The Ether Way

Bringing Resuscitation into the 21st century, or Seeing is Believing...

I do a fair amount of trauma anesthesia. An important part of trauma bay resuscitation is a quick and dirty transcutaneous ultrasound evaluation; Heart, pleural space, liver, spleen, bladder.

 Fifteen years ago, one of my partners had a patient develop pulseless electrical activity (PEA)  in the middle of an ortho case. (Well, actually, the story is so old that the patient developed what was then called electro-mechanical dissociation, EMD; same thing, different era…)

Anyway, she dropped a TEE (we were in a mixed cardiac practice), diagnosed a saddle embolus, the patient’s chest was opened, thrombectomy was performed, and he survived  (not without  a stormy course, of course.)

 I recently was discussing ACLS with a young cardiology colleague, and we were both discussing the ACLS “cookbook.” We were talking about  the least-common-denominator limitations of the ACLS system, and pretty quickly fell onto the usefulness of echo in sorting out PEA.  Virtually all the  non-metabolic etiologies of PEA (and tachycardia/hypotension) are amenable to echo diagnosis, and the windows required are not particularly difficult to grab; it’s basically a ventricular view. We’re not looking to diagnose aortic stenosis here. And an echo is instantly confirmatory (or not!) of asystole or v-fib. Ever see a v-fib which proves to be a lousy ecg signal with what is in fact, PEA with a beating, empty heart? I have.

There are a few implications of this discussion, some theoretical, some tactical.

First, my anesthesiology colleagues resent having to maintain ACLS certification; as one of them put it, “it’s like making a master chef take remedial sauce-making every two years.” I am such a "master-chef'," and I couldn’t disagree more, for three reasons.

First, I have seen too many codes botched by “bread-and-butter” anesthesiologists over the past two decades to harbor any illusions about the “master chef” designation of anesthesiologists a decade or more out of training. Many of them are right there, but some of them are not.

Secondly, ACLS is about a team approach to a high-tempo crisis. The team expects certain behaviors from the leader; if the leader does not fit her management style into a response pattern expected by the conditioning of the team, confusion and disorganization are the consequence. Especially with the young generation of clinician nurses, they need explanations to be comfortable, and once you have established your familiarity with the standard therapies, they will accept variation with brief explanation. I am reminded here of innovators like John Coltrane,  whose extraordinary trail blazing virtuosity was validated by his equally extraordinary command of the the traditional ballad-bebop forms. You gotta start from terra-cognita on your way to terra-nueva (we’re leaving out terra-incognita here…)

Finally. Things change. Aloha, bretylium and procainamide, welcome, Amiodarone. You can't ell the players without a program.

But I digress. I feel strongly that we ought to have a simple echo (like a sono-site; there is a great subcostal view to the right here) available at EVERY code, and the team ought to be trained to get the

windows that tell you what you need to know to diagnose the mechanical causes of PEA. It’s time. There are no disposables, so it’s a one-time cost. If you are being fussy about sterility, a sandwich bag with a tie-wrap, or a transderm-type occlusive sticky  will do.  I suppose you could have the ultrasonography team respond to every code as an alternative. But that seems like overkill, and in any case, crowds the room. It's time to do the (inevitable) validation work with and without. After all, an artist is only as good as his tools...

Seeing it from Both Sides

As the debate over health care reform waxes on, both sides have turned up the rhetoric, and moderate or reasonable voices on either side are being shouted down and lambasted.

On the Pro-Reform side,  there is this recent commentary from Don Wycliff in the Chicago Tribune:

http://www.chicagotribune.com/news/opinion/chi-oped0903wycliffsep03,0,2484870.story

He astutely points out that the federal government is already deeply engaged in providing or facilitating health care for millions of US citizens. His list includes the following entities, all of which would have to be eliminated to get the federal government ‘out’ of health care.

    - Medicare

    - Medicaid

    - VA health care

    - Military Health care

    - Indian Health service

    - the Surgeon General

    - the CDC and the NIH.

 A few observations:

- I’ve already written a substantial amount about the failures of the VA system, and how remarkably disinterested anyone appears to be in fixing them.  The current movement is no exception: there is no discussion of fixing the problems that everyone admits plague the VA system.  Veterans with the means to do so obtain their care elsewhere.  If the VA is a barometer of how the feds will deliver health care, then the results are cause for concern, not optimism. Also concerning is that there is little discussion from either side about fixing the VA. We owe it to our veterans to do vastly better, regardless of how the current debate goes.

- Medicaid is not entirely a federally run program ,it is administered locally by the states, and has generated a patchwork quilt of coverage that verges on ridiculous.  The hospital where I work is located near the Indiana border, and is the closest tertiary care center for the hundreds of thousands of people who live in nearby Indiana.  We can care for their insured, but not for their Medicaid.

- Medicare is a big bite, too big for this post.  Let’s just say that as Medicare demands more and pays less, care for medicare patients is going to be increasingly difficult to obtain.

- The Indian Health Service is worthy of its own post, but I am unlikely to ever get around to generating it.  The spectrum of people who provide care for the IHS includes some of the very best doctors I have ever met, to doctors who cannot obtain any other employment.

 - The NIH provides little care, and the CDC almost none at all.  Both represent enormous public good, and very worthwhile outlays of federal tax dollars.  While libertarians represent that the free market would create both entities if the feds did not; the fact that nothing resembling either one exists in any other country makes me certain that this contention is absolutely wrong.

On the other side of the debate is this break down of the numbers by Dennis Byrne, also published as a commentary in the Chicago Tribune:

http://www.chicagotribune.com/news/opinion/chi-oped0825byrneaug25,0,7272374.story

First, the commentary on this one, which is posted below the article itself, is fairly typical of the partisan bomb-throwing that has been going on.  The president may have wanted honest discussion, but this topic has provoked both sides to talk at each other, not to each other.

Byrne’s numbers:

- 46 million uninsured, of them:

    - 9.5 million illegals

    - 12 million eligible for some sort of government program, but have not bothered to sign up.  Given the nature of government bureaucracy, this is unsurprising.

    - 9.1 million people who are between jobs and temporarily uninsured.

    - 7.3 million families with an income greater than $84,000/yr

    - and finally, about 8 million working poor, without insurance.

First, if we’re not going to cover the illegals, we shouldn’t include them in the count.

Second, the 7.3 million families with an income of 84k or higher are either living as a free people should be allowed to, or a group of free riders who should be made to pay or play.

Third, the temporarily uninsured are truly uninsured. For almost everyone who is unemployed, the cost of continuing their employer sponsored health plan would consume their unemployment benefit.  If they want to eat, they cannot continue their health insurance.

Fourth, make it easier for those eligible to sign up for the government programs that already exist.  Be warned: doing this will increase the expense of these programs.  Interestingly, if this number is correct, Obama could generate health care for most of these people with a minimal investment in supporting and expediting their enrollment.  This would not require an overhaul in the system, but would require the money to care for an additional 12 million people.

Fifth, understand that the real issue here are the 8 million working poor and the 9.1 million between jobs.

Finally, there are ways of controlling health care costs that have not yet been incorporated into the language of any of the bills under consideration:

http://townhall.com/columnists/HughHewitt/2009/09/04/without_tort_reform,_it_isnt_health_care_reform_--its_a_plaintiffs_lawyers_protection_act?page=1

 Mr Hewitt is correct and very clever to have thought of this.

Brits throwing Granny Under the Tram?

A century-and-a-half ago, give or take a few years, a clinical/philosophical battle raged around the issue of surgical anesthesia. A school of thought, the "heroic" school, asserted that no morbidity or mortality was justified for the mere alleviation of pain and suffering, and they plainly rejected ether or chloroform on that grounds. Citing scripture and asserting a belief that pain was necessary for healing, they nevertheless gave way before a utilitarian understanding that the advantages of surgical anesthesia were worth some risk, and a relatively high risk it was. While anesthesia enjoys a mortality rate of probably 1:250000 now, in 1850 it was probably more like 1:300 give-or-take.Over the decades the same utilitarian calculus has been worked countless times for every therapy, from antibiotics (anaphylaxis! Stevens Johnson syndrome!) to elective cholecystectomy (bleeding! infection! Death!). A weighing of risk versus benefit.

In this case, The Liverpool Care Pathway, a protocol for providing comfort to patients who are judged by their caregivers as being close to the end-of-life, has been indicted as theoretically precipitating untimely death. The indictment is anecdotal opinion, but is reasonable in its concern; that the withholding of nutrition and hydration, and the administration of narcotics and sedation for the amelioration of pain can provoke death in a patient who in fact might not have otherwise died near term.How does this differ from the decision to extirpate an otherwise healthy 35 year old's gall bladder, based upon their colicky intolerance of mexican food, knowing that there is a distinct, if rare, incidence of death? Well, I suppose one could argue that the 35 year old is able to give informed consent, although I have yet to believe that any lay patient understands the risk of pulmonary embolus or common duct ligation. 

Could it be the relative imminence of death inherent in the decision to withdraw support? If so, then the issue is merely one of popular lack of understanding, since nothing is quite so dramatically imminent as a saddle pulmonary embolus in an otherwise healthy 35 year old.

Or are we uncomfortable because they are potentially "burying their mistakes" beyond the reach of oversight by virtue of the very nature of the intervention (or withdrawal thereof).

Or is it that there is an insidious dual-agency conflict here, with the care team acting as an economic agent of the state, callously inducing health care efficiencies by knocking off granny a couple of days, (or weeks?) early. Well, maybe. And maybe, the anecdotal warning of the experts is just that; a warning that one must be particularly careful about diagnosing futility prior to instituting self-fulfilling care plans. As they say in drowning resuscitation, the patient is not dead until they are WARM and dead, as a reminder that hypothermia can mask a survivable situation. And just maybe in turn, that warning was grasped by a controversy-hungry newsperson, preying upon the public mistrust of impersonal beaurocracy to gin up a little newsProbably it's all of the above, but the question remains, do the benefits of not forcing the dying to linger in suffering outweigh the risks of early death for the few who might have lived a little longer, or supersede the concern that compassionate facilitation becomes hard-hearted sacrifice for the "public good." 

 I'm with Ross Douthat in his recent op-ed on "slippery-slope"-ism in euthanasia. (And the Liverpool Care Plan certainly is euthanasia though late term euthanasia it may be.) On my list of likely slopes to slide down, the euthanasia-as-cost savings risk is pretty far down my worry list, Sen Grassley and citizen Palin notwithstanding.