Drinking As Much As You Want Before Surgery Can Decrease PONV.

The American Society of Anesthesiologists has very clear guidelines for deciding when patients should stop any oral intake before surgery. These guidelines were made to prevent patients from aspirating gastric contents upon induction of anesthesia. For years, the rules were no solid foods up until six hours before surgery and no clear liquids two hours before the procedure.

Granted there have always been complaints from patients about how miserable they feel by the time they get to preop from having to fast for such a long period of time. It's especially bad for patients whose procedures take place in the afternoon and were given instructions to be NPO after midnight. Since this is by no means settled science, there is ongoing research to help remedy the situation.

Some have advocated letting patients drink carbohydrate rich fluids to help with the hypoglycemia that makes the patients feel so deprived. However, they still say nothing by mouth for two hours before surgery. Now the British have done something even more bold than Brexit--all you can drink right up to going into the operating room itself.

In a followup to a study first published in the European Journal of Anesthesiology in 2017, researchers in the UK allowed patients to drink as much as they want immediately before surgery. Covering over 30,000 patients, the study showed that the rates of postop nausea was lower for patients who had unrestricted fluid intake, 3.8% compared to 5.2% for patients who could take clear liquids up to two hours before. Postop vomiting was also lower, 2.2% to 2.8%.

The $64,000 questions is what concerns anesthesiologists the most. What are the aspiration risks with unlimited po fluid intake before anesthesia? Surprisingly, they were very good. Only two patients suffered aspiration of gastric contents. Both patients had risk factors including BMI>35 and history of gastric reflux. That compares to a normal aspiration risk of 1 in 8,000 anesthesia patients.

The researchers speculate that patients who were allowed unlimited drinking before surgery had less postop nausea and vomiting because hunger itself can cause nausea. Their conclusion is that the risks of gastric aspiration is low enough that it justifies patients being allowed to drink fluids to prevent the higher likelihood of PONV.

These numbers look very promising on paper. However, in the much more litigious U.S. legal system, I think I will continue to follow the ASA's guidelines instead. People normally go hours during the day without eating or drinking anything. They can certainly do that the day of their operations.

When Did Medicine Become A Branch Of The Democratic Party?

Physicians used to be considered pretty conservative in their political views. They were considered very learned and commanded respect from their patients and communities; the definition of pillars of society. You probably didn't see too many physicians rolling around naked in the mud at Woodstock. Nor did you see them burning their draft cards/bras or march in antinuke rallies.

But times have changed. Medical societies, which are of course composed of physicians, seem to be veering more and more toward leftist ideology. The causes they espouse come right out of the Democratic party playbook.

The latest example is the American Academy of Pediatrics endorsement for a soda tax. They believe that taxing sugary drinks will lower heart disease and diabetes. They naively believe that the extra money from the tax should go towards subsidizing government programs to encourage people to eat healthier foods.

This is despite evidence that these soda tax policies don't work. When it was instituted in Philadelphia, the results showed that most people just bought their soda outside the city limits to avoid the tax. The tax hurt the business owners, many of whom were small businesses and minorities, who lost customers when they decided to buy their soda elsewhere, along with their other grocery needs. Another unforeseen consequence of the soda tax was that alcohol sales went up. If you have to pay extra for your soda, why not just step up to something else?

This soda tax endorsement is just one more piece of evidence that medicine has become a leftist organization. Along with medicine's endorsement of Obamacare and climate change, it's clear that this is no longer your father's or mother's medical practice.

Doctors Who Cheat

Amid the Hollywood actresses and hedge fund titans who were caught in the college cheating scandal, two healthcare professionals were also charged with using the services of Rick Singer, the mastermind behind this scheme to get children of the wealthy into elite colleges.

The first is Dr. Gregory Colburn, MD. He is a radiation oncologist in San Jose, CA. Graduating from UCLA, he has been in practice for over 20 years. He and his wife allegedly paid nearly $25,000 to have his son take an SAT exam with a corrupt proctor present to boost his score. When news came out, online reviewers quickly gave him one star. He is now being investigated by California's Medical Board and could have his medical license suspended.

The next medical professional's motive is a little more puzzling. Dr. Homayoun Zadeh was the director of periodontology at USC's School of Dentistry. He supposedly paid $55,000 to have his daughter recruited at USC as a lacrosse player, even though she doesn't play the sport. They reportedly had to refinance their house to make the payments. When word of his arrest became public, USC quickly fired him from the dental school.

I just wonder why Dr. Zadeh felt he needed to cheat to get his daughter into USC. She should have a huge advantage over most USC's applicants since her father is a tenured professor at the university. Unless she's a really mediocre student, what made the parents think she needed that extra boost to get her in?

While this episode is truly embarrassing and sad, I can understand the angst these parents are facing to get their children into "elite" schools. My own kids are very shortly going to start applying to college. There is enormous pressure for them to go to top flight schools, mainly as a vanity project for the parents. I personally went to a state university and have done well professionally, but in good school districts with many upper middle class families, the social pressure to one up other parents for bragging rights can become toxic.

I feel worse for the children. Whether they were complicit or not, having their parents' names splashed in headlines across the country must be incredibly traumatizing and stigmatizing. Knowing their parents have lost their jobs and their reputations, it makes you wonder if it was worth it. In hindsight, it obviously isn't.

What Do Anesthesia Program Directors Want?

Congratulations to all the medical students on another successful Match Day. I want bore you with the details about how anesthesiology did this year. As usual, there were more programs and spots available over last year despite increasing concerns about training too many anesthesiologists. However some of the increase can be attributed to osteopathic programs that are now part of the unified Main Residency Match. As usual, over 98% of positions were taken, though only two-thirds were filled by US senior med students. That compares with over 90% US seniors in highly desirable residencies like ENT or orthopedic surgery.

What I found more newsworthy is the NRMP's survey of program directors. For practically forever, med students have wondered what qualities residency directors look for when seeking applicants for their programs. That is one of the top questions I get asked every year. We now have concrete answers thanks to the NRMP.

The NRMP director survey is done for each specialty. Obviously I'm just going to talk about anesthesia directors. So what are the factors that make a student more desirable?

As you can see, the number one issue that makes a student competitive for an interview is the board scores, particularly Step 1. This is followed by the letters of recommendation, grades in the clerkship, Dean's letter, and class rank. Surprisingly, even though students sweat for weeks working on it, your personal statement isn't really all that important.

When it comes to how programs rank all their interviewees for the Match, the number one factor is interactions with faculty, followed by interpersonal skills, interactions with housestaff, feedback from residents, and board scores. This proves what I've been telling students all along--if you're credentials are strong enough to make it to the interview stage, the rest is all about personality and interactivity. It doesn't matter if you're the most brilliant student this side of Stephen Hawking. If you come across as an arrogant jerk during the interviews or a shrinking wallflower, you will not get ranked highly.

So go check out the rest of the survey by clicking on the link above. You'll find other interesting tidbits like the average anesthesia residency received over 800 applications, but interviewed less than 150. And how Canadian students are really screwed on American Match Day. Again congratulations to all.

Bigger Is Better, Even In Anesthesia

This is a cautionary for all anesthesia practices and residents evaluating anesthesia groups to join after graduation. Olean General Hospital in New York has just informed its anesthesia providers, Southern Tier Anesthesiologists, that it has decided to go with a different group for their anesthesia needs. Bye bye. And don't let the door hit you on the way out.

What's particularly galling is that STA had no conflicts with the hospital prior to them seeking proposals from others. STA members asked directly if there were any issues with their work and the hospital denied any work or personality conflicts. Ultimately the work contract was awarded to another anesthesia group out of Buffalo who were willing to work for less money.

STA had been OGH's exclusive anesthesia providers for 24 years. And OGH has been the exclusive hospital to STA for the last fifteen. Unfortunately they may just have been too small to compete with groups that are much larger and have economies of scale. STA only has six anesthesiologists and two CRNA's. Meanwhile, hospitals and insurance companies are merging at a furious pace. OGH is part of a much larger hospital group, Kaleida Health. When large corporations start running hospitals, loyalty takes a back seat to the bottom line.

For the anesthesiologists in STA, the future looks bleak. It's unclear if they will be absorbed by the Buffalo group if they are willing to work for less money. Otherwise, there are no other hospitals within an hour drive and the physicians will have to move away to find other jobs.

While it may be desirable to work in quaint small towns with Mayberry quality lifestyles, medicine isn't practiced like the 1950's anymore. Corporate medicine is creeping into even the smallest medical practices. I've had personal friends who thought they found the perfect anesthesia jobs after residency. Then one day, they show up for work and find out their hospital has negotiated with a different anesthesia group willing to work for less money. They were suddenly unemployed. Devastating.

In order to compete, doctors will need to team up or get run out of town by companies with billions of dollars in revenue and no compunction to fire staff at will if it helps their stock holders. I wish all the luck to the members of Southern Tier Anesthesiologists in their careers and hope they land somewhere that will provide a more stable job environment for themselves and their families.

The Fallacy Of The Universal Time Out

Scott Baker, MD

Is it possible to legislate away human error? It would appear not. Despite the best intentions of hundreds of bureaucratic agencies and thousands of rules governing every conceivable aspect of medical practice, plain old human error still rears its ugly head to make sensational news headlines about the latest grievous injury to a patient.

Last week, an Iowa woman sued her surgeon, Dr. Scott Baker of Sioux Falls, SD for removing the wrong body part. In 2016, Dena Knapp of Iowa was supposed to have an adrenal mass removed by Dr. Baker. Instead, the surgeon was notified by the pathology department afterwards that he had removed a kidney, not the adrenal. To make matters worse, Ms. Knapp states that the surgeon lied to her about the mistake and claimed he did not get all of the mass and needed a second operation, never informing her that he had accidentally removed a healthy kidney. She went to the Mayo Clinic for her second operation. Now she claims that her one remaining kidney is starting to fail and she is suffering from severe mental distress and pain.

Can you see the difference between the adrenals and the kidney?

This incident has so many open questions. It also points out the fallacy of imposing more and more rules on people in order to prevent human error. First of all, let's agree that the surgeon made a huge error in judgement when he somehow mistook a kidney for the adrenals and took the wrong one out, even if they are right next to each other. However, I'm curious about what the rest of the surgical team  was doing when the error took place? As part of the Universal Protocol required by the Joint Commission, every member of the team in the operating room had to confirm the correct patient, surgical procedure, and site of the procedure prior to the start of the operation.

So that begets the question, where was the rest of the OR staff when the kidney was being removed? Did the nurse or the surgical tech, who would have been right there to document the specimen being removed from the patient, not notice that they were being handed a kidney and not an adrenal? Was the surgeon's assistant not confident enough to tell Dr. Baker that he was resecting the wrong organ?

For that matter, what about the anesthesiologist in the case? We are an integral part of the surgical team and consider ourselves leaders in patient safety. That includes being an active participant in the Universal Time Out. Did the anesthesiologist not notice that the surgeon had removed the kidney by accident? Was anything said to the surgeon by anybody in the OR when the nephrectomy was taking place? So many unanswered questions that I'm sure will be aired out in court very soon.

This is just the latest medical malpractice case to make headlines since the practice of Universal Protocol was conceived in 2004. No matter how many rules are enacted, the best protection for the patient is one of the simplest--stay vigilant.

Don't Google Check Your Attending

Now is the season when medical students all over the country start doing away rotations in their desired fields hoping to gain experience and come away with a favorable letter of recommendation for their residency applications. We are currently trying to accommodate dozens of students each month who come and go through our hospital who are undergoing this ritual.

In general, most of the students are great to work with. They are eager to learn and still in awe of some of the amazing work we do in anesthesia. Many have little experience in our specialty other than what they see on TV or over the drapes during their surgery rotations. It's a pleasure to have them around.

But that doesn't mean that they are all easy to work with. We love it when they ask great smart questions about what they are seeing in the operating rooms. However I recently had one student who loved asking questions but then would quickly look up Google on his smartphone to double check the answer I gave him. This was beyond annoying.

If you just want to learn from Google, why bother going to a far away rotation to questions everything somebody is trying to teach? Sure maybe my own fragile ego may have something to do with my insecurity when I'm up against an omniscient presence like Google. But I don't like being told while I'm teaching that my MAC number for Sevoflurane was just a fraction of a decimal point different from that almighty search engine. I find it rude when I'm questioned about every nugget of wisdom I'm trying to impart on our future anesthesiologists while I'm in the process of doing so. It got to the point where I stopped teaching that particular student anything. Instead we just sat there and talked about his personal life and interests, which frankly he seemed far more receptive to than anesthesia.

Every anesthesia attending I discussed this situation with agreed that the student should be more tactful in how they question their instructors. Don't Google check your attending unless you're invited by them to look something up together as a shared learning experience. If you question something that was said, you can always look it up later and perhaps ask another attending about the discrepancy in information. But to constantly berate your teacher with the internet will quickly shut down the conversation and leave you poorer for it. And that's not why students spend thousands of dollars and months of their lives to gain experience to be smart physicians.

The Genius of Sting

I have been a fan of Sting since his Police days in the 1980's. Well, mostly early Sting music anyways. His later solo career works just became too mellow for me. So while driving home from work the other day, I was listening to the oldies station (God when did my favorite music migrate to the oldies station?) when they started playing Sting's "If I Ever Lose My Faith In You". I've heard it hundreds of times before but not recently. Then I suddenly caught these lyrics in the second verse.

Some would say I was a lost man in a lost world.

You could say I lost my faith in the people on TV.

You could say I'd lost my belief in politicians.

They all seemed like game show hosts to me.

What?! This song was released back in 1993. Yet the lyrics are so prescient of our current times and politics. In four simple lines he so perfectly encapsulates the present day controversies regarding fake news, Russian collusion, lost emails, special counsels, qualifications for higher office, etc.

Sting, wherever you are, you are truly a genius.

Jahi McMath Has Died. Again.

The family of Jahi McMath released news that their daughter has passed away. If you don't remember who Jahi was, she was the adolescent who suffered anoxic brain death after complications from a tonsillectomy and uvulectomy for sleep apnea in 2013. She suffered her second death last week after complications from an abdominal surgery.

Multiple doctors declared the child brain dead five years ago yet the family refused to accept the diagnosis. Even though there was no blood flow to the brain, the family pointed to such findings as twitching of the fingers and toes. Most doctors would say those are spinal reflexes that has nothing to do with brain activity but they found a sympathetic judge who kept the child on a ventilator in the hospital until they found another facility in New Jersey willing to take this "patient".

This case had huge implications for the anesthesia community. For years afterwards, the ASA's CME material repeatedly emphasized the active ingredients in the metabolism of narcotics and how to be extra careful sedating obese young patients in recovery. In all the years before the McMath case, they never discussed this issue once. 

Thanks to the Jahi McMath media circus, at least there was tremendous educational opportunity for physicians. She did not die twice in vain.

The Anesthesiologist Who Attacked Senator Rand Paul Is Sentenced

Remember the bizarre story last year when Senator Rand Paul of Kentucky was attacked by his next door neighbor? The neighbor was an anesthesiologist by the name of Rene Boucher. The incident left the senator with multiple broken ribs and lung contusion. Now it has come to a conclusion.

Dr. Boucher pleaded guilty to the assault and has been sentenced to 30 days in jail. He will also pay a $10,000 fine and serve 100 hours of community service. This sentence seems light to me considering that he pummeled the senator when his back was turned and was unprovoked. His lawyers had requested a 21 month sentence.

During the court hearing, we find out that Senator Paul was not as seemingly innocent as first appears. It seems that the two neighbors did indeed have a longstanding dispute over lawn maintenance. Senator Paul dumped a bunch of grass and tree clippings right on the property line between the two. This was no ordinary pile of leaves. This was a 10 foot by 5 foot stack that sat there for a few weeks.

When Dr. Boucher complained, the senator did nothing about it. Eventually the doctor brought in a dumpster and had it hauled away himself. Then Senator Paul did the same thing again. Then again the anesthesiologist had a dumpster come remove it. This repeats itself several more times. At one point Dr. Boucher even set the pile of grass on fire, burning himself in the process. He asked for the homeowners association to do something about this but they were not responsive.

The last straw came when Senator Paul, who sounds like a big asshole, blew grass clippings over into his neighbor's house. That's when the doctor turned rogue and blind sided the senator. Sounds like Rand Paul was the neighbor from hell. Wonder how he is taking care of his lawn this year?