Shut Up And Go To Sleep

The New York Times has a great piece about the increasing popularity of awake surgery. No, I'm not talking about the nightmarish scenario of being conscious while somebody cuts into your abdomen and you can't move or protest because you've been paralyzed. The article refers to using regional anesthesia to block pain sensations to the extremities while the surgeon operates. These are most likely to be used for hand or arthroscopic surgery.

Most patients who elect to be awake during their operations usually do it out of a sense of curiosity. Others are simply uncomfortable being rendered unconscious. A few prefer the quick recovery of not having had any sedation. They are able to drive home on their own right after their procedure.

However, there are downsides to having the patient alert in the operating room. They may not be able to handle the sight of blood and the sensation of cutting into tissue as well as they might have assumed in preop. But worse for the operating team, the patient may simply just want to talk too much due to their anxiety or curiosity. And guess who will be responsible for conversing with the patient? That's right, the anesthesiologist.

We are the ones at the head of the bed, behind the ether screen. We are the only person in the room that the patient can see continuously the whole time. Says Dr. David M. Dickerson, assistant professor of anesthesia at the University of Chicago, "You might have to make small talk throughout the entire case. They don't teach that in medical school."

That is exactly why patients should be sedated and preferably unconscious during an operation. The patient becomes a major distraction to every staff member working in the room. The surgeon has to watch what he says about the progress of the operation lest the awake patient thinks something is going wrong. He cannot confer with other surgeons or the anesthesiologist about the other patients on the operating schedule without violating HIPAA rules. The anesthesiologist is put in the position of making inane conversation to ease the patient's anxiety. Every alarm and beep on the monitor will trigger another question from the patient. Every instrument that gets dropped by the surgical tech will lead to the patient asking if everything is okay. This constant distraction from the work involved can lead to worse care. There just doesn't seem to be many advantages to keeping patients awake.

Lastly, the newspaper article has extensive quotes from surgeons and patients. Unfortunately there were comparatively few mentions of anesthesiologists. I would think the journalist would want more information from the professionals who make this miracle of awake surgery possible. Were the ASA or the ASRA contacted for their opinions of this hot new trend in medical care? If not, I think our professional societies need more work on their outreach to the media and public.

Are Comfort Animals A Patient's Best Friend?

Not a service animal

We have a pretty strict visitation policy at our hospital--no minor children are allowed in Preop Holding or Recovery Room. The reasons are pretty logical. First of all, it can be frightening for small children to be around sick patients. They may be scared by the sight of blood or hearing loud moaning and even screaming coming from uncomfortable patients. Plus there's always the possibility of the children coming in contact with a contagious patient.

However the rules don't apply to people's pets, or euphemistically called comfort animals. I had a patient who asked to see her young children in Preop prior to her operation. The nurse told her the rules and denied the request. However when the same patient asked to have her comfort animal brought in, it was no problem at all. They let the small dog into the room and even let it sit in the gurney with the owner. We were told that it is against the Americans with Disabilities Act to deny this request. Pushing the boundaries further, the patient then asked to bring the dog into the procedure room while she was having her procedure. The surgeon was too cowed to say no. I was flabbergasted.

So a person's own children are not allowed to see their parents one last time before an operation but animals don't face the same restrictions? Instead of the owners' own selfish reasons for bringing their animals to the hospital in the first place, maybe they should be more considerate of other people.

Comfort animals can be unruly, especially ones who are not actual well trained service animals but are really pets with ill fitting vests. Some people have allergies to pet dander. We are very aware of a patient's food and drug allergies but somehow it is okay to allow animals into a hospital setting.

This is apparently a worsening problem for businesses everywhere. Comfort animals are being brought onto airplanes and into stores under the guise of being service animals. Most people are too polite to say anything even if the presence of the animal makes them feel intimidated or simply annoyed.

So what was the solution to our Preop drama? We had our own pitbull at the ready. The charge nurse intervened and very clearly and emphatically told the patient that she was not allowed to bring the dog into the procedure room. Despite a weak protest, the nurse held her ground and the issue was resolved. That nurse deserved every dollar of her salary that day.

Anesthesiology Match--Enough Already

Another Match Day has come and gone. As usual there is plenty of celebrating going on, and rightly so. After four years of incredibly hard work, the end of the tunnel is in sight. Of course that will be followed by an even longer and darker tunnel otherwise known as residency. But we'll forget about that and let the bright eyed students have their moment.

But for us practicing physicians, it behooves us to pay close attention to Match Day too. It can foreshadow trends taking place in our field. And the trend for anesthesiology isn't looking great. For one thing, the supply of anesthesia residencies is outstripping the number of students who want to be anesthesiologists.

Click to enlarge

As this chart from the NRMP shows, the number of anesthesia spots filled by U.S. medical students is trending down. This year, only 66.8% of PGY-1 positions were taken by American students. This is down from 73% in 2015 and almost 75% in 2013. The popularity of anesthesiology has held steady for years. This year, 803 U.S. seniors matched into anesthesiology. In the past five years, the number of U.S. matches usually ranged from 750-800. So if the numerator holds steady, that must mean the denominator is exploding. And here it is.

Click to enlarge

This year 1,202 PGY-1 positions were offered in anesthesiology residencies. That is up from 1,000 spots available only 2013, a 20% increase in just five years. Then you look at the historical data and it is even more terrifying. In 2008 there were only 666 spaces. So in ten years the number of PGY-1 positions has nearly doubled. If you want to look back even further--

Click to enlarge

Imagine that. In 1997, only twenty years ago, anesthesia residencies offered only 317 first year spots. Lest you think that was because of the nadir in anesthesiology interest at that time by medical students, in 1991, during the supposedly halcyon days of anesthesiology, just 329 positions were offered. That was when anesthesiology was truly considered an elite residency and nearly impossible to match into. So we've almost quadrupled the annual supply of anesthesiologists in 25 years.

For comparison, this year the number of categorical surgery positions offered were 1,281. Back in 1997, surgery programs had only 1,009 PGY-1 spots, a much more reasonable 20% increase in two decades since it follows more closely to the increase in general population.

Where are all these new anesthesiologists going to practice later? Already it's almost impossible to find a job after residency without first completing a fellowship. Almost all the anesthesia residents I know now go into some sort of post residency training. Are we all going to fight for scraps with the CRNA's in the OR and Surgical Home leftovers with the hospitalists? Hope all you guys have a side business in botox injection or day trading stocks because the amount of money for anesthesia is not increasing and we keep flooding the supply of anesthesiologists into the healthcare market. 

Best Music Streaming Service For The Operating Room

For some reason the anesthesiologist has become the de facto music DJ in the operating room. Funny since I never took an elective in DJ 101 in medical school or residency. But since we are presumably the only members in the operating room who have "free" time to put on everybody's favorite tunes, people just expect anesthesia to provide the entertainment while they "work". Music is so integral with the job of an anesthesiologist that I've devoted several posts to them. I wonder if Ralph Waters or Virginia Apgar ever got requests to play their surgeons' favorite radio stations while they were busy revolutionizing anesthesiology.

When I first started my career in the early aughts, CD's were still the standard way to play music. I remember anesthesiologists whose carts were stuffed with CD's, all the better to ensure that the surgeon's favorite music format was available. Then the iPod came along and revolutionized OR music. Suddenly people had thousands of songs at the ready in their pockets. In fact, this took away some of the burden of being a DJ since the surgeons often brought their own iPods with them. We just plugged it in and played the folder they requested.

No nobody carries iPods. Instead we all have phones. But phones aren't ideal for playing music since the surgeon doesn't want the tunes to be interrupted by an incoming call. So once again the anesthesiologist is in charge. But CD's are dead. Everybody now streams their music instead of carrying around a bunch of MP3 files. All you need is a phone or computer that can log into the internet and a good Wi-Fi signal.

Since there are dozens of excellent music streaming services out there, I'm going to give you my opinion of only the ones I've tried. It's not all encompassing and my tastes are pretty mainstream. Almost all of them have a free tier and a paid tier. I always use the free services. I have enough hands reaching into my wallet to pay for another subscription service. I need to mention that I am NOT endorsing any of these services or getting paid for mentioning them. I'm just doing this as an educational service for my fellow anesthesiologist. So here is the rundown.

Apple Music--I never use it. Why? Again because I'm cheap. They don't have a free service with ads. It's either pay a monthly fee or nothing. Plus I never feel hip enough to listen to their main music channel Beats 1. So pass.

Amazon Music--Since I am an Amazon Prime member, this service is free. Unfortunately they've recently introduced another tier of membership that requires a monthly fee. Naturally I haven't signed up for that. But the free section is pretty nice. One nice perk is that virtually every single CD you've ever bought from Amazon has their MP3 files automatically loaded into your Music app. Therefore your old CD's are available with the click of a button without having to carry them around. I was amazed how many CD's I had bought over the last two decades. The reason I don't use Amazon Music that much is that their themed playlists are pretty limited. The lists don't have a great number of songs in each so it gets pretty repetitious.

Pandora--This was what everybody was using a couple of years ago. It was a revelation to be able to request virtually any song ever recorded and it just starts playing through your speakers. So why don't I use it anymore? I got seriously annoyed with it when I would request a song or artist and Pandora would start substituting what they think I would like to hear instead. If I want to listen to Louis Armstrong, I want to hear Louis Armstrong. I don't want it to play something else it thinks I would like too. Too many frustrations so it is gone from my life.

Spotify--This one is so close to residing in my home row of app buttons. They play what I want them to play. It is mostly free. If I want to listen to Joshua Tree by U2, I can get it without them streaming something else they think I might want to try. Sure the album would play in random order in the free tier but I can live with that. So why isn't it my default streaming service? Again their computer generated playlists are pretty small. Over the long course of a multilevel spine operation I don't want to hear the same song three times or have to search for another channel to play. Though I don't use Spotify every day I still keep it as my backup.

I Heart Radio--This is my go to streaming service for a year now. In fact I'm listening to it as I'm writing this. (FYI I'm not at work while I'm writing.) Why has I Heart Radio captured my heart? As you can probably guess, it's free. Yes they have a subscription tier but I haven't found a need to go there. You can listen to terrestrial radio stations if you like, as long as they're part of the I Heart Media corporation. The most popular stations in Los Angeles are on there, like KIIS FM and KBIG. But mostly I use the service because they have excellent playlists. I usually play I Heart 70's, I Heart 80's, I Heart 90's, etc. playlists depending on the age and tastes of the surgeons. They have hundreds of playlists to choose from and you can listen to them almost all day without hearing a repeat. Many people in the OR have asked me where I got the music since the selection is so good. They frequently guess Spotify and are surprised when I say I Heart Radio. They almost always say they are going to download the app to try.

So for all you anesthesiologists who have to suffer through another request for music by your surgeon, I hope this helps. With the modern miracle of music streaming, we no longer have to lug around a bunch of physical music media to satisfy everybody's tastes and whims. This is probably the greatest advance in the well being of the anesthesiologist since the invention of the skin temperature sticker.

Rude Canadians. Who Would Have Thought?

Our Canadian friends up north have a well deserved reputation for being friendly, intelligent neighbors. It's hard to imagine they could be rude to anybody. However a very ugly and public dispute has erupted within their ranks, surprisingly between their own physicians.

The Ontario Medical Association recently concluded contract negotiation with the provincial government for physician pay. This is what happens in a single payer system where all the doctors are essentially employees of the government. The contract called for annual pay raises of 2.5% for four years. Apparently this was considered not worthy for consideration by a majority of the membership. Then the sh** started hitting the fan.

One anesthesiologist emailed the OMA president Virginia Walley, MD, "You are a c***. Crash and burn as you deserve to do!! This will be a no vote and the end of the OMA. Sincerely, F*** YOU and the OMA!!!" OMG!!!! This is coming from an ANESTHESIOLOGIST, one of the most respected and intelligent of all physicians.

Other members of the OMA leadership who were involved in the contract negotiations or who publicly supported the contract have also come under withering criticism. They've been accused of having a mental illness, told off in a foreign language, and even been threatened with physical harm.

What's going on here? Why is there so much animosity with our northern colleagues? Clearly, being an employee of the government is not all it's cracked up to be. Is the stress of being in a single payer healthcare system finally catching up to the doctors? They really have nothing to complain about when American physicians have been facing shrinking reimbursements for years. But when one gets used to the utopia that is universal healthcare, any little disruption can cause one to lose their bearings.

Oh, and to the anesthesiologist who wrote that horrible email to the president of the Ontario Medical Association. You've lowered yourself to the level of our genital grabbing president. If you are unhappy with your government pay consider moving to the States. You'll fit right in.

Day Without An Anesthesiologist

Another day, another meaningless protest. Ever since the inauguration of President Trump, it feels like there has been a protest nearly every single day. Some people might say this is a healthy expression of democracy in action. I say it's another reason for people to skip work and school.

Today has been designated the Day Without A Woman. Women are staying away from their jobs and stores to prove how important they are. Ironically this boycott by women only goes to show how inconsequential we as individuals are in society. Life goes on whether we show up or not.

By contrast, if you have a day without an anesthesiologist, all hell would break loose. Suddenly ASC's and hospitals around the country would virtually shut down. Their main profit centers, the operating rooms, would go silent, depriving the centers of their life blood. Pain scores would shoot up as the expert care of our pain specialists are removed. There will be lots of broken teeth and traumatized airways as inexpert intubations prevail. Hearts would go unmended. Cancers unresected. Broken hips unreplaced. It would be a calamity.

So all those women can go out there with their pussyhats and march all they want. If nobody notices any difference with them gone, did they really make that much of a contribution? But watch out if anesthesiologists walk out en masse. The country would come crumbling down before the first surgeon can ask, "Is anesthesia here yet?"

It's Anesthesia's Fault

It's a common refrain among surgeons that if something goes wrong, it's always anesthesia's fault. Whether there was excessive intraop bleeding or prolonged postop ileus, inevitably the surgeon will deflect responsibility and tell the patient it was the actions of the anesthesiologist that led to the complication.

Now there is a study to try to identify the extent to which the anesthesiologist is responsible for surgical morbidity and mortality. Presented at the ASA annual meeting last year, the authors evaluated one million cases culled from the Medicare database. They looked at three surgical procedures in particular: AAA repair, CABG, and colectomy. From these, they attempted to eliminate all possible other causes of surgical complications so that the focus was only on the anesthesiologist involved in the case.

What they found was that the anesthesiologist was responsible for 3.1%-4.5% of complications. As a matter of fact, the difference in complication rates between the lowest performing and highest performing anesthesiologists varied by a factor of three. For comparison, they found that surgeons were responsible for 4.2%-5.2%.

So maybe there is something to the myth that everything is anesthesia's fault. By everything I mean 3%-5% of cases. But if there is even one legitimate anesthesia complication, it will naturally balloon up to encompass all the ills of the operating suite. It's a good thing we have a great lifestyle to compensate for this insanity.

Anesthesia On Autopilot

For years people, mostly medical students, have feared that anesthesiology would succumb to the inevitable advances in technology. Anesthesiologists would be relegated to the role of observers while robots did the actual work. Witness the high expectations of the automated Sedasys system for infusing propofol.

But reality always has a way of sneaking back into the picture. Skilled anesthesiologists look like they're replaceable because they make everything look easy. But that is only possible through years of education and hard work. While one might be able to program a robot to give anesthesia in ASA 1 patients, life will throw you an unexpected curve. As the video above of a Tesla on Autopilot shows, machines are only as capable as their programmers. And no programmer is going to write software that will cover every single possibility that might crop up during a case.

At that point, do you want to be the patient that crashes into the barrier at 70 miles per hour behind robot controlled anesthesia, or would you rather be the one being steadily guided by human hands around an innocuous bend in the road?

Medicare For All?

President elect Trump has stated that his plan to replace Obamacare would allow everybody access to health insurance. While the Republican Congress struggles to decide what to replace the PPACA with, perhaps Trumpcare would be another version of the old public option, a Medicare for all.

It doesn't sound as preposterous as it seems. What are some of the advantages of allowing universal access to Medicare? First of all, it would have almost immediate bipartisan Congressional support. Universal Medicare was championed by Bernie Sanders during the primaries. Much wasted bloviating on both sides of the aisle would be eliminated by implementing universal Medicare instead of arguing about tax credits and and pandering to the wealthy.

Medicare is also widely accepted throughout the country. Virtually every hospital and physician already accepts Medicare. There would be far less concern about narrow hospital and physician networks. You can just go to your old doctor and the plan will be accepted. The claim that you can keep your doctor if you like your doctor will finally be true.

Universal Medicare is portable. Change jobs? Keep your Medicare. Move across state lines? Same Medicare in all fifty states. Universal Medicare would also drive competition in the health insurance market. Already hundreds of counties have only one choice for health insurance. Universal Medicare would give these companies more competition to lower prices and allow people to buy insurance if the private companies don't offer any plans. In essence, the entire country becomes one giant risk pool for health insurance, which was one of the goals of Obamacare.

Don't forget people actually like Medicare. It's one of the untouchable pillars of the federal government. It would have immediate mass appeal. Intuitively it makes sense to most people. This is what people think of when they talk about universal health insurance in other industrialized countries. Its appeal would make the legislation much easier to pass.

How to pay for it? People will buy into it just like they purchase any other health insurance plans. Unlike regular Medicare, people will buy the insurance, with the premiums based on income. The more money you make, the more you pay for Medicare plans.

Business deductions for health insurance could also be eliminated to help pay for universal Medicare. Right now this sweetheart deal brokered in the early 20th century gives unfair advantage and income to people who work for companies that offer health insurance. Small business owners, private contractors, part time workers, and millions of others don't get this deal. Removing health insurance deductions for businesses would free up billions of dollars and remove price distortions in the health insurance markets.

So could Trumpcare be a form of Medicare for all? It's hard to fathom what goes on under his orange hair every day but who knows? He is not beholden to either political party and can put forward his own plans without worrying about appeasing the right or the left. He just might do something this bold and Big League.

Meet Tom Price

If you have any questions about who is going to lead the medical care of this country for the next several years, the New York Times has a lengthy article about Dr. Tom Price, the nominee for the next secretary of health and human services. It recounts his ascent from a community orthopedic surgeon to majority leader of the Georgia Legislature and now potential boss of the largest expenditures in the federal budget.

In a one sentence blurb, the article briefly mentions that Mr. Price has a plan to replace Obamacare with something better and more substantive. While the mainstream press may keep harping on the Republicans' lack of a real plan to get rid of the PPACA, Mr. Price has already published very long and specific ideas he introduced as the Empowering Patients First Act. So next time you hear some uneducated colleague moan about Republican grandstanding, you can just point to Mr. Price's website and show them that there are plans in place if one cares enough to make an effort.