Tuesday, November 11, 2014

What Really Happened At Yorkville Endoscopy?

The release of the Health Department's inquiry into the death of Joan Rivers has certainly shed some light on the event last August at Yorkville Endoscopy clinic. While the following is merely speculative, and we may never know exactly what occurred in that procedure room, we can certainly use some analysis of published data to try to draw a clearer timeline of what led up to her demise.

For months, most anesthesiologists, including myself, thought for sure that Ms. Rivers went into laryngospasm during the case. This is because most of us have seen it happen during a routine endoscopy. Then word came out that there was an ENT surgeon involved who may have been examining her vocal cords without prior consent to look for a source of her hoarse voice. This really put the laryngospasm theory into overdrive. We all slapped our foreheads with our palms and went "Duh! What do you expect will happen when you touch the cords during a sedation case?"

The official report from the Health Department doesn't paint such a clear cut picture. First of all, as it turns out, an anesthesiologist was present during the procedure. I guess Dr. Cohen will use an anesthesiologist for his VIP patients after all. The report also throws the whole laryngospasm theory in doubt. In the document, it helpfully lists Ms. Rivers' vital signs from preop up to when she went into cardiac arrest at five minute intervals. After looking at the data closely, it seems more likely she did not go into respiratory arrest at all before the cardiac arrest.

We know that she had perfectly normal vital signs in preop at 8:44 AM: BP 118/80, HR 62, O2 sat 100%. The patient went into the operating room at 9:00 AM. Then we get to see the vitals as they occurred during the procedure. 

9:12 AM: BP 117/60, HR 71, O2 sat 92%
9:16 AM: BP 92/54, HR 56, O2 sat 94%
9:21 AM: BP 89/44, HR 54, O2 sat 97%
9:26 AM: BP 84/40, HR 47, O2 sat 92%

The report does not indicate what time the procedure started. However it does say that Dr. Korovin started first with a nasolaryngoscopy before handing the patient over to Dr. Cohen for the EGD. The endoscope was removed from the patient at 9:28 at which time Dr. Korovin attempted to perform a second nasolaryngoscopy. At about 9:30 was when Code Blue was called.

So let's assume that the first VS was the baseline before the patient entered the room. Judging by the drop in blood pressure and oxygen saturation at 9:16, she had probably already started receiving some sedation with propofol. The electronic anesthesia record noted that propofol was given at the following times: 100 mg @ 9:21.45, 100 mg @ 9:21.46, 50 mg @ 9:21.48, and 50 mg @ 9:21.50. This is a total of 300 mg of propofol pushed in five seconds.

The anesthesiologist claims that those quantities are mistakes. The patient had only received 120 mg of propofol for the whole case, which she wrote in an addendum to the record later that day. She told the investigators that she accidentally double clicked the computer for the 100 mg boluses and really meant to click on 20 mg bolus instead of double clicking 50 mg boluses.

One thing about electronic medical records--just because you click on an event doesn't mean it actually happened at that time. You may have been too busy with your responsibilities before realizing you forgot to enter it on the computer. You then finally document it even though it happened a few minutes prior. Even though the anesthesiologist may appear to have first bolused the propofol at 9:21.45, it is conceivable that this was a slow bolus given over several minutes but not charted until that time. If we presume that the hypotension seen at 9:16 was already the beginning of the sedation, then the drug was not entered into the computer for five minutes. At that point the anesthesiologist documented 100 mg at 9:21 even though it may have been given over several prior minutes.

Why was her O2 sat only 92% at 9:12 even though the rest of her vitals were normal? This maybe an instance of bad oximetry data. There are many reasons for a sat monitor to pick up an erroneous reading. Perhaps her fingers were cold. Maybe she was shivering. Or maybe somebody was moving her arm. The computer will record whatever number it sees at a particular time without regard to its accuracy. It is up to the user to write a note explaining the false data in the record.

As the oxygen saturation started to drop during the procedure, the anesthesiologist says she turned up the oxygen flow and applied jaw thrust to open up the airways. The anesthesiologist's statement that she kept the O2 sat greater than 90% is true based on the recorded data. But unfortunately that was not Ms. Rivers' problem.

I've seen many laryngospasms during an endoscopy. On nearly all of them, the O2 saturation drops first because the patient can't pass any air. Then the body starts fighting like mad to open up the airways. This results in a severe tachycardia that doesn't slow down until the cords open up or the O2 sat drops so low that the heart becomes ischemic, leading to bradycardia, a most ominous sign.

But Ms. Rivers' problem doesn't seem to be hypoxia. Her sat never goes below 90. Instead we see hypotension and bradycardia first. This is most likely due to a depressed cardiac output. If the CO drops, the O2 saturation eventually falls too as the heart can't pump enough blood for adequate oxygen exchange in the lungs.

What could have caused her heart to fail? Right at the top of the list is propofol. That is why propofol is such a dangerous drug. If not used judiciously, it can cause severe cardiac depression and hypotension, sometimes fatally. In an elderly patient, the impaired heart function can be quite profound. While I want to give the anesthesiologist the benefit of the doubt and agree that she didn't give 300 mg of propofol to an 81 year old in a span of five seconds, which would no doubt lead to a catastrophic bottoming out of her blood pressure, even 100 mg of propofol if pushed too quickly can cause a severe decreased cardiac output.

Another possibility is a strong vasovagal reaction. This is especially true with something as stimulating as a laryngoscopy. If the patient is not sedated adequately, the stimulation from the procedure can cause the BP and HR to drop in some people. This usually goes away once the stimulant is removed by withdrawing the scope. Respiration again is not impaired but the sat may fall because of the decreased blood flow to the lungs and tissue.

Could she have suffered a pulmonary embolus? A PE can cause acute hypotension and bradycardia as the right heart workload suddenly increases. But a PE also usually causes severe hypoxemia, especially for one that leads to death like a saddle embolus. The medical examiner's report also failed to mention a PE as the cause of her death.

An acute myocardial infarction? Maybe. But it would be awfully coincidental for her to suffer an MI right at the time she was getting a procedure done, though it wouldn't be outside the realm of possibility.

If laryngospasm is no longer the likely cause of Ms. Rivers' death, it also explains why she had a hypoxic brain injury. It is easy enough to treat laryngospasm, especially with an anesthesiologist and an ENT surgeon at the bedside already. If it can't be broken with positive pressure ventilation, then give a muscle relaxant to open up the cords and intubate the patient. None of that should take so long as to cause brain ischemia. However if she had heart failure, the low cardiac output would starve the brain of oxygen leading to its death. She sent into cardiac arrest at 9:30 and was not fully resuscitated until 10:00. That is a full thirty minutes of suboptimal blood flow and oxygen exchange to the delicate brain tissue. Thus the brain dies.

Therefore the most likely reason that Ms. Rivers died that day was her heart failed. Either she went into such a severe vasovagal reaction during the laryngoscopy that they couldn't revive her heart or the anesthesiologist felt she needed to give so much sedation to perform the laryngoscopy (Anesthesia! The patient is moving!) that it irreversibly impaired her heart function.

That's just my two cents.

Joan Rivers. The Health Department Report Shows Major Violations.

New York's Health Department has released its findings on the events leading up to Joan Rivers' death at Yorkville Endoscopy last August. It gives a fascinating reading on how celebrity and unprofessional behavior of physicians can interfere with the best laid plans to protect patient safety.

Basically the report states that Yorkville Endoscopy failed in its responsibilities in these four areas:

1. Have a process in place to assure that only authorized personnel are permitted in the procedure room.
2. Have an effective process in place to assure that only credentialed physicians can perform procedures.
3. Ensure that informed consent is obtained for all procedures that will be performed and
4. Ensure a "Time-Out" (a preprocedure protocol for verification of the correct person, procedure, and site) was called to confirm each procedure to be performed.

Essentially, all these deficiencies point back directly at the ENT surgeon, Dr. Gwen Korovin. The report states that Dr. Lawrence Cohen, the gastroenterologist, wrote that Ms. Rivers needed an EGD to evaluate for gastric reflux and hoarseness in her voice. However, two nasolaryngoscopies were performed by Dr. Korovin, as confirmed by the anesthesiologist. The first one was performed before the endoscopy while the second one was done immediately afterwards. The Interim Medical Director and the Vice President of Clinical Operations both confirmed that Dr. Korovin had no privileges to perform procedures at Yorkville. Ouch.

The endoscopy technician said she had never seen Dr. Korovin before. During the Time Out, there was no mention of a nasolaryngoscopy to be performed on the patient. Dr. Korovin's role in the procedure room was not brought up during the Time Out. There was also no consent for Dr. Korovin to do a procedure or Ms. Rivers to have a laryngoscopy.

The report clearly documents the downward spiral that took place in the room. Ms. Rivers' baseline vital signs were: BP 118/80, HR 62, RR 16 O2 sat 100%. During the course of the procedure, the vitals steadily deteriorated:

9:12 AM: BP 117/60, HR 71, O2 sat 92%
9:16 AM: BP 92/54, HR 56, O2 sat 94%
9:21 AM: BP 89/44, HR 54, O2 sat 97%
9:26 AM: BP 84/40, HR 47, O2 sat 92%

Two minutes later, a Code Blue was called. Even the type of cardiac arrest is in dispute. One note, called the Cardiac Arrest Record, indicated that the patient became pulseless at 9:30. Meanwhile, a different page called the Endoscopy Code Blue Record said that the patient went into ventricular tachycardia with a pulse. In either case, there is no indication that she received the proper resuscitation protocol per ACLS.

Much of the events mentioned came from the GI tech and administration staff, as the physicians in the room have all essentially lawyered up and refused to give any incriminating statements. However the anesthesiologist was cited for two major violations. As part of her routine preop exam, she failed to mention the height and weight of Ms. Rivers. This could easily have led to an overdose of propofol if the correct weight is not used in calculating the rate the drug was given.

A second misstep was in the documentation of the drugs given during the procedure. In the computerized anesthesia record, the anesthesiologist said she gave a total of 300 mg of propofol. Yet in an addendum she said only 120 mg was given. When asked about this discrepancy, she said that she only administered a 100 mg bolus of propofol followed by a 20 mg bolus later. The computerized record showed she gave boluses of 100 mg, 100 mg, 50 mg, 50 mg all within five seconds of each other. Those other boluses, she said, were accidental double clicks on the computer for 100 mg. She couldn't explain how she double clicked 50 mg boluses when she claimed she only gave 20.

There are no statements made to the Health Department from the GI physician, Dr. Cohen, himself. I'm sure the anesthesiologist's statement that Dr. Cohen took a cell phone picture of the patient while she was asleep will not help his case. He probably has some very expensive lawyers right now telling him to just shut the f*** up for now.

What a tragic end to a brilliant comedic career.

Monday, November 10, 2014

Why Is The Doctor Testing Your Grandma For Ecstasy?

You want proof that medical schools are full of smart people? Just follow the money. The Wall Street Journal has a report out on the exploding growth in the number of drug tests being administered on Medicare patients. In 2012, the government healthcare program for the elderly spent $445 million on drug testing, up nearly 1,500% in five years.

Why is this happening? In the past, a doctor could bill Medicare $20 for each class of drug that was tested using a simple urine dipstick exam. Then four years ago, the feds thought they would try to save money by capping the total bill to $20 for each urine specimen. This didn't sit well with some physicians.

Doctors then figured out that Medicare doesn't put a limit on urine drug exams using more high tech equipment like mass spectrometry. Medicare allowed doctors to bill for each individual drug tested using the new machines. This turned into a goldmine for some enterprising physicians.

Dr. Robert Wadley of Raleigh, NC started a urine drug testing firm called AvuTox that used a mass spectrometer. Each drug that is screened is billed over $20 to Medicare. A standard panel that AvuTox offers consists of over 40 different substances tested. The tests included range from standard narcotics to ecstasy to PCP, which are rarely positive in patients over 65 years old. His average payment from Medicare in 2012 was $1,265. AvuTox received $7.3 million from the government, the tenth highest drug testing reimbursement in the country. Dr. Wadley was paid $1.4 million from the program for his own patients. "Urine drug testing is how I pay the bills," he admits.

AvuTox then parlayed it expertise in Medicare billing into a scheme for patients with regular health insurance. It offered its services to other doctors, who pay the company a flat fee. The physicians then bill the patient's insurance company for the tests and they get to keep the balance. On AvuTox's website, they claim doctors can make as much as an extra $96,000 per year. That claim has since been taken down once the media started asking about it.

Dr. Wadley states he is innocent. He says he had no idea he was doing more urine drug testing on the elderly than other doctors. He believes all the drug screens he performs and bills the government for are medically necessary to detect any drug abuse problems that aren't being picked up.

Some doctors even go so far as to cause the problem that they will eventually bill Medicare to detect and treat. Dr. Fathalla Mashali, a Massachusetts pain physician was the single highest recipient of Medicare money for urine drug screening in 2012--$2.8 million. Ironically he was also arrested by the FBI for Medicare fraud for prescribing narcotics to known drug users and not performing physical exams to document their need for pain meds.

Some doctors just get too greedy for their own good. But the government makes it so easy to do so, especially if you're smart enough to get into medical school.

How Much Money Does It Take To Buy Happiness?

Today's Wall Street Journal discusses how much money it takes for one to be happy. There's the usual platitudes about how money can't really buy happiness. However, a couple of charts that accompany the article belies the writer's point. One chart, shown above, correlates happiness levels with income. Not surprisingly the more money you make the happier you are. What's interesting is that at an income of greater than $500,000 per year, 100% of people are very happy with their lives. A second chart in the article that measures life satisfaction with income also shows that at greater than half a million dollars per year, 100% of the survey respondents were very satisfied.

So there you have it. All you need to be absolutely positively sure you'll be happy is to make $500,000 per year. That means all those neurosurgeons, interventional cardiologists, and spine surgeons should be golden. But since we anesthesiologists can see that many of them are not happy, that throws this whole study into the appropriate place where it belongs, in the round outbox sitting under my desk.

Sunday, November 9, 2014

Do Robots Make The Perfect Health Care Provider?

Did Disney animators create the perfect health care provider? In the movie "Big Hero 6", a big huggable robot named Baymax was created by his inventor to help diagnose and treat whatever human ailments he finds.

He has all the qualities that many people say doctors and nurses should have but are usually lacking. He comes running as soon as he hears sounds of distress, like "ouch". He always has his patient's best interests at heart, refusing to leave until the sufferer has acknowledged his improved status. He possesses an infinitely vast wealth of medical knowledge. He is nonjudgemental. He doesn't ask for money. And the best part, with a quick change in programming, Baymax can become a kick ass, karate chopping, villain foiling, flying superhero. Wouldn't it be cool if doctors could do all that?

Some people would say that medical personnel in this country are almost like robots already but not in a good way. We increasingly rely on algorithms to manage our patients instead of using our judgement, or the art of medicine. Who reads textbooks anymore when we simply download the latest medical information on our smartphones from sites like Google and Up-To-Date? And many patients complain that doctors are so harried by their overbooked schedules that they show the same empathy as humanoids.

So perhaps this movie is just a sign of the frustrations that people have with their current providers. This fantasy is what many people wished their doctors should be but aren't. Maybe there is a take home lesson in this film if we are willing to accept our own shortcomings.

By the way, the movie is awesome. Disney did not pay me to shill for them, but I wouldn't mind it if they did. Hello Robert Iger?

Why You Can't Rely On TV Reporters For Medical News

I learned of a new heart rhythm the other day. I had never encountered it in my cardiac physiology classes or subsequent CME courses. A local Los Angeles TV station aired a heart rending story about the death of a 90 year old former nurse due to a pharmacy error. The reporter said she was receiving diltiazem to treat her "atrial fibulation." Hmm. I wonder if there is some sort of connection between the nurse's heart and her lower leg. Also if you watch the video clip, you will hear the reporter pronounce diltiazem as "dil-tee-azem" instead of "dil-tie-azem". So don't be surprised if patients come to your office pronouncing their medication the wrong way.

Saturday, November 8, 2014

The Focus On Patient Safety Pays Off For Anesthesiologists

The ASA Committee on Professional Liability has released its latest finding on malpractice insurance premiums for anesthesiologists. And the news is good. Anesthesiologists have not paid such low premiums for insurance in decades. The survey by the ASA was based on numbers from 25 medical liability companies that collectively cover 16,000 anesthesiologists, or a quarter of the U.S. anesthesia population.

As you can see from the chart, the numbers continue to fall, following the same trend from the past several years. These premiums are for $1 million/$3 million policies. In other words, $1 million payout per claim and up to 3 claims per year. The 2014 average premium is only $17,845 compared to $26,665 ten years ago. These numbers are dwarfed by the confiscatory premium rate of $40,028 thirty years ago, when the specialty was in the midst of a malpractice insurance crisis.

These numbers are just averages. They vary significantly by geographic location, rural/urban divide, and age of the physician. Anesthesiologists who practice in Florida, Illinois, and Washington, D.C. pay the most, averaging over $30,000 per year. Midwestern anesthesiologists in states like Iowa, Minnesota, Nebraska, and Wisconsin pay the least, with average premiums of less than $10,000. That's just another reason why anesthesiologists should move away from the blue coastal states to the more physician friendly Midwest.

If you're a pain management doctor, the news isn't as good. The average premium for pain doctors is $20,130. However that is still down about eight percent compared to last year. Pain physicians have consistently paid about ten percent more than regular anesthesiologists through the years.

Why are anesthesiologists' malpractice premiums falling? My guess is that our specialty's strong emphasis on patient safety has decreased the likelihood that patients will find fault with our work as the basis for a lawsuit. This is unlike the call for expediency and profits practiced in other fields like gastroenterology. The GI docs are paying the price for being so rapacious. Their average malpractice premiums have actually gone up, rising from $17,900 in 2011 to $20,000 in 2012. If I were a GI physician, I would seriously question my society's constant downplay of the role anesthesiologists can play in allowing them to perform a safe endoscopy on their patients. Looks like the insurance numbers are not in their favor.

So keep up the good work, my fellow anesthesiologists. Though patients may not fully comprehend the magnitude of our involvement in guiding them through a safe operation, the green eyeshaded accountants at the nation's malpractice insurance companies do.

Why Is Goldman Sachs Interested In Anesthesia?

Did you know that anesthesia is a growing market? The field currently has about $12 billion dollars in sales. It is projected to grow at a 9.5% annual rate over the next several years, reaching sales of $19.6 billion dollars by 2018. That rate of expansion puts such venerable growth companies like Coca Cola (6.22%) and Proctor & Gamble (8.05%) to shame.

What's driving this enviable growth? Demographics plays a part. As the U.S. population ages, people will need more operations for their various ailments such as cataract and orthopedic surgeries. But another major contribution is the much derided Obamacare. When millions of people gain health insurance, they are suddenly able to afford the procedures they have been putting off, like screening colonoscopies and hernia operations. So more anesthesia providers will be needed to perform these operations.

Herein lies the opportunities that have been keeping major bankers and private equity firms busy. Anesthesia in the U.S. is very fragmented. There are hundreds of different anesthesia groups practicing all over the country. However, they are slowly and inexorably being subsumed into large geographically diverse anesthesia groups in order to compete more effectively against the equally gigantic hospital and insurance companies.

This has led groups like Goldman Sachs (Resolute Anesthesia) and Moelis Capital Partners (North American Partners in Anesthesia) into buying anesthesia practices all over the country. There have been nearly one hundred acquisitions in the last five years worth billions of dollars as these investor spy an enormous opportunity to make money thanks to demographics and healthcare laws.

What do the doctors who sell their practices to these investors get out of the deal? For one, they will finally get a steady paycheck. Their incomes will no longer be at the mercy of stingy insurance companies, underpaying government entities, and unreliable patients. Somebody else will should all the risks of poor reimbursements. The doctors also won't have to deal with the headaches of byzantine government regulations and the escalating costs of maintaining a modern medical office. All the expenses of running a medical group will be borne by somebody else.

But passing the buck to a new employer carries its own costs. By selling out to large corporations, the anesthesiologists trade a higher but unpredictable income for a smaller but steadier salary with hopefully more benefits than what a small anesthesia group can afford. The buyout firms hope to make a profit by having a better position to negotiate favorable reimbursements with hospitals and insurance companies.

So for all you medical students who hope to one day have your own independent practice without anybody looking over your shoulder, I'm afraid it may already be too late. Your medical degree will only entitle you to join one of the thousands of physician minions in the country who toil for millionaire bankers, the true 1% of the nation.

Thursday, November 6, 2014

Celebrity Doctors And Their Celebrity Patients

The New York Times has a lengthy puff piece on the ENT surgeon who was present during Joan Rivers' final and fatal procedure, Gwen Korovin, M.D. Dr. Korovin graduated from Cornell then went to SUNY Syracuse for medical school. Upon graduation she did her residency in Manhattan's Lenox Hill Hospital. There, she was mentored by Dr. William Gould, an ENT physician with many celebrity patients. When Dr. Gould retired, Dr. Korovin assumed his practice, retaining many of his famous clients.

Dr. Korovin was highly recommended among the rich and famous. She appeared to have treated everyone on Broadway for throat and sinus ailments. They all loved her. And she loved them back. She was glamorous in her own right, dressing in chic outfits that rivaled her patients and attending their red carpet premiers. Like a good concierge physician, she apparently could be reached at all times day or night by her patients. She received their loyalty when she confronted show producers and demanded they let the stars rest their voices instead going on. So much for the old show business ethos, "The show must go on."

The writer, who admits he has been Dr. Korovin's patient, name drops the doctor's patients throughout the article. Stars like Cher, Bruce Springsteen, Elvis Costello, Ariana Grande, and many others are mentioned. I wonder if all these people that are named gave the author permission to mention them as being patients of Dr. Korovin. If not, this is a huge HIPAA violation.

Perhaps it was these ongoing relationships with VIP patients that ultimately led to her downfall. She may have been just a bit too cocky as she breezed into Yorkville Endoscopy that fateful day last August to treat her good friend Ms. Rivers. She was so sure of her status that she couldn't even bother identifying herself to the staff at the surgery center, some of whom assumed she was the patient's makeup artist.

The coroner's report ultimately stated that Ms. Rivers died from an anoxic brain injury from a propofol sedation that was "a predictable complication of medical therapy." A doctor who has no credentials for working at a surgery center can just waltz in without any identification is a complication of medical therapy? When a doctor can perform a procedure that the patient may not have consented to is a complication of medical therapy? When a surgeon is so confident of her relationship with her patient that she can commit the atrocious act of taking a selfie with her phone while the patient is asleep under anesthesia is a complication of medical therapy? An ENT surgeon who is actually present in the operating room when a patient suffers laryngospasm but incredibly is unable to establish an emergency airway is a complication of medical therapy? Wow. Who paid off the coroner's office in New York?

Whether the doctor will be sued by Ms. Rivers' daughter for medical malpractice is still to be determined. But that is the life of a VIP doctor. Your mistakes are just as outsized as your patients.

Doctor, There Is A Hair In My Anesthetic

Ewww. A human hair was found stuck in the stopper of a Hospira produced bottle of local anesthetic. The company has voluntarily recalled the drug, which is a single dose, preservative free 1% lidocaine. They were distributed from May 2014 to June 2014 with an expiration date of April 1, 2016. The lot numbers are NDC 0409-4279-02, Lot 40-316-DK.

Says the FDA, "[if] the particulate breaks and pieces are able to pass through the intravenous catheter, injected particulate material may result in local inflammation, phlebitis and/or low-level allergic response to the particulate or microembolic effects." Gee no kidding.