War With CRNA's At The VA

With exquisite timing, right in the middle of National CRNA Week, the president of the American Society of Anesthesiologists sent a blistering email to ASA members lambasting the Veterans Administration for not taking seriously concerns about CRNA's practicing independently.

The Spokesman-Review article that Randall M. Clark, MD, FASA referred to describes attempts by anesthesiologists at the VA hospitals to use a whistleblower program called "Stop the Line" to report unsafe patient care conditions outside the normal chain of command. This is in response to the VA allowing CRNA's to practice independently at the nation's veterans hospitals. 

The anesthesiologists have used "Stop the Line" four times but have received zero response from the department. When news of these reports were discovered, the nurse anesthetists were not terribly happy. They threatened work stoppages and slowdowns in retaliation. 

Predictably the CRNA's are framing this as an access issue. Without their presence, they warn that veterans will have less access to lifesaving surgery and face major delays in care. 

Frankly, I find this latest skirmish between anesthesiologists and CRNA's pointless. If the ASA is trying to prevent CRNA's from practicing independently, that horse left the barn years ago. The Covid pandemic opened the door to the nurses practicing without physician supervision nationwide during the Trump Administration and the nurse-friendly Biden Administration is unlikely to change that. 

Once nurse anesthetists have a taste of independent practice, it is very difficult to force them back into a care team model. It's the same feeling when anesthesia residents finally become attendings--nobody wants to have somebody looking over their shoulder when they've had the opportunity to make their own decisions about patient care without being second-guessed.

At this point, it really is futile to try to return to the care team model where CRNA's have already practiced independently. The best outcome for the ASA is a tenuous detente where we maintain the physician supervision that is still in place and attempt to not lose any more ground. 

ICE or BEV With Your Blizzard?

Just a quick introduction. I don't own a Tesla or any electric vehicles but I found this information very educational as we head off into our battery powered future.

Remember that blizzard in Virginia on January 4 that made national headlines? The state highway system came to a complete stop, trapping travelers on the road for nearly 24 hours. A truck driver tweeted that a Tesla driver knocked on his cab window and asked him for a blanket to keep his kids warm. He wondered what would happen when the Tesla ran out of juice. Would that poor family freeze to death as they waited futilely for a rescue?

That tweet became major news. A Washington Post op-ed (paywall) worried about what will happen when the country's transportation goes completely battery electric vehicles (BEV) only. Electric cars are much more difficult to get off the road when they run out of power compared to internal combustion engine (ICE) powered autos. You just need to add a couple of gallons of fuel into the tank and the car is good to go. 

The good folks at Car and Driver decided to run a little experiment with this scenario. They took a 2019 Tesla Model 3 Long Range and idled it next to a 2022 Hyundai Sonata N to see which car would last longer. The average outside temperature during this test was 15F though it got as low as 9F. They set both cars' climate controls to 65F.

Well guess what--the Tesla could last nearly as long as the Hyundai in this demonstration. The Tesla has the advantage of Camp Mode which turns off every part of the car except for climate control when the car is in park. The Hyundai's engine idled at full power the entire time. The Tesla started out with 98% charge on the battery and ran for 37 hours straight, leaving about 17% charge or 50 miles remaining. In theory, it could have continued for a total of 45.1 hours. The Hyundai's engine was stopped after 24 hours but they calculated it would have gone a total of 51.8 hours with its 16 gallon gas tank.

US Dept. of Energy

The Tesla was able to achieve this because BEV's have more efficient motors. The Model 3 used up 1.6 kWh per hour while the Hyundai burned through 10.6 kWh per hour. Another reason BEV's are safer in unexpected emergencies is because electric vehicles are more likely to have a full "tank" every time they go on the road since most owners charge their cars at home overnight. Meanwhile, ICE owners don't usually fill up their cars until well under half-tank. Good luck trying to find a gas station when there is an emergency evacuation order. 

So next time you snicker at the BEV driver and their worries about range anxiety, just remember that they are more likely to have a full tank in their car than what you're currently driving. In fact, when was the last time you even saw a BEV stranded on the side of the road because they ran out of juice? In Los Angeles, cars are stranded on the sides of the freeways every day because they ran out of gas.

By the way, that truck driver later tweeted that the Tesla family did just fine when the Virginia highway finally opened up. They still had 18% charge on their Tesla when they finally made it off the road to the nearest Supercharger station. I'd be more worried about trying to find a bathroom in a blizzard than getting stuck long enough for an electric car to lose all of its battery power while trying to stay warm. 

Anesthesiologist Who Killed Surgeon Goes To Jail

Just a follow up from a story from back in 2017. Dr. Stephen Kyosung Kim was charged with murder when his patient, Dr. Mark Greenspan, a 71 year old orthopedic surgeon, died after surgery. Blood and urine drug tests showed Dr. Kim had Demerol and Fentanyl in his system at the time of the incident.

Dr. Kim admitted that he had stolen Demerol 50 mg from the Rodeo Drive Plastic Surgery Center in Beverly Hills that morning. He administered a general anesthetic to Dr. Greenspan even though they had discussed using regional anesthesia. Dr. Kim then left the operating room to give himself Demerol and Toradol. He subsequently fell down and hit his head but came back to the OR to finish the case. While in recovery, Dr. Kim overdosed Dr. Greenspan with Demerol and the patient became apneic and went into cardiac arrest. Dr. Kim tried multiple times to intubate Dr. Greenspan but was not successful and the surgeon died. 

The anesthesiologist admitted to the prosecutors that he had a drug addiction and had taken narcotics over 150 times while at work. His medical license was subsequently revoked. After four years, Dr. Kim pleaded guilty on December 2021 to manslaughter and was immediately taken to jail. It is expected that he will return to court in December 2023 and be sentenced to two years of jail time which he will have already served. 

This tragic case once again illustrates the unfortunate link between anesthesiology and drug addiction. It's well known that anesthesiologists have one of the highest incidents of addiction in medicine. I have unfortunately covered multiple incidents of drug addiction among anesthesiologists, including here and here. Eighty percent of US anesthesiology residencies have had at least one drug impaired resident. Almost a fifth of all residencies have experienced the death of a resident due to drug overdose. Male anesthesiologists are considered the highest risk for drug addiction and suicide among all physicians. A deadly combination of high stress work and easy access to narcotics makes drug addiction an ever-present risk of working in the field. If you suspect an anesthesia colleague may have an addiction problem, say something. It may save his, and his patients', lives.

Doctors Are Vassals Of The State

If there is any doubt that doctors do not have autonomy in their workplace, recent court decisions regarding vaccine mandates have proven it. A couple of weeks ago, The Supreme Court ruled that the Biden Administration's vaccine mandate for all employers with more than 100 employees was unconstitutional. Congress never authorized this action and the executive branch doesn't have that authority no matter how the administration contorted the laws. Then last week a US District Court in Texas found that vaccine mandates for federal employees were also unconstitutional, again citing overreach of the administration in their use of federal laws. 

So does anybody in the US need to get the vaccine? Large employers cannot force their employees to take the coronavirus vaccine. Federal employees also cannot be required to accept the vaccine. Small employers have not had any federal mandates for their employees to receive it or get fired. The only federal mandate for vaccines that was accepted by the Supreme Court was for doctors, nurses, and all medical industry who accept Medicare and Medicaid reimbursements. Yup, it's all about the money.

The reason the Centers for Medicare and Medicaid Services was able to force healthcare workers to get jabs despite deep concerns among large groups of the population, including doctors and nurses, is that there is a clause in the Medicare laws that states the government can do whatever it takes to make sure the programs function smoothly. Therefore it gives the Secretary of Health and Human Services broad authority to make sure they run uninterrupted, which in this case means healthcare workers who accept money from CMS do not get sick from Covid and they do not transmit the virus to their patients.

I am not a vaccine skeptic. I got my first shot the first week that it was available at our hospital. I have since been boosted. I just find it frustrating that even though physicians are some of the most highly educated people in the country, we are under the boot of the federal government with little recourse for dissent. 

Besides vaccine mandates, other government rules keep doctors on a very short leash. EMTALA laws tell us who we can and cannot treat (spoiler: we have to treat everybody). HIPAA laws decide what we're allowed say. Through the Joint Commission, they dictate what we can wear, where we can eat, how we dispose of trash, and essentially all functions of a healthcare facility. Doctors are threatened with loss of their livelihoods if they exercise their freedom of speech to talk about their skepticism of the consensus. Our incomes are based on the whims of the federal government where they threaten to cut reimbursements every year. Medicare reductions of 1-2% are considered a win for the healthcare community even though inflation is soaring all around us. 

Do physicians have any constitutional rights left? When physicians first got into bed with the federal government, many were anxious about cozying up with such a large entity. We were assured it would be just a small program, costing only a few billion dollars each year. Besides, shouldn't doctors just suck it up so the elderly and destitute can receive their rights to decent healthcare? Half a century later, as the programs expand their eligibilities and the demographics of the population has changed, Medicare and Medicaid enrollment are now over 100 million people. 

The medical community essentially cannot function without government money. With so little leverage, is it any wonder the Congress can so easily talk about cutting medical reimbursements each year and face almost no backlash? We are required to follow rules that would have a private employer facing an ACLU lawsuit within five minutes. If we're going to ride the bull, we're going to have to expect to get gored.

Doctors Should Make Passive Income A Priority

Doctors are always complaining about being overworked and underpaid. They dream of accomplishing the gospel of FIRE, financial independence/retire early. Yet few physicians are able to execute that plan because it calls for massive financial deprivation (saving 50% or more of your income) and social hardships (no fancy cars or vacations to pay off debt). All this to retire by the age of 50 and worry whether your portfolio will last the next 40 years. 

Yet you regularly read news of people who are able to parlay their smarts and sweat equity into substantial passive income. There are the two children from Dallas, 14 and 9, who are now making $30,000 per month mining cryptocurrency. Ishaan Thakur and his younger sister Aanya started by converting their gaming computer to mine ether after watching YouTube videos. The first day they made $3. Just like that they made money from thin air. Satisfied with their results, they added more processors and made $1000 their first month. As they made more crypto income they kept adding more processors. In four months they were making $36,000 per month! Their only expense is paying utilities to a data center which is about $3000 per month. These kids are doing the ultimate FIRE and could retire before they finish high school.

Then there is this story of an ex-pastor and his wife who are now living comfortably on their rental income generated from 30 properties. They started with nothing and were able to accomplish this feat in two years. (Business Insider subscription required.) The young couple were living paycheck to paycheck in Denver when their daughter had a medical emergency. They realized how little safety net they had. So they started watching house flipping shows on HGTV and read real estate investment books. They sold their house in pricey Denver and bought a house in St. Louis, saving hundreds of thousands of dollars. The family began with one house where they did all their own rehab to save money. Before long they were renting out the property, earning a small income. With that cash flow they kept buying more houses, fixing them up, and renting them out. Within two months they were renting out three properties making $1000 per month. Now less than two years later they have thirty properties and live comfortably on their rental income.

It seems like doctors should be able to generate this level of passive income easily with our high levels of education and large salaries to start. These people did not go to school as long as us and basically started out with nothing but their smarts and hard work. Why can't doctors routinely do the same thing?

Is it because with our high salaries it takes a lot of passive income to move the needle and so many doctors don't think it's a worthwhile endeavor? If you're making $4000 per month and generate an extra $1000 per month renting houses, you've substantially increased your earnings. However if you're earning $40,000 per month as a doctor, making another $1000 per month doesn't seem worth the trouble.

Or maybe it's because we're too busy to think about starting a second income stream. When you're working sixty hours per week, the last thing you want to worry about is going to a rental to fix a leaky toilet after getting off work at 7:00 PM. If you hire somebody to do all the repairs then that destroys your cash flow and you wind up losing money on that property. So perhaps doctors would rather spend their off hours resting at home than running off to fix a tenant's complaints.

Maybe our education narrows our mental focus. All those years of medical school blinds us to business opportunities when they present themselves because we're concentrating so much on running a medical practice. Any thought about earning extra money invariably is medically related, such as becoming an expert witness for malpractice cases or getting honorariums giving talks for pharmaceutical companies. We should broaden our scope and look beyond the medical industrial complex. With our ample incomes, why can't doctors also buy a bunch of crypto miners and start generating crypto money? If two children can do it, surely physicians with over a decade of higher education can too. 

Next time, before buying that new Mercedes to replace the three year old Mercedes, maybe think about keeping the old car and use that money for creating a meaningful change in your life. Plenty of people are able to create wealth for themselves with far less education and cash flow. Perhaps we should get on this gravy train too.

Anesthesiologists Are Better Than Nurses At Rapid Response Resuscitation

In a presentation made at the just finished ASA annual conference in San Diego, Faith Factora, MD of the Cleveland Clinic showed data that pointed to anesthesiologist-led rapid response teams produced better outcomes than ones that were led by nurses. 

She examined data from 2010-2012 when nurses led rapid response teams vs 2012-2018 when anesthesiologists were in charge. There were 1437 cardiac arrests and 7727 deaths involved during that time. Cardiac arrests and deaths were found to be lower when anesthesiologists were involved in the care of the patients.

Of course having an anesthesiologist available to go to all the rapid responses in the hospital can become very expensive and it ties up a scarce anesthesiologist from working in the operating room. However it may be worthwhile in cases where the patient is having complex problems like a cardiac arrest vs. somebody who is having a vasovagal syncopal episode.

The irony is that most anesthesiologists would probably rather not be leading rapid response teams in the hospital. We very much prefer to be left alone in the OR's and devote our full attention to the one patient on the table, not running all over the hospital putting out fires. If we could pawn that job off to nurses and have hospitalists lead the RRT's then most of us will be okay with that arrangement. 

Happy Dodransbicentennial Ether Day!

Morton inhaler

I did not make up that word. Dodransbicentennial means 175th and today is the 175th anniversary of the first public demonstration of ether. It's a real word because Wikipedia says so and Wikipedia is the source of all knowledge in the world now.

On October 16, 1846, William Morton showed how ether can induce unconsciousness in a patient undergoing surgery at the Massachusetts General Hospital. The event was published in the New England Journal of Medicine and recently voted the most important article in the history of the publication. The operating room where the event took place is now called the Ether Dome.

So if you need another reason to party this weekend, raise a cold one to Dr. Morton and the invention of anesthesia. That was truly a seminal moment in medicine and I wouldn't be exaggerating to say that it changed the course of humanity forever. For more information, check out the Wood Library-Museum of Anesthesiology. 

Anti-Vax UCLA Anesthesiologist Removed From Hospital

UCLA anesthesiologist Christopher B. Rake, MD was escorted out of UCLA Medical Center for refusing to take the Covid vaccine. He filmed himself as he was led out of the building.  As he's leaving, he says to the camera, "This is what happens when you stand up for freedom. This is the price you have to pay sometimes. I'm willing to lose everything, my job, paycheck, freedom, even my life. United we stand, divided we fall." The hospital has placed him on unpaid administrative leave, which is just fancy words for getting fired. 

Dr. Rake, NOT an ASA member, graduated from Tufts University School of Medicine in 2004 and completed his residency at UCLA. He has been a prominent spokesman for the anti-vax movement in Southern California. He was filmed in Santa Monica at a rally against the vaccine and talking about Q-Anon. He is so adamant against the vaccine mandate that he hasn't even tried to use a medical or religious exemption. 

One one hand, he can be admired for standing up so strongly for his principles. He's willing to lose his reputation and livelihood for something he truly believes in. For most of us, it is far easier to just give in to these mandates and take the shot. It's not that different from the flu vaccine that all healthcare workers in LA County are required to get each year. Get the shot or get fired. 

However, I wonder what Dr. Rake thinks about all the other rules we willingly follow to improve our lives and those of others. What about childhood vaccinations for measles, mumps, rubella, tetanus, etc.? How about seatbelt laws? Rules against driving while under the influence? Airport security inspections? All these things are personally uncomfortable or restrictive. Yet we tolerate them because we know they help the greater good.

Good luck to Dr. Rake finding another anesthesia job. He will probably have to move out of California since we have some of the strictest rules against anti-vaxxers in the country. However, hospitals all over the country are requiring their healthcare workers to get vaccinated so it won't be an easy job search. 

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.