Thursday, May 6, 2021

Awake While Under The Knife

This is a surgical patient's worst nightmare. Frankly it's also an anesthesiologist's worst nightmare too. In July 2020, Matthew Caswell underwent a hernia operation at Progress West Hospital in O'Fallon, Missouri. Unfortunately he was awake for at least thirteen minutes during the operation. The anesthesia team had paralyzed him then forgot to turn on a volatile agent to induce amnesia.

Mr. Caswell said he knew something was off when he could feel his skin being cleaned with the cold prepping agent. Expecting that his anesthesia would kick in any moment, next thing he felt was the knife cutting his skin. He was paralyzed and could not inform the anesthesia team that he was awake. His heart rate jumped from 70 to 115. Meanwhile his blood pressure shot up from 113/73 to 158/113. He could feel three trocars inserted through his abdominal wall and his abdomen being insufflated for the operation.

According to the lawsuit, the anesthesia team at this point should have noticed that something was wrong. Yet no further anesthesia was given for thirteen minutes. In the meantime he could hear and feel everything that was going on in the operating room. Mr. Caswell said he was so scared he thought he was having a heart attack.

The anesthesia records later showed a "Significant Event Note." It said that "review of the anesthetic record demonstrates a delay in initiating inhalational anesthetic after induction of anesthesia." Mr. Caswell and his mother were "immediately informed regarding the delay in initiating the inhaled anesthetic agent until after the start of the surgical procedure." It goes on to say that the hospital provided emotional support immediately after the surgery and they would offer psychological counseling for free. His mother took a video of Matthew immediately after the operation and it's clear he has been traumatized by the entire ordeal.


Mr. Caswell is suing Washington University along with the anesthesiologist, Brian Weber, MD, JD, and Kathleen O'Leary, CRNA. (Though the first page of the complaint says Dr. Weber's first name is Brian, the subsequent pages of the complaint call him Bruce. I can't explain the discrepancy.) I can't think of much defense they can mount against this tragedy. Better just write a big fat check right now. Lucky for them the plaintiff is suing each defendent for only $25,000 each. 

This is going to be an unfortunate black mark on this young anesthesiologist's career. It's the kind of incident that can easily derail a promising new physician and make him question everything he's learned during training. Though not as traumatized as the patient, Dr. Weber is likely to feel enormous guilt for a very long time.

There are various methods to prevent surgical recall. Some have advocated using a BIS monitor to track a patient's level of consciousness. Other's show that making sure enough inhalational agents in the patient will prevent recall just as well as the BIS. Giving the patient midazolam preoperatively can help ensure amnesia in case not enough gas has been given to the patient.

Perhaps the most important thing the anesthesiologist can do is to always be vigilant. Be constantly aware of what is happening to the patient. Just because an operation is likely to be routine and uneventful is not an excuse to stop monitoring the patient scrupulously. If the anesthesia team in this case had been more attentive to the stresses manifested by Mr. Caswell's tortured surgery, maybe they wouldn't have waited thirteen whole minutes before finally giving him his anesthesia.

Wednesday, May 5, 2021

Anesthesiologists Need Space Too

 

Looks about right for an anesthesia work space.

Anesthesiologists are frequently an afterthought when it comes to designing operating rooms. I've worked in operating rooms so small there was literally just enough space for the patient gurney to get wheeled in and no room to walk around it once the patient was inside. I've worked in rooms that were literally former janitorial storage rooms. I vividly remember administering anesthesia in rooms so tiny that when you went to relieve the anesthesiologist inside, that person had to get out first before you could squeeze yourself into the space. There was just enough room for the anesthesiologist to stand in place, never mind a space for a chair.

A dream space for the anesthesiologist.

All that discomfort and disrespect for the anesthesiologist may be changing. The New York Times has written about a revolution in operating room design. The article follows the OR remodels taking place at the Medical University of South Carolina. Led by Dr. Scott T. Reeves, the chair of the department of anesthesia and perioperative services at the hospital, they are making OR's that are bigger and far more accommodating for all the staff. They even take into account how to future proof the new rooms, deciding where to place bulky equipment like X-rays and robotic surgery that are used with increasing frequency during operations.

This is a far more professional way to design the operating rooms than what I've witnessed in the past. I remember when we were opening a new wing of the hospital and the anesthesia department had its first chance to see how the operating rooms would look. We had absolutely no input into the space during the design phase. They never asked for nor received any input from the anesthesiology department. Needless to say, the placement of the anesthesia equipment was suboptimal, almost dangerously so. 

Upon review of the blueprints, we noted that the rooms were drawn with plenty of space around the operating table for the surgeon. However, the anesthesia machines and carts were not drawn to a realistic scale and were squeezed into the corners of the rooms. Our anesthesia machines were easily twice the width and depth of the models that were used in the blueprints. To this day, we still have problems with placing the machines in the proper locations to ensure patient safety. But the surgeons have plenty of space to do their work though. 

I'm glad hospitals like MUSC, Stanford, and Loma Linda are not forgetting the needs of all the staff in the operating rooms. Surgeons may think they walk on water in the OR, but without consideration for all the other professionals in the OR, they and their patients would sink pretty quickly.

Monday, April 26, 2021

ASA Gets Sued For Scientific Article


Pacira BioSciences, the maker of Exparel, a liposomal bupivacaine, has sued the American Society of Anesthesiologists and writers in the journal Anesthesiology for economic damages. They are seeking a retraction of the articles. The articles involved in the lawsuit appeared in the February 2021 issue.

According to Pacira, the papers in question disputed their assertion that liposomal bupivacaine is superior to plain bupivacaine. The articles exposed possible biases in research that originally led the company to tout the superiority of Exparel over bupivacaine. Previous papers claimed that Exparel achieved increased analgesia 24 hours after injection. However further study of the data showed that it did not meet the relevant threshold to make this statement.

Other biases leading the FDA to approve Exparel include the company submitting studies comparing the superior action of the drug to placebo. This is an easy thing to prove as it most likely will be better than injecting saline into the body. However when the company conducted research comparing Exparel to other local anesthetics like ropivacaine or nonliposomal bupivacaine, it failed to show increased effectiveness.

Why would a company sue the ASA over studies questioning its drugs? As always, just follow the money. When Exparel was approved by the FDA, sales at the company increased double digits annually, reaching over $400 million in 2019. One dose of Exparel costs $334 compared to only $3 for regular bupivacaine. Yes Exparel costs over 100x more than nonliposomal bupivacaine. To promote this costly drug, the company over the last decade has spent over $25 million to 27,000 physicians for speaking fees and nonaccredited educational events ie/fancy dinners at the local steakhouse and free gifts and rounds of golf.

In the lawsuit, Pacira claims it, "has suffered and will continue to suffer significant pecuniary harm as both existing and potential customers who have seen the disparaging articles, have either canceled contracts with Exparel, declined to purchase Exparel, or are considering removing Exparel from hospital formularies."

I want to congratulate the ASA for publishing some hard hitting articles that will help patient care and improve healthcare economics. However I also remember that there were some MOCA Minute questions in the past that stated liposomal bupivacaine is superior. I hope the writers of MOCA Minute go back and review these questions in light of the new research. ASA, keep up the good work to keep us anesthesiologists well informed and patients safe.

Tuesday, April 20, 2021

Tesla Crash Kills Anesthesiologist

A Tesla that was supposedly on Autopilot crashed into a tree near Houston on April 16, killing both passengers. It's been revealed that one of the passengers is William Varner, MD, an anesthesiologist who worked at Memorial Hermann Hospital in Texas. Now there is some controversy regarding this tragic accident.

Initially, it was reported that the crash occurred when two men were trying out the Autopilot feature in the Tesla. When the police investigated the incident, they reported that nobody was in the driver's seat. One was in the front passenger seat and one was in the backseat. They said they were almost 100% sure of their findings.

The crash was so intense that it took the firefighters over four hours and 32,000 gallons of water to put it out. It was complicated by the nature of the flame, which was an electrical fire, not the usual gasoline fire that firefighters are more used to. The fire was so stubborn that the firemen had to call Tesla for advise on how to extinguish it. By the time the fire burned out, the vehicle was just a metal carcass, almost unrecognizable. 

When news of the accident came out, Tesla's stock price dropped immediately when the stock market opened. Elon Musk, CEO of Tesla, then quickly came to the rescue of his company.

He claims that the Tesla in the accident didn't have its Autopilot featured turned on prior to the crash. In addition, that car didn't purchase the complete Full Self Driving features that costs an extra $10,000. Therefore it's not the cars fault that it crashed into the tree. Somehow two people were in the car and nobody was in the driver's seat when it was moving but the Autopilot wasn't on. Not sure how to square these claims and counterclaims.

When I first read this story a few days ago, I thought it was just another case of good ole boys doing stupid things late at night after having too many drinks. Now that we know one of the victims is a respected anesthesiologist, it makes me question the entire assertion about the police findings. Guess we'll hear more when the investigation continues. 

RIP Dr. Varner.

Sunday, April 18, 2021

CRNA's Take Over America


The American Society of Anesthesiologists' worst nightmare is now at hand. Due to clever promotion from the American Association of Nurse Anesthetists, the vast majority of patients in the U.S. can be sedated by CRNA's without any physician supervision. According to the AANA, there are now 42 states that do not require the CRNA's to take direction from any doctor.

The ASA thought they were doing well holding the opt-out of supervision states to just 17. Covid changed that calculus almost overnight. By pushing the narrative that critical care physicians are in short supply due to the pandemic, the AANA was able to convince a panic stricken federal government to drop the requirement for physician supervision during this health emergency. Unless a state specifically keeps the opt-in regulations, in essence the federal government has allowed all states to drop requirements for physician supervision.

This is just a temporary situation, right? Once we have herd immunity and everybody has gotten the vaccine, we can go back to the way we were, amiright? Uh huh. So far, government officials like Dr. Anthony Fauci don't seem to be in any hurry to declare the pandemic under control. Instead there are new variants popping up seemingly each week that require people to keep wearing their masks and consider getting annual booster shots to tame the virus. Though economies are starting to open up, control of the virus appears to be still a long ways off.

The longer the government and payers taste the elixir of CRNA billing, the more they are going to stay with the opt-out model. As our own group has experienced, CRNA's make anesthesia billing more viable as payers relentlessly pursue cost cutting measures. CRNA's can do 90% of the work anesthesiologists can do at half the price. Payers don't care about the anesthesia complications that arise from unsupervised nurses. That is the risk they are willing to take when confronted with the stark economic advantages of opting out. 

For a long time the ASA has had its finger in the dike lobbying to prevent more states from removing physician supervision. Unfortunately for the organization, and all patients and anesthesiologists, there probably won't be a happy ending to this story. The covid tsunami has swamped that wall and the last barrier to removing physician supervision has probably been breached.

Wednesday, April 14, 2021

Pandemic Takes Its Toll On Doctors' Incomes


There's no getting around the fact that the pandemic was devastating to the economic well being of nearly every industry last year. Healthcare was no exception. Between the loss of revenue from cancelled appointments and procedures to the increased expenses of paying for personal protective equipment and scarce hand sanitizer, many people in medicine saw their incomes slashed or evaporated.

Medscape has just released its 2021 edition of its annual Physician Compensation Report. It was drawn from a poll taken from October 2020 to February 2021. It therefore captures all the income made from 2020 and reflects on the continuing difficulty physicians were having during the severe winter surge in coronavirus cases.

The bottom line is that many physicians saw their incomes drop but hardship was not spread evenly. Anesthesiologists took a big hit with a five percent reduction in income compared to the year before. The average salary is now $378,000. However other fields like plastic surgery and oncology saw big jumps in income. So overall, physician income last year was about flat from the year before.

The average income numbers masked some really painful situations for doctors. Ninety-two percent of doctors said covid caused their incomes to decline, mainly due to loss of hours, patients, or even their jobs. In fact, 13% in the survey said they went for a period with no income at all, with the average length of time about three months. That is a scary prospect for people like doctors who have high expenses to meet like student loan debt and office overhead to maintain.

The top three reasons doctors said their incomes dropped were: reduction in hours, no annual pay raise, and reduced staff hours. However 45% said the pandemic didn't affect their salaries at all. If their incomes dropped, about 40% predict it will return to prepandemic levels within twelve months so at least the affects were only temporary.

Unfortunately for my group, our incomes are not likely to ever return to the salad days prior to covid. We dissolved our anesthesia group due to multiple economic weaknesses that became glaringly obvious during the pandemic. As Medscape's survey shows, employed physicians make a lot less than self-employed, an average of $52,000 less.

So our group's plight last year was not unique, even if it was still extremely painful to live through. We, like many other doctors across the nation, and the world, were hammered by the coronavirus both professionally and economically. So far we have made major adjustments and forged ahead to a totally different business model. We can only hope the coronavirus has been contained well enough for now so that we can get some back from what was lost for the last year and hope this truly is a once in a century medical phenomenon.

Tuesday, April 13, 2021

The Medical Boards' Money Machines


The maintenance of certification (MOC) run by the various medical boards is one of the most despised activities that physicians have to endure. The various tests and continuing medical education materials cost thousands of dollars in order for a physician to keep his board certification and stay gainfully employed. The kicker is that there is no evidence that any of these activities actually improve a physician's clinical acumen. As proof, look at the doctors who have lifetime certifications and never have to take any of this crap. These older physicians who grandfathered into these certificates should be the ones who need CME's, not the newly graduated doctors who still freshly retain their recent training. Yet these older doctors will vehemently deny they are any less qualified to see patients than their younger colleagues.

Many doctors have long suspected that the existence of MOC's is just a money making scheme perpetuated by the medical boards. Now Medscape has done a deep dive into the tax returns of the American Board of Emergency Medicine and it shows how lucrative running a monopoly institution can be. 

According to the ABEM's 2018 tax return, the organization reported $19 million in revenue and has $38 million in reserves at its disposal. It also reported $16 million in expenses with a profit margin of 11.2%.  How does this small medical organization with only 41 employees make millions of dollars? 

The ABEM states its major revenue maker are the tests it administers to physicians. New certification costs $4.7 million to administer and brings in $5.4 million. Fair enough. Continuing certification, on the other hand, only costs $1.6 million but hands the ABEM $7.3 million each year. Even Microsoft's profit margins aren't that good.

For comparison, the article looked at the American Board of Radiology. Their revenue numbers are similar to the ABEM so it can be assumed their expenses should be too. The ABR reported initial certification brings $4 million while the continuing certification makes $10 million.

What does the ABEM do with all this money? They lavish their directors with paid vacations to exotic locales, even including their families in on the largess. The company retreats are in lavish settings like Hawaii and Park City, Utah. They fly first class and get virtually unlimited meal expenses. The directors also make mid six figure incomes that dwarf the average salaries of the doctors who they are supposed to represent.

These numbers are only going to go up as more physicians graduate and need board certification and MOC while older physicians who don't make any money for the boards retire. In the years ahead the boards can only look forward to an ever increasing revenue stream, even before they raise prices for their monopoly services. 

Is it any wonder that there is such resentment of the medical boards? Their monopoly status, sanctioned by the government, insurance companies, and hospitals, makes them virtually unaccountable to the doctors who have to pay for their services to keep their jobs. The only beneficiaries of MOC are the boards themselves, not physicians or patients.

Friday, April 9, 2021

Best Anesthesiology Residencies


US News & World Reports has released its annual rankings of medical schools in the country. The list is split between medical schools that primarily focus on primary care and schools that are more research oriented. The research oriented schools are no surprise. They comprise the usual suspects of top universities in the country: Harvard, NYU, Duke, Columbia, Stanford.

The survey also lists the top specialty fields at each school. I'm assuming this means the residencies that are located at the schools. It is based "solely on ratings by medical school deans and senior faculty from the list of schools surveyed." In other words it's a popularity contest. They rank several residencies including internal medicine, radiology, surgery, and anesthesiology.

So let's cut to the chase. Which anesthesiology residency did these medical school faculty think is the best in the country? No surprise here, they closely mirror the top research medical schools. The top ten from one to ten are: Johns Hopkins, Harvard, UC San Francisco, Duke, Penn, Michigan, Columbia, Stanford, NYU, and UCLA. These are almost all the same schools as the top research schools in the list.

What about the best surgery programs? You would think that having a great surgery residency is almost a prerequisite for having a great anesthesiology residency since the two professions work so closely together. Once again, the list closely matches the best research schools. They are: Johns Hopkins, Duke, Harvard, Michigan, UCSF, Penn, Stanford, Columbia, UCLA, and Washington University.

Since these rankings are based on their presumed reputation from faculty members, there is an inherent bias towards well known schools like the Ivies and East and West coast schools. Just remember that, like going to college, it's not the name of the school that you graduate from that matters. It's what you do with your education afterwards that will determine your success in this world. If you graduate from virtually any anesthesiology residency you will be considered to have gone into one of the best jobs in medicine.

Wednesday, April 7, 2021

CRNA's Take Over Wisconsin Hospital

No anesthesiologists work here.

This is the type of news that makes anesthesiologists' blood run cold. Watertown Regional Medical Center in Wisconsin has removed all their anesthesiologists and replaced them with CRNA's. Wisconsin is one of the states that allows CRNA's to work without physician supervision. Therefore they can practice independently without even a surgeon supervising them. How does this cost cutting move by the hospital make the surgeons feel? In a decidedly indifferent comment, Adam Dachman, DO, a surgeon at Watertown, said, "It's a misconception that physicians are required to administer anesthesia." Ouch. Thanks for standing up for physician brotherhood.

This attitude is what I was afraid of when I said the anesthesia care team model will be the end of physician anesthesiologists. With the ACT model, anesthesiologists' roles become more like physician assistants. We're outside the operating rooms, dealing with preop history taking, starting IV's, making sure the patients are ready for their surgeries. Meanwhile, the CRNA's are the ones that are administering the anesthesia. They are the ones the surgeons will interact with 90% of the time. Our interactions with surgeons diminish to the point where they feel the CRNA's are doing all the work and no physician anesthesiologist is needed. This makes the hospital administration's decision to save money by firing all the anesthesiologists that much easier and less controversial with the staff.

The federal government is helping the demise of physician anesthesiologists by allowing the nurses to practice nationwide without supervision. Under the guise of increasing medical access during a pandemic, the CMS is letting CRNA's work independently so physician anesthesiologists can use their critical care skills to treat the maximum number of patients. This provision is supposed to sunset in June as the pandemic eases across the country. Not surprisingly, the AANA has something to say about that. They are talking with the nurse friendly Biden Administration about extending the opt out provision to the end of the year and possibly beyond. 

The coronavirus has been a seismic shift in how medicine is practiced. For anesthesiologists, it may be the final push out the OR doors that we have always feared. 

Sunday, April 4, 2021

Things That Don't Belong In A Human Orifice


The orifices of the human body usually proceed in a one way direction. It either goes in or out. It can be very painful if one violates this law of nature. Anyone who has ever had a Foley catheter inserted or undergone a colonoscopy will attest to that. This hilarious Buzzfeed article lists some grotesque, gag inducing, so unlikely it-must-be-true-stories told by medical personnel of their encounters in the emergency room with foreign objects inserted into different holes of the body. It made me remember one of the most unbelievable and vivid sights I had ever experienced in the ER.

It was early morning and the ambulance dropped off a young man in excruciating agony. He didn't want to talk about it until after we pulled the curtains around his gurney. Once we did that, he pulled back the bedsheet and there was the most enormous, angry looking penis that I had ever seen. It was not enormous in any kind of enviable way. This was not just any ordinary case of priapism either. At the base of his penis was a very tight, very small metal penis ring. It was preventing the blood in his erection from draining back into his body. The penis was purplish in color as arterial blood was not able to enter the organ. It was becoming ischemic. If this was not corrected soon, he could lose his penis. This was a medical emergency.

The urologist on call was notified. When he came down, the man complained that it felt like there was something inside his urethra too. The urologist then ordered an X-ray of the man's groin. What was on the X-ray was even more astonishing. In the film, one could see various objects lodged inside his urethra. There were several fishing weights, paper clips, and even the spring from a retractable pen. Smartphones weren't invented at that time so I couldn't take pictures of that film but I'll never forget it.

Apparently what happened was the man was drinking heavily and doing drugs during his sexual encounter. He then passed out. While he was unconscious, his partner starting doing these masochistic acts on him and left. He finally woke up from the pain and called 9-1-1 since he couldn't drive himself to the hospital.

The urologist carried a small ring cutter for just this purpose. I guess this wasn't his first rodeo. Unfortunately, the penis ring was so tight and the tissue around it so swollen that he couldn't get the ring cutter around it to snap it off, no matter how much lubrication he put on the cutter. It was also excruciatingly painful for anybody to touch the patient's penis, even with sedation.

Ultimately the patient had to go to surgery to remove the penis ring and all the objects inside his urethra. I never found out how the man faired afterwards. I'm sure the surgeon was able to save his penis and urinary function but that is one lesson the man hopefully will never forget. Ask any physician and they will all tell you their stories of patients with some foreign objects inserted into a body cavities. 

For anybody who wants to explore their sexual fantasies by inserting objects into various orifices. Please. Be very careful. Or we'll be seeing you in the ER eventually.