The Ether Way

Sux Kills... or does it?

A trial is underway in Reno Nv of a critical care nurse accused of injecting his wife with succinylcholine as a means of killing her. Apparently, he's not the first to think of this, although it seems as if the FBI toxicology lab can measure succinylcholine and succinylmonocholine, a metabolite, in urine post mortem. And they testified that it was present. The Las Vegas Review Journal has a report. A Reno report has a PULMONOLGIST claiming that Sux injected in the buttocks could not cause death. And to think, I've worried in the OR all these years...

The Preop interview and personal salvation

 

Every working morning for twenty years it’s the same.  A funny hesitation, a mild tendency to procrastinate. Do I dislike my practice? No. I love to give anesthetics, the messier the better. From time to time, I toyed with why I should feel this reticence, poking at it in my mind the way a person will poke at something caught between their teeth. And then one day, I happened across a passage from William Carlos Williams’ auto-biography. Williams was a practitioner in Patterson NJ back in the early part of the century, a brilliant poet, and a clear eyed observer of his practice and the human condition. He wrote:

I would start out on my morning calls after only a few hours' sleep, sit in front of some house waiting to get the courage to climb the steps and push the front door bell. But once I saw the patient all that would disappear. In a flash the details of the case would begin to formulate themselves into a recognizable outline...Along with that the patient himself would shape up into something that called for attention, his peculiarities, her reticences or candors. And though I might be attracted or repelled, the professional attitude which every physician must call on would steady me, dictate the terms on which I was to proceed.

And I thought, “that’s it!” Every working day, I take lives into my hands. Now that sounds corny and melodramatic. But it’s not. We don’t wander around like actors in some TV show, each step imbued with “terrible purpose.” We walk around worrying about our kids report cards and our leaky plumbing, but that other thing is always there not very far back in our minds, like the thanksgiving turkey you can’t smell roasting after a few minutes, but if you go outside and come back in, the odor is overwhelming. Each morning, I - we all, dive in to the lives of other people - suffering, frightened, hopeful people, and we assume virtually total responsibility for their well being. We give them whatever informed consent we feel we must, and then we reassure them; with our manner, with our matter-of-factness, we reassure them that we are in control. Now, I know bus drivers, pilots, taxi drivers, teachers; they all take responsibility for the well being of others. But for us, it's different; maybe it's because the patients are so scared and vulnerable, or maybe it's the part where we put them into drug-induced comas... Then again, maybe it's just being around surgeons. That assumption of total responsibility is a weighty emotional burden.

Long ago, my preop interview became less pre-flight check-list and more gut-check and sniffing for smoke. (I'll write more about sniffing for smoke in another post) Paradoxically perhaps, the most important thing to me is to bond to the patient; it's the second part of that WCW observation. I might do eight or ten cases in a day; the consequence of treating my work as a technical exercise is the risk of  inattention and the sort of boredom that drives the desperate discontent that I see in so many of my colleagues.

I spend a minute or two, sometimes more, at the start of each pre-op just SEEING THE PERSON. If the planned operation is in any way serious, I start by offering my condolences that the patient needs to undergo the ordeal at all. People are frequently taken aback by this; patients sometimes tell me that I’m the only caregiver in their experience that has stopped to offer sympathy (could this be possible!?); occasionally they cry. I get a few thank you notes. (For caring?) I mostly do this as a way to dope-slap myself into being sure I’m not just “passing gas.” And not just because I don't think I could get good outcomes by just “passing gas;” but because if I were just “passing gas” for thirty years, I'd come to hate it, or hate medicine, or hate myself, or hate the world…

As the Buddha said, "Work out your own salvation with diligence."

This, then, is part of mine.

Surgery with a warranty?

An article in the New York times  discussess the new HHS reporting on mortality for cardiovascular admissions, (among other things). It was clear that the executive branch was not too enthusiastic in the first place. Not clear why they relented, but the link to the HHS site containing the  "report" takes you to a  fragmented database query screen that after some significant massaging gave me the reassuring news that none of the Nevada Hospitals were any worse (or better) than the other 4400+ average hospitals in the country. No "shame" list of the worst, no "praise" list of the best. You gotta ask the right question. Fifteen years ago, when I was Chief of Staff, every hospital in town had much better data on outcomes than has ever seen the light of day. It is in everyone's commercial interest to advertise the "perception of quality" rather than compete on outcomes and measurable quality. Data has a pesky way of getting in the way; just ask GM.

There was another thing in the paper a while back; Geisinger clinic in PA is marketing surgery with a warranty; 90 days fixed price, all costs included CV surgery. Bring-backs - 0$. Sternal debridements - 0$ Pacers/AICDs - 0$(?) Don't know that one. Presuming they hike their doctor reimbursement appropriately, that's a nice way to align everyone around efficient, good outcomes. Mike and Rob, what do you think?

Wu Wei and the Anesthesia life

In my academic time, it was said that anesthesiologists came in two types; doormats and land mines. I was, by nature, a land mine, and suffered the fate of the land mine; I blew up. Early on in my career,  then co-faculty mate and now co-author, Andy Kofke watched me throw a chair through a wall in frustration over bad ICU care. (It didn't help me or the patient...) My colleagues over the years knew that my frustration was just, but they also knew (which I didn't) that my emotional response was not functional. And so, emotionally spent after some years, I wandered out to private practice, and the solace of a bigger paycheck.

By comparison, the doormats of my day were pathetic puny creatures, who did what they were told to do by the surgeons, right or wrong, and hid behind the "blood-brain barrier" (that's the ether screen or sterile drape separating anesthesia from surgery for the uninformed). They would frequently take out their frustration by bullying their subordinates/trainees or would be detached from it all; "it's just a job, man." They marched through their days in quiet desperation. Many of them are still doing so.

Between doormat and land mine there is a third way. It is Wu Wei. Wu Wei is an ancient Taoist concept.The literal translation is "do nothing," although a better translation would be "Don't force matters." If it seems trite, it is only because the concept is so ingrained into our awareness by countless new age imitations, who don't quite get it right (and neither will I here, in these few words).  Every contented senior anesthesiologist understands Wu Wei, although virtually none know that it is called that by the Taoists. I stumbled upon it as a realization (rather than just an intellectual concept) quite by accident a decade ago. Wu Wei is not simply "going with the flow." Wu Wei is to be aligned with the nature of things; it is to be as the dripping water wearing away the stone. It is yielding when pushed, and advancing when the way is clear. It is to flow with events, and to gently guide them when appropriate. For you golfers out there, the golf grip illustrates the principle of Wu Wei; too tight and your swing sucks, too loose, and your club goes sailing.  To attempt to force events out of their natural tempo and order only brings frustration and disharmony - stress.

You know when you have it right when you are in a state of grace. When the anesthetic "feels good" and it seems and looks effortless. When the circulator looks at you and says, "you make it look easy,' dude you're one with the Tao... Supervising residents (or CRNA's) never goes well until one attains something like Wu Wei. My best colleagues and professors had it; the light firm touch, calibrated to the needs of the pupil or nursing colleague. Many of my future entries will, in one way or another, be about attaining this state of grace during different phases of a case...or career...or life.

Now, when my surgeons start to rant and fuss about slow turnover times, I tell them about Wu Wei and encourage them to go gently. It never works, for they are surgeons. But it always helps me to remember that barking, frustrated surgeons and slow turnovers are part of the natural order... and I smile and remember who I was.

Narcotics Prescribers Beware...

An example of public whipsaw between pain policy and the "WAR ON DRUGS" An article in the New York TImes Sunday Magazine titled "When is a Pain Doctor a Drug Pusher?"

The Academic Struggle

1. The stature of medicine has changed relative to other career choices.  Highly motivated individuals choose medicine as a career much less frequently than they did when we were younger.  Medicine, which is increasingly hobbled by regulation and outside interference, is much less attractive than either business or law.  Go-getters have gone into other professions.

2. The hey-day of NIH funding in the 1970s and 1980s - when the NIH had more money than good research to fund - is the baseline that academic institutions utilize when shaping their goals and expectations for NIH funding.  The pie has gotten smaller, the quality of the work has gotten substantially better, and the number of people competing for funding has increased enormously.  The award rate is low - 10% - and likely to go down, not up, for the foreseeable future. Many believe that 'outsiders' may face insuperable obstacles to obtaining NIH funding.  Regardless, I believe that academic chairs - in all specialties - are well advised to not count upon the NIH for funding.
    Importantly, the science funded by the NIH is increasingly highly specialized. MDs are less and less competitive for the funding in the few areas that are not highly specialized.  The sad truth is that most people who obtain PhDs in biology cannot successfully compete for these funds. Indeed, the basic science has become so specialized that the people executing it may not appreciate its clinical ramifications.  Only a small subset of clinicians have the competence to (and do) read the associated basic science literature.  I remain astonished at how little I hear about P2X3, ASICs, C-Jun kinase, and JNK in our world....    The sad truth is that the manipulation of these receptors should be within the provenance of anesthesia, and it’s not.

3. There is no NIH set-aside money for anesthesia.  All of the higher-ups understand this, but it bears mention.  Why? Because even in domains where there is set-aside money (e.g. trauma), there is no longer sufficient money to keep everyone who wants to be or should be funded in money..... which is why the number of NIH funded MDs continues to decline, and is approaching the number of NIH funded anesthesiologists...
    I wouldn't bank the future on NIH  money though.  As someone who worked with an NHLBI funded researcher as a fellow, I know from direct personal experience how the HIV budget was doubled every year while the NIH budget stayed flat. 

4. The NIH payscale continues to lose ground to private practice dollars.  This is especially true in anesthesia, but is also a problem that plagues all academic medical specialties.  The sad truth is that the only way that the NIH has been able to retain investigators at the NIH is to allow them  to moonlight for the pharmaceutical industry in droves.  Attempts to control and manage this have been unsuccessful, as any ‘reasonable’ policy would require them to turn out the lights on an empty campus.

5. The proportion of students and residents who are married and have children has grown (or seems to have) over the past 20 years.  I attribute this to both the change in the kind of person who goes into medicine and may be a consequence of the HIV epidemic (which has pushed those who plan to marry to do so earlier than they once did). As a group, these people are less likely to arrive early and stay late.  This significantly diminishes their development as academics.  It has also generated the best predictor of academic success I now have - which is seeing someone here at 1800 doing non-clinical work.

6. Geographical Isolation.  As a group, we no longer practice in a very restricted geographic area, but are sprawled across an enormous complex.  This frustrates all efforts to assemble the group to a far greater degree than anyone appreciates.  Whereas it was once possible to have everyone assemble in the chairman's office or the break room for a quick 30 minute meeting, more than half of our faculty are now engaged in clinical activity that is a quarter mile from these locations.  Mid-day assembly is a terrific advantage to those departments which can sustain it.  Medicine grand rounds is a mid-day event- everyone can make it (attendance is not always great).  The price? You push some work later into the day... and stay late that day....  These mid-day meetings are an important source of stimulation and positive reinforcement from which procedure-driven medical specialties are increasingly isolated.

7. The 80 hour mindset will be a substantial obstacle for our junior faculty to overcome.  That this is in place for Gen-X will make overcoming it that much harder.

8. The regulatory burden of research has grown enormously in the past few years.  Whether your interest is in conducting human studies or animal studies, the requirements for training in 1. the protection of human subjects 2. HIPAA, and 3. Animal use and care have escalated substantially (animals still have better protection than humans).  It is no longer easy for someone competent to conduct a study to execute the necessary paperwork - they have to complete a variety of courses and training intended to increase their competence.  At most academic institutions, the IRB has become one of its largest bureaucracies, and a large number of people at these institutions now find at least part-time employment in generating the documentation needed to comply with IRB requirements.  All of this has increased the friction to doing little studies, and the start-up costs for anyone who is interested in participating in them.  One of the reasons why US based research is shifting in the direction of endless surveys and into safety is because these domains are substantially less encumbered by these regulations.  This is important - we still have faculty who are asking questions and following the path of least resistance to generate insight.  If  you haven’t found all of the obstacles yet, there is growing pressure to register every clinical trial.

9. The teaching rule.  In every other medical specialty, academics can generate income while providing clinical service at a rate which surpasses what they could in private practice.  Full professors of medicine typically earn as much or more than their private practice counterparts.  In anesthesia, a career in academia entails an absolute decline in lifetime earnings that can never be offset.  While this restricts academia to those who truly feel the call, it also prevents residents with substantial medical school debt from choosing it as a path, no matter how strongly the sirens might sing to them.

Anesthesia and Flying

My flying friends tell me that administering anesthesia is like flying a plane. I don’t know myself, since the only flying I’ve ever done is with radio controlled gas powered planes, (with pretty pathetic results.) I think my friends may be a bit fanciful in their comparisons, since I see them running out on the weekend to fly their Cessnas, (surgeons fly Beech or Cirrus) not coming to the OR to do an extra case…

When I trained, we spent quite a bit of time reviewing National Transportation Safety Board crash investigations, and my pilot/professor/gurus always seemed to find the take home point in those flying mishaps. I still have my tutor George Bush’s (the Wisconsin Professor, and a personal hero of mine) voice in my ear admonishing me to “stay ahead of the plane,” in the OR, by which he meant, don’t just react to events, look ahead and set things up as the case proceeds.

Along these lines, I recommend an interesting book for anesthesiologists; “Deep Survival “ by Laurence Gonzales. The first chapter deals with carrier deck flight ops, and the whole is a fascinating neuro-biological study with obvious applicability to anesthesia (both the giving and receiving).   

My friends at the University of Chicago who study critical events, like to compare anesthesia, the nuclear power industry, and flight ops. This topic is not something I feel personally qualified to opine about, but my friend and co-author Mike O’Connor is, and I hope he will discuss this issue in future posts.

So, last year, a retired commercial aviation pilot asked me during the preo-op interview how much experience I had. I figured I work 45 hours a week in the OR actually giving anesthetics, 48 weeks a year. I’ve been doing so for twenty years in Las Vegas. Allowing myself  a conservative 5000 hours for my years in training and as an assistant professor, that comes to 48,200 hours. Giving flying a generous 2:1 discount for the sake of argument, that’s still over 24000 hours of equivalent “flight time”; more than most top-tier career commercial pilots.

That puts me, and my like-aged colleagues in a pretty remarkable experiential position, and it shows clinically. At the risk of offending the anesthesia gods, my anesthesia partners, all in their fifties, don’t get in much trouble in the OR, and are pretty good (and comfortable) at getting out of the trouble that our surgeon-clients occasionally wander us (our patients really) into.  Besides the previous Posts concerning controlled studies vs. experience, there are other implications to this flying/anesthetics metaphor, which I intend to explore in future posts. I note, for instance, that we all carry a wary, but essentially un-emotional attitude into the OR regarding the technical aspects of what we do. While I might be sad about the misfortune of a young trauma or cancer patient, It’s been a long time since I was worried or anxious about a clinical situation. In fact, if I were the least bit anxious about what I was expecting to do, I would consider it an emotional manifestation of my judgment that for whatever reason I wasn’t up to the task.

I love reading what Kofke and O'Connor are writing. I am experiential; they are experiential...and intellectual. If things go well for me, I expect to spend another 20,000 hours in the OR before I'm done. I hope I can continue to improve to the end...

A Wonderful An(a)esthesia Blog

I wandered into this blog on my perpetual hunt for anesthesia sites. The Westmead Anaesthesia Blog, which is in a sort of a journal club format from Sydney has great article selection, great graphics, and is a perfect idea... Love those Aussies!

Quality is the Common Thread

My group, Anesthesia Medical Consultants provides care predominately for the Spectrum Health System.  Both of these entities are the result of merger processes which took place eight years ago.  Both AMC and Spectrum are now the 800 pound Gorillas for west Michigan.

Many services in the system are dominated by large, single specialty groups like ours.  The system would like these groups to work more closely with it and each other in strategic planning, expansion of the referral base, common electronic record, integrated clinical pathways and, of course, cost control.  The docs want little of it.  They believe that the administration wants nothing more than control of their practices and revenues.  Do we need all that when we are busy and providing good care?

Of course some of the specialties would like to expand or develop new clinical programs but they believe that the system should provide the facilities and get out of the way.  So the conflict is a desire for clinical growth with both sides unwilling to cede control of the process.

A couple of weeks ago I was reading the STS/SCA guideline on “Perioperative Blood Transfusion and Blood Conservation in Cardiac Surgery”, a much needed and very good piece of work. Section seven addresses using a multidisciplinary approach to develop institutional transfusion guidelines and point of care testing. How many places have done that?  Section eight discusses Total Quality Management (TQM) in blood transfusion and conservation.  For those of you who have developed guidelines have you instituted TQM?  These two recommendations help take you from being a good shop to a great shop, in my opinion.

So what is the common thread between professional distrust and guideline/TQM development?

Guidelines, point of care testing and TQM require a level of multidisciplinary commitment and participation that rarely exists in a private practice environment.  The doc’s scratch in the game is meeting time and a willingness to submit to a guideline instead of individual practice preferences. The hospital has to commit the resources for point of care testing, data management and quality support personnel.  Big investments by both groups.  A level of integration that few private practice institutions have.

Survival in an environment of increased competition for fewer resources will require greater integration of a hospital and its medical staff.  Quality programs can serve as the spring board for that integration.  Successful quality programs have commitment of time and resources by both physicians and hospital for the good of the patient (which is what both sides say they care most about.)

Quality is hard work, takes leadership skill, time, money and process knowledge.  It can result in a level of trust and cooperation that has not existed before.  It improves patient outcomes, supports program development, builds practices and improves the bottom line for all involved.  Clinical quality is an integration and survival tool.  Always the optimist; you can call me naïve.  I’ve seen other attempts at cooperation based on joint business ventures end up in bickering over money and leaving some stakeholders in the cold.  Quality programs are inclusive of all clinical stakeholders and it is patients not currency we are working for.  Let’s get at it! (posted for Rob Dean)

Virginia Apgar

A very cool post I happened upon  in my never ending quest for anesthesia stuff on-line; it's a  history of Dr Virginia Apgar... the anesthesiologist who invented the Apgar score