fraud will ensue and billions of tax payer dollars will be lost to people who are not supposed to receive this largesse.

Yet these same groups have no qualms of possible massive voter fraud, which is arguably more important than Obamacare itself. The outcome of elections determines whether legislation like the Affordable Care Act gets passed in the first place. When the political make up of the government can be decided by fewer than one percent of voters in close elections, it's unfathomable that we don't guard more closely this right that was won by the blood of our country's ancestors. If guarding the integrity of Obamacare is paramount, the least we could do to honor our forefathers is to do the same for our constitutional right to free and fair elections.

Sunday, September 14, 2014

The Murky Death Of Joan Rivers

I have tried not to comment on the untimely death of comedienne Joan Rivers last week due to the fact that the investigation into her demise at the Yorkville Endoscopy center in Manhattan is still ongoing. However, more details are starting to leak out about that fateful day and the story is starting to get more disturbing.

Ms. Rivers was scheduled to have a procedure performed at the center that day by her personal gastroenterologist, Dr. Lawrence B. Cohen, to evaluate a worsening hoarseness in her famously raspy voice. Ms. Rivers appeared to be in good health and spirits at the time, even performing the night before at a club.

Now it's not uncommon for GI docs to evaluate hoarseness. What does the GI tract have to do with poor phonation? Severe gastric reflux can produce acid that comes up the esophagus and potentially damage the cords. Therefore it's not unheard of for a GI physician to perform an endoscopy to look for evidence of reflux that might lead to vocal cord damage.

Up to this point I have no problems with the story. Then the whole episode starts to go awry. At first the news was that Ms. Rivers went into respiratory and cardiac arrest during the procedure. The first thing I thought of was laryngospasm, which is not uncommon during upper endoscopies performed with only conscious sedation or monitored anesthesia. An anesthesiologist present would have known precisely how to reverse the laryngospasm as that has been drilled into us since day one of residency training. However, it would have been unusual for Dr. Cohen to have used an anesthesiologist to give sedation to Ms. Rivers since he is well known in academic circles for looking with disdain at using anesthesiologists at all for endoscopies. He's one of those GI docs who feels he can simultaneously perform his duties of a gastroenterologist and an anesthesiologist without jeopardizing patient safety. So it's highly likely that Dr. Cohen was the one directing the nurses in the room to give IV sedation for the procedure, despite the claims of Yorkville spokeswoman Marcia Horowitz, who states that an anesthesiologist is always at a patient's bedside throughout the procedure and "immediately assumes control of the airway and assists with a patient's ventilation" if the patient is in jeopardy.

Ms. Horowitz says the center has three or four anesthesiologists working any given time to help with airway management. Yet they also say that succinylcholine is not available at the facility. Whaaa? I don't know of ANY anesthesiologist who will work anywhere without having access to at least one vial of succinylcholine at a moment's notice. It is precisely for emergencies like a laryngospasm that a rapidly acting muscle relaxant is most essential. So to claim that they have multiple anesthesiologists standing by with all the latest resuscitation equipment ready yet have no sux around doesn't make any sense at all.

Now comes the bombshell that Ms. Rivers had her vocal cords biopsied by an ENT surgeon who isn't even authorized to do procedures at Yorkville Endoscopy. In fact the surgeon was assumed by the center's staff to be a makeup artist for Ms. Rivers. Curiously, without knowing the identity of this person, they let her into the procedure room with her little black bag of equipment. If that's not the worst Joint Commission violation in the first degree, I don't know what is. First of all, did Ms. Rivers even know this surgeon or that she would be coming in during her EGD to possibly perform a vocal cord biopsy? Was the surgeon's name on the consent? Was there even a consent for vocal cord biopsy since the staff didn't even know the surgeon? Are the staff at Yorkville Endoscopy so intimidated by the GI doctors that they are afraid to raise questions about irregularities in the procedures?

The identity of this ENT hasn't been revealed, yet she could possibly be the worst ENT surgeon in the world. An ENT surgeon has looked at thousands of vocal cords during a lifetime of practice, including many airways horribly deformed by cancer. Therefore if Ms. Rivers went into laryngospasm, presumably the ENT would have just as much or more experience than the anesthesiologists in intubating her to reverse her hypoxia. One may assume that anesthesiologists have more experience with intubating the trachea, but many anesthesiologists who work at these outpatient ambulatory centers probably haven't intubated a patient in years. Even if the ENT had difficulty intubating Ms. Rivers, which they eventually did, the surgeon would have been the perfect person to perform an emergency tracheotomy to save her life.

So this raises the question of how Ms. Rivers was being monitored during her endoscopy. Did she have all the basic monitoring equipment in place according to ASA guidelines, including pulse oximetry? Even if she went into laryngospasm, there is usually at least a few seconds to get the endotracheal tube in place to prevent hypoxia leading to cardiac arrest and brain damage. The surgeon would have been in precisely the right location to quickly insert the tube. Yet it sounded like they didn't realize the patient was desaturating quickly until it was too late. 

So as you can see, a lot of this story doesn't make sense yet. The investigation into what happened in that procedure room will take months to complete and may never be completely revealed to the public. In the meantime, Dr. Cohen has lost his job as the medical director and procedurist at Yorkville Endoscopy. And I'm once again having to explain to my patients in preop why they won't suffer the same fate as poor Joan Rivers.

Saturday, September 13, 2014

Lineman For The County

I walk over to the ICU to pick up my next patient coming to the operating room. She is having severe GI bleeding and the doctors had been calling all day to the OR asking when we are going to bring her. When I walk into the room, the young patient looked relatively healthy, awake and alert and breathing room air. That's a pleasant surprise for an ICU patient.

Then I look at her monitors. She is in sinus tach going in the 140's with the last measured systolic blood pressure of about 100. I ask the nurse in the room who is getting the patient ready for the transfer about the heart rate. "Oh, it's been that way all day," she answers. What have they been doing to treat the tachycardia and hypotension? She replies, "the patient was given a 500 cc NS bolus and one unit of blood. The heart rate is now down from the 160's earlier." I see. The nurse also kindly volunteers that the ICU team gave her a small bolus of esmolol to try to bring down the rate but unfortunately the blood pressure bottomed into the 70's so they didn't try that again. The team's opinion is that the patient is very sensitive to beta blockers. I force myself from rolling my eyes.

I then ask her what kind of IV access the patient has. The nurse isn't quite sure since she had just started her shift. We look under the patient's blankets and find her lone IV, a delicate little 22 gauge catheter dangling on the back of her hand. Is this the only IV she's had all day? The only one that they're using to give fluid boluses and transfusions? "Yes," she says. "They were planning on putting in a central line later tonight." I couldn't help letting out a deep sigh of frustration.

What's her urine output been? "Oh, she doesn't have a foley catheter. But she is making urine. She just went on the bedpan." Does the patient have any more blood available in the blood bank? "Yes she has four more units ready and the team wanted to send one with the patient to the OR." Well at least they got something right though it would have been infinitely more helpful if the blood was given prior to the patient's procedure.

We quickly wheel the patient to the operating room. This mismanagement of a critically ill patient is going to take some work on my part to get her through the procedure. I proceeded by placing in her the appropriate monitors for somebody who is on the verge of hypovolemic shock. While I was getting the patient lined up, the OR phone rings. The circulating nurse picks it up and calls to me, saying the ICU resident needs to talk to me. Feeling no desire to talk to these incompetent boobs, I tell her that I'm busy resuscitating the patient and I can't come to the phone. She relays the message then hangs up. "The ICU resident is just asking if you could put in an arterial line and central line while you have her in the operating room." I gritted my teeth and tried to ignore that request while Glen Campbell plays in my head.