Wednesday, November 8, 2017

This Is The Dumbest Way To Conduct Residency Interviews.

I'm not sure why I never noticed before, but I finally realized that my fourth year medical students were paying hardly any attention in the operating room. Instead they were glancing at their smartphones incessantly every few minutes. I thought maybe these millenials just can't stop checking their Instagrams even at work. But then one of them told me up front that he will be on his phone to check his emails for any residency interviews that might be offered and will be distracted the entire time.

Why? Don't they just send out a letter informing you that you were accepted for an interview? He just kind of rolled his eyes and looked sympathetically at me like I was his senile grandfather. He explained that these days, residency programs will send out mass email to everybody they find acceptable for interviews. However there are not nearly enough spots in the program for everybody they invite. Therefore only the first few people who answer the emails will get the interview. He had several friends who missed out on interviews at coveted programs because they were busy and didn't reply to their emails within 30 minutes of receiving them.

I was astounded by this revelation. Just to confirm that the first student wasn't pulling my leg, I asked another student in a separate room and who didn't know the first one, if this was true. She said yes. During these program interview months they are constantly checking their emails. But how do you know when to look? She said it depends on where the residency is located. If they are on the East Coast, the acceptance email may arrive on the West Coast at 5:00 AM Pacific time. Conversely for those on the East, the West Coast programs may send out their emails when it's 8:00 or 9:00 PM Eastern time. Essentially they are locked to their smartphones from the time they get up until nearly bedtime.

I don't know when or how this started and I'm not sure why it's done this way, but I have to say the way medical residencies send out invitations for residency interviews is one of the stupidest ways I can think of to find future physicians. When did finding our best and brightest doctors turn into a radio call in contest where the first ten callers get tickets to the Bruno Mars concert?

It just doesn't seem fair that after years of hard exhausting work, these kids may miss their number one choice for a residency because they were actually paying attention at the hospital. Some of our students have travelled thousands of miles and spent thousands of dollars to come for their externships. It's really not right they waste all those resources checking their email accounts when they should be trying to impress us to get into a residency. 

I'm really surprised the ACGME allows this conduct to occur. They should be looking after the medical students' best interests. The students gain nothing during the important autumn months of their fourth years if they're worried they may miss the most pivotal interview of their lives because they put the phone down to go to the bathroom. How can the residency programs care so little about the crucial fourth year medical education? They are just being too lazy to conduct a proper vetting of the applicants who they really think will do well at their programs. Maybe they should go back to snail mail like back in my youth. Our medical students are getting no favors with this "Survivor" method of choosing their careers. The future of medicine deserves better than this.

Tuesday, November 7, 2017

My Experience With Propofol Frenzy

The Mayo Clinic Proceedings recently had an informative article on a condition called propofol frenzy. This is a state where propofol has an unintentional effect of causing increased agitation rather than the expected sedation. I wish this article had arrived a few months earlier because I was flummoxed by a patient with the exact same problems.

I had a female patient describe to me how she always goes into "seizures" after getting propofol for endoscopic procedures. I was skeptical of her description and explained to her that propofol actually attenuates seizures and is used to break seizure activity. I should also mention that she says she's allergic to benzodiazepines. Her old anesthesia record didn't document any complications from previous sedations so I assured her I would use as little propofol as possible to get through her procedure.

The endoscopy proceeded without incident and was quickly completed. Postop, she was extremely lethargic, much more than would be expected from a small brief interaction with propofol. After about 20 minutes she started to thrash her head. Then she began trying to get out of bed and then falling hard back onto the mattress. It took four people to hold her down and keep her from injuring herself. The entire time she was not aware enough to answer questions. When we brought her husband in, he said that is pretty much what happens every time.

Finally after about one hour she started to calm down and became responsive to commands. After two hours she was calm but felt too groggy to go home. We finally decided to admit her because of her symptoms. The admitting team even ordered a Neurology consult to rule out seizures. Of course they found nothing.

The Mayo article notes there is no known cause why propofol causes a paradoxic reaction in some people. Maybe it deactivates GABA receptors in some whereas propofol normally activates GABA. But nobody knows for sure. It's not related to the quantity of propofol given. The seizure like activity is not attenuated by adding more drugs like benzos or narcotics.

The only recommendations are to anticipate the symptoms if a patient tells you they get seizures with propofol and to avoid propofol if possible. Perhaps attempt sedation with dexmedetomidine, benzodiazepines, or narcotics if propofol frenzy is a possibility. And always listen to your patients.

Senator Rand Paul Attacked By Anesthesiologist Over Landscaping?

Here's a quick follow up to the bizarre incident last week in Kentucky. Senator Dr. Rand Paul was out mowing his yard when his neighbor, retired anesthesiologist Dr. Rene Boucher, assaulted him without provocation. The senator was wearing sound cancelling ear protectors at the time and did not see or hear his attacker coming. In the melee, Sen. Paul suffered five rib fractures, pulmonary contusions, and facial lacerations.

What is so strange about this is that the two have been neighbors for years. They both practiced at the same hospital in the past. However the two have not spoken to each other in years. Though they had very different political leanings, other neighbors discount the idea that political ideology played a role in the fracas. According to Jim Skaggs, the developer of the community and who lives nearby, "They just couldn't get along. I think it had very little to do with Democrat or Republican politics. I think it was a neighbor-to-neighbor thing. They just both had strong opinions, and a little different ones about what property rights mean." In other words, "Stay off my lawn!"

Dr. Boucher is currently being charged with fourth degree assault, a misdemeanor. Based on the severity of the senator's injuries, the prosecuting attorney may upgrade that to a felony. Somehow I think there is still more to this story than what is being discussed so stay tuned.

Monday, November 6, 2017

Another Experimental Cocktail To Die For

Here we go again. State prisons all around the country have been having increasing difficulty achieving their public duties to execute convicted felons. Drug companies have made it a policy not to sell their pharmaceuticals for executions because, well, they were not approved by the FDA for that purpose. In the meantime, the court systems have halted executions when they believed the prisoners would suffer any kind of pain during the process. In desperation, prison systems have been experimenting with different cocktails of drugs to carry out their deathly functions.

We saw recently how Florida became the first state to use etomidate as part of their drug cocktail for executions. Propofol has been getting more difficult to attain as drug companies and pharmacies demand that their wares not be sold to the penal system. Now Nevada is trying another novel drug: cisatracurium. The state will be trying a new potion consisting of fentanyl, diazepam, and cisatracurium on Scott Raymond Dozier. Mr. Dozier was convicted of two separate murders. He is schedule to be executed November 14.

Naturally there are all sorts of objections to this, besides the general disagreement with capital punishment. The state's Chief Medical Officer, Dr. John DiMuro was an anesthesiologist. However he resigned a week ago and his replacement is a psychiatrist. Some fear that a psychiatrist would not know how to administer these drugs. The state assured that there would be trained medical personnel at the time of injection.

The ACLU also objects that cisatricurium would paralyze the prisoner but not actually kill him, causing him to die of slow painful asphyxiation. This actually makes some sense. None of the drugs being used would be considered fast acting. With this combination, the prisoner would die from oxygen deprivation, which is very slow. This is unlike the previous drug cocktail of pentathol, succinylcholine, and potassium. Those drugs are all rapid acting and lead to amnesia and cardiac arrest quickly. So if not enough benzos are given, and this can be tricky since many of these prisoners have histories of drug abuse that require larger than normal pharmaceuticals to work properly, the condemned may awaken before the cisatricurium has stopped his breathing long enough for the heart to fail. They would have to administer massive doses to be sure the drugs take effect quickly.

Naturally this debate will continue since they are trying to execute somebody using chemicals that were developed to help life, not end it. If they truly wanted to end Mr. Dozier's life quickly, history has cleverly invented all sorts of contraptions to do just that. However, we Americans are just too squeamish to consider using them as part of our "sophisticated" modern society.

Anesthesiologist Attacks Senator And It Has Nothing To Do With Obamacare

Here is the poster boy for the Anti-Trump Derangement Syndrome. Senator Rand Paul of Kentucky was severely injured over the weekend by his next door neighbor. Apparently the good senator was just minding his own business and mowing his yard when he was unexpectedly tackled by physician Dr. Rene Albert Boucher. Sen. Paul suffered five broken ribs (!) and cuts to his face.

As it turns out, Dr. Boucher is a retired anesthesiologist who is affiliated with The Medical Center at Bowling Green. He is a pain medicine specialist and graduated from the Des Moines University College of Osteopathic Medicine. He has been practicing medicine since 1982. His claim to fame is that he invented something called the Therm-a-Vest, a rice filled vest that is heated up in the microwave than worn around the thorax to relieve back pain. It was marketed on QVC but never took off. The doctor retired in 2015. The ASA will be happy to hear that he doesn't appear to be a member of the society.

The deranged physician is a registered Democrat and his Facebook pages are filled with anti Trump and liberal rantings. If he was smart, he would have realized Sen. Paul, an ophthalmologist, is one of the senators that's inhibiting the more conservative members from carrying out the Trump agenda. But there is no reasoning with stupid.

Republicans Give Doctors The Middle Finger

So all you doctors who voted for Republicans in the last election thought you were going to get a big ole tax break thanks to the GOP's control of all branches of the federal government. Candidate Trump and all the Republican Congressmen claimed they were going to enact massive tax reform to give the middle class YUGE tax relief if they got elected. Well guess, what, they won and we doctors lost.

The Republicans in the House of Representatives released their tax reform bill last week and it sure likes they are giving doctors and other professionals the middle finger. It has to do with pass through corporations that many professionals like doctors, lawyers, and architects use. It's a legal way of lowering taxes by separating out the business taxes from the personal taxes. Its more famous users include former Senator John Edwards and former Congressmen Newt Gingrich. By declaring an extremely lower personal income relative to their total income from their businesses, they were able to save thousands of dollars from their payroll taxes.

The Republicans have decided that businesses who use pass through corporations should get a lower tax rate just like the large corporations that will receive a substantial tax cut. In this case, the pass through tax rate will be lowered to 25% from the owner's personal rate, which is usually in the upper brackets of the tax system.

However this new lower rate does not apply to a few select professions. Why? According to Rep. Chris Collins of New York, a Republican, "If you earn your income as a doctor, a lawyer, an architect, you're not getting anything. But you're not supposed to get anything--that's how you earn your income. It was intended to lower the rate for manufacturing companies making widgets and employing other people."

And you wonder why doctors are always getting screwed by the federal government? This Congressman said physicians are essentially just leeches on the government and the country. We only take money and don't contribute anything to society. Never mind that doctors have a huge influence on how trillions of dollars are spent in healthcare. All those millions of people who work in this industry, from the office clerk, to nursing staff, to hospital administrators, medical device manufacturers, and insurance companies, are dependent on doctors. If physicians decide not to use their services, they would be facing the unemployment line tomorrow.

But no, Congress thinks doctors don't deserve a tax break because we don't make any widgets. This is one more nail in the coffin of doctors in private practice. More doctors will start realizing that being an employee of a large medical corporation is the future of medicine. Taking less income is surely more appealing than wrestling with the indignities heaped upon us by our own government every day.

Sunday, November 5, 2017

Animoji Karaoke

I have wasted far too much time this weekend watching the latest internet sensation, animoji karaoki. Thanks to the iPhone X and its face detection technology, people have discovered more uses for the front camera than just unlocking the phone and taking selfies. Even though the phone was just released to the public three days ago, there are already lots of amusing karaoke clips on Twitter and YouTube. My kids and I can't stop watching them and you probably will get a few good chuckles too.

Friday, October 13, 2017

How Propofol Works

Like reliving a long forgotten nightmare from biochemistry.

Anesthesiologists have a surprisingly poor understanding of how anesthesia works. Maybe it's because we don't really understand how the brain itself functions or how consciousness is formed. All we doctors know is that the FDA approved these drugs for anesthesia. We inject them into a patient and, voila!, the patient is unconscious. Why is that? Sure we can recite some mumbo jumbo about GABA and NMDA receptors, but how do these cause the brain to fall asleep? It's remarkable that the FDA approved these drugs without more complete information on their mechanisms of action.

Now there is another explanation for how propofol and other induction agents work their magic. Published in the Proceedings of the National Academy of Sciences, researchers discovered that these drugs inhibited the movement of kinesins. What is that, you ask? In case you have completely forgotten your microbiology after twenty years of practice, kinesins are little intracellular motors that transport material along microtubules that allow the cells to function.

The researchers found that propofol, along with etomidate and ketamine, decreased the effectiveness of these kinesins to move their cargo. Though the rate of transport isn't affected, the distance the kinesins can move their cargo is decreased. Thus the neurons are not able to function normally and supposedly this will lead to unconsciousness. Or something like that. You'll have to go read the research paper yourself to get a more cogent summary of their work. I threw away my college microbiology textbook decades ago.

Who Is Better At Assessing Surgical Risk?

JAMA Surgery has a paper asking who is better at assessing surgical risk: internal medicine residents or surgery residents. The answer is obvious--neither. It is anesthesiologists who are best equipped to determine the potential for postop complications. Duh. It is what we do every day. Patient safety is like 95% of our thought process. It's practically in our DNA. It is even in the title of this blog, "There are no substitutes." We train for years and years learning how to guide a patient safely through their surgeries. So the question about whether internists or surgeons are better at deciding patient safety after surgery is ludicrous. The anesthesiologists are the guardians of surgical patients.

Wednesday, August 30, 2017

Dubious Milestone In Anesthesia

Anesthesiology has given the world great advances in medicine and healing. In fact, it was voted one of the highest achievements in the history of medical literature. Unfortunately, lately the only time anesthesia is mentioned is when it causes harm, or even death, usually in a sensational fashion.

Now anesthesia has entered the public discussion once again with the news of a prisoner execution in Florida last week. For the first time ever, the drug etomidate was used as part of the IV cocktail to cause the death of a convicted inmate. This news seems to be more widely covered in British media. They appear to be more fascinated with capital punishment than the Americans probably because capital punishment is outlawed in most of Western Europe.

Mark Asay, a white Floridian, was convicted of the racially motivated murders of two minority men back in 1987. After decades of litigation, he was finally put to death with a combination of etomidate, rocuronium, and potassium. This has caused an uproar besides the usual moral handwringing over the death penalty in general. The defense attorneys argued that etomidate is an unproven method for achieving death. They hired doctors who testified that etomidate can cause pain prior achieving its effects.

Meantime, the pharmaceutical company that manufactured the etomidate is objecting to its obviously non-FDA approved use of the drug. This is the reason that more drugs are becoming off limits for use in the death penalty. Previous attempts using pentathol, propofol, and midazolam have been thwarted because the penal system was unable to acquire the drug due to manufacturers' refusal to sell the product or the courts have deemed them cruel and unusual punishment and thus illegal.

Because of these difficulties with IV injections for capital punishment, some states like Mississippi are considering bringing back the old reliables like a firing squad, electrocution, or the gas chamber. That is probably the proper approach. Stop bastardizing anesthetics that were invented for medical purposes to somehow humanize an inhuman act. Centuries of human executions have given us plenty of methods to kill somebody for state reasons. Don't drag anesthesia into this mess.