Anesthesiologists, Stop Wasting Oxygen!

The Covid pandemic feels endless. As soon as one area starts controlling its rate of transmission, the virus seems to pop up elsewhere to ravage the population. This has led to various states of emergencies at different times and locations. It's like a deadly game of whack-a-mole.

One thing all these virus affected areas have in common is that there is a great need for large amounts of oxygen. Virus victims often present to the hospital gasping for air. They're frequently placed on high flow nasal cannulas or BiPAP to assist their breathing. If it's severe enough, they may have to be intubated and mechanically ventilated. All these devices require massive amounts of oxygen flowing 24 hours a day.

With thousands of people requiring oxygen to keep them alive, oxygen shortages have been reported in this country and around the world. Some hospitals in the state of Florida reported having less then 36 hours of oxygen left. India has run out of oxygen in some cities, resulting in hundreds, perhaps thousands, of people dying needlessly.

So it ticks me off when I come in to work in the morning and see the gas flows on the anesthesia machine turned up to maximum with no patient in sight. It's especially aggravating on a Monday morning when one wonders if that machine has been turned on like that the entire weekend. 

Not only is this a huge waste in a time where there are shortages of oxygen in many places, it is also detrimental to the patients that might be placed on that machine later in the day. High gas flows will dry out the CO2 absorbant. The dessicated absorbant can form a chemical reaction with the volatile anesthetics to produce carbon monoxide which is then absorbed by the patient. 

It is so easy to prevent this from happening. I make it a point to turn off all my gas flows right before I take my patient out of the room. There's no need for the machine to be pumping out ten liters of oxygen per minute between cases. At the end of the day, just push a button to turn off the machine so that no gas flows are present to dry out the CO2 absorbant. 

In a time when anesthesiologists are debating whether sevoflurane or desflurane is better for the environment, something as simple as turning off the gas flows after each case can produce real tangible benefits for all mankind during this health crisis. So do it! Turn off the gas when you're done. Even if you don't live in a high Covid infection area, this simple consideration can help patients all over the country and around the world.

Are Anesthesiologists Just Glorified Nurses?

In a provocative op-ed in Anesthesiology News (free membership required), Dr. Karen Sibert, past president of the California Society of Anesthesiologists, dared to ask if anesthesiologists are truly practicing like physicians, or merely doing nurses' work. Full disclosure: I know Dr. Sibert personally and have worked with her in the past.

She asks why are anesthesiologists responsible for drawing up drugs? Why are anesthesiologists the ones to hang medications on IV pumps? Why are anesthesiologists charting IV fluids and urine outputs? Do you ever see internists grab a syringe and check out drugs from a Pyxis to give to a patient? Of course not. They write an order and the pharmacist and nurse carries it out. Oncologists don't hang drugs themselves. They give orders to a nurse who then loads the IV pump to give to the patient. When a surgeon asks for preincision antibiotics, who does he give the orders to? That's right. It's the anesthesiologist who mixes it up and administers it to the patient. How did anesthesiologists' duties become so mundane and nursing oriented?

Dr. Sibert goes goes into a little bit of history of anesthesiology to explain the current conundrum. In the early 1900's, most surgeons would use a nurse to administer sedation in the operating room. The same nurse might then follow the surgeon to the office later in the day for office duties. There was no such thing as an anesthesiologist involved. Then along came Ralph Waters, MD. 

Dr. Waters was one of the pioneers of anesthesiology, a lion of the specialty. He treated anesthesiology as a true science, with rigorous research and observations. He began the first anesthesiology residency in the United States, at the University of Wisconsin, Madison in 1927. 

But unfortunately the practice of providing anesthesia had by then been strongly established as a nursing duty supervised by a surgeon. It took decades of work before anesthesiology was officially recognized as a physician specialty and fully independent of a surgeon's purview. 

Dr. Sibert noted the difference between the European model of giving anesthesia versus the American one. Europeans require two professionals present during critical phases of the case, either an anesthesiologist and an assistant or an anesthesiologist and a nurse. The US does not have this requirement so a CRNA can do the job all by themselves without any supervision of an anesthesiologists.

European anesthesiologists are also much more involved in the patient care throughout their hospitalization, not just in the operating room. Patients are evaluated by anesthesiologists preop. They are then followed through the operating room, possible ICU stay, postop recovery, pain management, and even after discharge. The anesthesiologists act as a hospitalist or internist for the patient. This is the aim of the Perioperative Surgical Home that was so in vogue a few years ago. But most American anesthesiologists would rather quit than to have to follow their patients that thoroughly. ("If I wanted to be a hospitalist, I would have gone into medicine and become a hospitalist!")

Those are the kinds of responsibilities that medical students and residents are trained to excel. We're experts at evaluating the big picture to determine whether a patient can safely undergo anesthesia and to take care of them perioperatively. Why do so many anesthesiologists not want to broaden the scope of their practice and are satisfied with drawing up syringes of propofol and just get through the day? 

Because it's easy, that's why. It takes hard work to really think about how to navigate a patient through preoperative preparations, surgery, and postop recovery. It's so much easier and more lucrative to just sit in the operating room and push syringes of drugs while a computer automatically charts all the vital signs. We're being paid to do nurses work while making a doctors salary. 

Is it any wonder that surgeons look on with disdain when they peer over the ether screen and see anesthesiologists staring at their cellphones? Do you think surgeons care whether the person on the other side of the screen is a physician anesthesiologist or nurse anesthetist as long as somebody is paying attention to their patients? It's only a matter of time before the insurance companies and hospital administrators realize this too and make their own adjustments.

Doctors Are Not As Essential As They Think They Are

Remember at the height of the pandemic last year when people were hanging outside their windows applauding healthcare workers for their selfless sacrifices to treat Covid patients? That was quite an ego boost and seemed to signal that people finally realized how essential doctors and other medical workers are to the well being of a nation and the world. But now, when it's time to match the rhetoric of appreciation with cold hard cash, all the applause is silenced.

The federal government is on schedule to cut Medicare reimbursements to doctors close to ten percent next year. The complicated formula for this involves the expiration of bonus hero pay of 3.75% enacted last year. Then there is another 5.75% cut to meet budget neutrality rules that were put into law back in 2011. Altogether, that plus other scheduled pay cuts add up to a nearly 10% reduction in Medicare reimbursement next year. This is happening even though doctors are already making less than plumbers. (Many readers have pointed out that Medicare actually pays doctors around $80-90 per hours rather than $45 that I wrote previously. Well, $90 per hour after years of higher education and hundreds of thousands of dollars in student loans still stinks. After you take out taxes, it's closer to $45 than you think).

How pernicious are these annual drip drop reductions in physician pay? Since 2007, GI doctors have seen their Medicare reimbursements drop 6%. Cardiac surgeons are down 8%. And cardiologists are lower by 22%. What other professional field has seen their pay actually go down over the last 15 years? 

Meanwhile, the cost of running a medical business keep rising. Staffing salaries are higher. Utilities are higher. Insurance is higher. Taxes are higher. Yet doctors are expected to pay all that with less income coming in. 

You want to know who the government considers the real essential workers? All you have to do is follow the money. The Biden administration announced they are increasing federal workers' pay over two percent next year. That may not sound like much but it's still better than the cuts doctors are facing. On top of that, the federal workers also get a brand new paid holiday to enjoy their new money, Juneteenth. Could you imagine the uproar if the government unilaterally cut their workers' pay ten percent and they had no say in its implementation? The entire federal government would shut down within 24 hours as they all go on strike and stay home.

Yet doctors continue to act as martyrs and just accept the reductions in reimbursements year after year. This makes it necessary for them to run faster than ever just to stay in place. Or more commonly, most doctors now don't run independent practices anymore. Many have gladly sacrificed their independence by working for large medical corporations. Independent doctors just don't have the resources and time to be fighting behemoth entities like insurance companies and the government. 

You would think the five trillion dollar budget supplement that Congress is haggling over could include more money to treat the country's population. Unfortunately clean energy and immigration reform for illegal aliens seem to take precedence over caring for sick people in America. They do it because they know they can and we doctors won't put up much of a fight just as we have not done so for the last fifty years.

Nimbex Is Dead. Long Live Sugammadex

I've been a lifelong fan of cisatracurium (Nimbex). It has been my neuromuscular blocker of choice ever since residency. Why do I love it so much? Let me count the ways.

I've found that Nimbex is very predictable in its metabolism. I've been burned badly before when I used another agent like rocuronium on a patient with renal insufficiency and the patient had incomplete reversal at the end of the case that necessitated reintubation. Not good for the patient or your reputation as an anesthesiologist.

Thanks to its Hoffman elimination, I don't have to worry about a patient's kidney or liver function. The drug just metabolizes at a very steady and predictable manner. This is particularly important when a patient may have an unknown issue with their renal or hepatic functions and suddenly you're wondering why the patient isn't waking up. Nimbex is also very easy to reverse. Neostigmine easily takes care of the drug and the patient emerges quickly. 

Sure you can't use Nimbex for rapid sequence induction but that's okay. Most cases don't require RSI anyway. Due to Nimbex's property of predictable reversal, I've stuck with it long after many of my colleagues switched to roc. But now that's all changed thanks to the miracle of sugammadex.

Sugammadex (Bridion) is a drug invented specifically to reverse the paralysis induced by rocuronium. But it also works with other aminosteroid compounds like vecuronium. I feel it has revolutionized NMB reversal the way propofol transformed the induction of anesthesia.

First of all, Bridion works very fast. I'm always amazed by how quickly a patient starts moving after it is given, even if there is still a fair amount of inhalational agents on board.

Rocuronium no longer needs to be carefully titrated in order for it to be reversible at the end of the case. This is especially relevant in procedures that finish rapidly like in ENT. Those cases always present the conundrum of the need for deep paralysis followed by a quick emergence. There's no greater predicament for the anesthesiologist than staring down at a patient with zero muscle twitches and an impatient surgeon wanting to get his next case started ASAP. Prior to sugammadex there was no way to reverse a deeply paralyzed patient effectively.

One can give roc to anybody with sugammadex. Before, I was always leery of using Bridion in dialysis patients because there was always a small chance that the reversal agent would wear off before the body has cleared the NMB. I have yet to see that happen. It's just as easy to wake up a patient with renal failure as a patient with normal kidney functions.

With all these advantages, rocuronium and sugammadex have become the combo of choice in our department. Nimbex use has practically disappeared. Bridion is in such high demand that our pharmacy is complaining about the high cost of the drug. Whereas one 200 mg vial of sugammadex costs about $100, one vial of neostigmine costs $10, and that can be used with multiple patients. Our sugammadex costs are now disrupting our pharmacy's budget because people are using it so often. In addition, the anesthesiologists frequently use more than one vial per patient as some are now becoming too lazy to titrate their NMBs properly.

Are there costs that are saved because we use so much sugammadex? One has to consider the cost benefit analysis for a weak patient in PACU that requires reintubation. What are the costs of prolonged OR use because the patient took a longer time than anticipated to wake up? What is the cost of the psychological trauma in a patient who is gasping for breath because he is too weak to breathe? Or the patient who is too weak to protect his own airway when extubated too early and she aspirates, requiring hospitalization for pneumonia? All these should be taken into consideration when calculating the cost of using sugammadex.

Are there downsides to sugammadex? I've already mentioned the exorbitant price of the drug. That hopefully will come down in a few years when the drug goes off patent and generics flood the market.

Worse than that though is that I think sugammadex makes anesthesiologists lazy and they lose an essential skill. It's a real art to titrate paralytic agents properly so it can be reversed quickly at the end of a case. It's not something that can be taught in a book since each patient is unique in their ability to metabolize NMBs and every surgical case is different. With sugammadex, it doesn't matter at all. This is particularly detrimental to the anesthesia residents. It is just as easy to wake up a patient with zero twitches as one with four twitches. There is no learning there. Just give more sugammadex! But they didn't learn anything about the art of controlling anesthesia.

This is all part of the long standing trend of making anesthesia ever faster and easier to use. From halothane to desflurane. Pentathol to propofol. Pancuronium to rocuronium. If we're not careful, anesthesia could become too easy to administer. There are plenty of people who would love to get anesthesiologists out of their procedure rooms. From gastroenterologists to cardiologists, having one less physician in the room would be a dream come true. If anybody ever makes reversal agent for propofol, anesthesiologists would soon be unemployed.

How Much Do CRNAs Make And Why I'm Totally Jealous

US Bureau of Labor Statistics

The U.S. Bureau of Labor Statistics has released the numbers for the average salaries of CRNAs. You better sit down for this. They are quite astonishing. Remember when nurse anesthetists first broke into six figure incomes and everybody thought that was amazing? Well now they are doing much much better. According to the federal government, the average CRNA income was $189,190. However many CRNAs are doing even better than that. The nurses in Oregon are doing the best, with annual incomes of $236,540. As a matter of fact, CRNAs from eleven states earn over $200,000 per year. 

Why should I be jealous of this when the average income for anesthesiologists is twice as much? Medscape's annual physician compensation survey this year showed that anesthesiologists reported earning over $370,000 per year. I shouldn't be upset that somebody makes half my income, right?

Remember that CRNAs also have work schedules that resemble any other nurses in the hospital. They have a set schedule during the day that are practically inviolable. If they have a 12 hour shift, by golly they are only working 12 hours that day. We've had an instance where the case reached a critical period and because it happened right at the end of their shift, the anesthetist simply walked away from the patient and boogied their way to the parking lot. The anesthesiologist was the one who stayed behind to finish the case and make sure the patient was satisfactorily taken to the recovery room.

The anesthetists also have guaranteed morning and afternoon breaks along with a luxurious lunch break. We've had CRNAs literally quit because they didn't get their required lunch break one day. I've had days where I'm lucky to get a two minute run to the bathroom between cases. Getting a daily 30 minute lunch break is the stuff of fevered dreams.

CRNAs also don't work as many hours. Like other nurses, they work three days a week. Ours also don't take any calls or work any weekends. So with all that free time they can work at other locations and double their salaries if they so choose.

I've been told by CRNAs that not all of them have such schedules. Many of them work in remote or dangerous places unlike anesthesiologists who prefer to congregate in nicer locations. Some also take calls and work long unpredictable hours like anesthesiologists. But I suspect those work conditions are fairly uncommon and they always have the option of moving to a different job with all the perks.

So yes I'm jealous of the CRNAs. I know many anesthesiologists who would gladly take half their incomes for a work schedule that includes guaranteed breaks, guaranteed hours, three day work weeks, no calls or weekends, and the most important thing, little liability for any incident. I would say that's a fair trade. Wouldn't you agree?

Medicare Pays Anesthesiologists Less Than Plumbers

American doctors may be among the highest paid physicians in the world, but that wouldn't include anesthesiologist who receive their patient reimbursements through government healthcare. 

In an interview in Becker's ASC Review, Dr. Scott Harper, Assistant Professor of the Department of Anesthesiology and Perioperative Medicine at the University of Alabama Birmingham, noted that Medicare pays anesthesiologists the equivalent of $45 an hour for their services. That's less than what your local plumber charges you to come in and look at your clogged toilet.

With new federal laws prohibiting doctors from balance billing, which is charging patients for the balance of a medical bill not fully paid for by insurance, the problem is only getting worse. Insurance companies have no incentive to reimburse doctors fairly because they don't have to deal with irate customers who have to pay out of pocket anymore. Now these companies are canceling contracts and lowering thier reimbursement rates, getting closer to Medicare rates.

Anesthesiologists already have to put with Medicare payments that are only about one third of private insurance reimbursements. Medicaid, which is government insurance for the poor and indigent, pays even less. The wide expansion of stingy Medicaid is how the Affordable Care Act aka Obamacare is able to insure millions more people, on the backs of doctors and hospitals. 

If the private insurance payments keep going lower, anesthesia private practice will be a thing of the past. We will all become hospital employees like emergency medicine or pathologists. Only hospitals will have the leverage to negotiate fair contracts with these behemoth insurance corporations. Individual anesthesiologists will not be able to sustain a viable business model with payments that rival the plumbing profession because plumbers don't have to pay back six figure student loans and five figure malpractice insurance premiums as part of their business expenses. 

Are American Doctors Overpaid?

Here we go again--another article that compares physician incomes around the world. It's not surprising that they almost always show American doctors are paid more than any other country's, seeming to confirm the belief that the US healthcare system is too expensive because of greedy doctors. However, there is a big caveat in any of these international physician income comparisons. We will get to that. This time, the income survey comes to us courtesy of Medscape. 

Medscape International Physician Compensation Survey

Medscape's study, in a survey of thousands of doctors around the world, once again shows American doctors are paid much more than anybody else, with an average income of $316,000. This is almost twice as much as second place Germany ($183,000) and United Kingdom ($138,000). Mexican physicians earned the least in this survey, averaging only $12,000.

American primary care doctors made about the same as their German counterparts, $242,000 to $200,000. But that is still twice as much as the UK, $122,000. Our specialists made far more than anywhere else, with male specialists earning $376,000. Meanwhile the German specialists made $194,000 and the UK specialists earned $155,000. It's plain that the Europeans place more of an emphasis on compensating their primary care doctors rather than their specialists like we do here.

Since American doctors make the most money, it goes to reason that our net worth is far higher than anyone else's. American physicians' net worths average $1,742,000. The UK doctors' net worths average only a third of Americans, $657,000. Germans are even lower, $441,000.

What are the debts that physicians have to carry? As expected, doctors around the world have mortgage payments to make and car loans to pay off. No surprise there. What is unfortunately not covered in the survey are the expenses that American doctors are faced with and makes our system uniquely expensive and burdensome.

American doctors carry a huge amount of student loan debt when they graduate from medical school. That expense is carried through the three to seven year residency and fellowship programs when there is not enough income to pay back the loan. Therefore doctors here are burdened with a giant fiscal deficit when they first begin their practices. Perhaps this important aspect of American medical economics is not asked of our international counterparts because their doctors are usually trained for free or with just nominal fees. 

International physicians also don't have to worry as much about medical malpractice lawsuits. American doctors face annual five to six figure malpractice insurance expenses that our global compatriots don't even have to think about. 

Yes American doctors make more money than anywhere else in the world. But we also have the highest education debts and the highest insurance expenses. You subtract these payments and our incomes aren't so disparate after all.

Past President Of The Kansas Society Of Anesthesiologists Indicted For Fraud

Scott T. Roethle, MD

This is totally effing unbelievable. Dr. Scott T. Roethle, MD, an anesthesiologist residing in the state of Kansas, has been indicted by a federal grand jury for healthcare fraud. What makes this case so difficult to fathom is that Dr. Roethle is a past president of the Kansas Society of Anesthesiologists. He has also served as a delegate to the ASA and an executive director of the Kansas City Medical Society. In addition, he appears to be involved in multiple start up companies according to his bio. 

According to the indictment, Dr. Roethle was charged with receiving kickbacks worth $674,000 for writing prescriptions for patients he never saw or documented. He would charge $30 per prescription. His orders were usually for orthopedic devices or lab tests that the patients said they never asked for. This fraud carried on from 2017 to 2020. Medicare says they lost $26 million for these phony prescriptions. He has medical licenses in 22 states and thus could write prescriptions for patients all over the country. 

I'd like to think that there is more than one Scott T. Roethle who is an anesthesiologist in Kansas. I would love to be proven wrong and chalk this up as a mistaken identity. But Google only found one Scott Roethle, MD and the ASA's own membership directory showed only a single anesthesiologist in the whole country by this name. In a physician review website, Dr. Scott Roethle is listed as having ten disciplinary actions taken against him by different medical boards across the country. How do doctors continue to find hospitals who will hire them when they've got so much baggage? 

Dr. Roethle, good luck with your court case. I hope they throw you in the slammer and take away your medical license forever for besmirching the reputations of anesthesiologists everywhere. Was your life really worth a measly $30 per prescription or $674,000 over four years? Any decent anesthesiologist can make much more than that working an honest job.

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.

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.