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...

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.

So, who's organ is it, anyway?

I don't get it. In the American capitalist way, we let 45,000,000 people live on the verge of bankruptcy because they can't afford health insurance; it's the "free market." We let kids live in rotting homes in dangerous neighborhoods with bad schools. Why? because their folks can't or won't work. It's the "free market." We let people swelter in the summer and freeze in the winter if they can't afford energy costs. We let people wander through the streets homeless because they have psychiatric disease. All free market based policies.

But organs? Not a free market. Selling organs is illegal. Verboten. c'est defendu. The organ procurement businesses make a ton of money, which they pay out to their employees and boards because they are "not for profit" (snort, snort, chuckle, chuckle). The hospital makes top dollar, as do the pharmaceutical companies that provide the immuno-suppressants. But for the donors and their families; nothing. nada. zip. "The good feeling that comes from having saved a life."

As a consequence, we have a shortage of organs, and a nightmare of a procurement system that is willy-nilly inefficient, with the kind of sub-rosa black market that we all piously denounce as it periodically bubbles to the surface in the media, where some rich guy buys an organ outright and pays some willing team to install it. Sounds like a UK-style two-tiered healthcare system to me; doesn't it to you?

Ayn Rand was sometimes right (well, frequently, actually); selfless acts seldom go unexploited; in this case, the benefit redounds to that perennial villain, the insurer who gets the organ for free. I can't think of a less deserving beneficiary. And don't insult me with some macro-economic argument about how the organ costs would just be passed along as higher premiums; the private health insurance business is the next best thing to being able to print your own money, but don't get me started!

I'm a yellow dog democrat and a Wisconsin democrat, so I believe in markets; regulated markets; and no black market would benefit more from being brought in from the darkness to the light than the organ market. Imagine that the family of the deceased received a payment of $10,000 for a kidney, or $20,000 for a liver or heart; organ availability would skyrocket, poor families would have funeral expenses defrayed, or might have the money to pay for an education or other needed care. If living donations were allowed, they would require a guarantee from the recipient's insurance company that all expenses incurred as a consequence of complications of the donation procedure would be covered; fair is fair. Probably the government (medicare, medicaid would not participate in paying for living organ donation; too dangerous) I could spend the rest of the day refining the regulatory aspects of this scheme, but you get the idea.

So, does this seem despicable? No more despicable to me than the self-righteously hypocritical ways in which we manipulate free market principles when it suits us. A regulated market in organs, especially cadaver organs, would solve a significant societal problem; the scarcity of such biomaterial, and it ought to be put on the table...

The trouble with tribbles...

All bad precedents begin as justifiable measures.  -Julius Caesar

Desperate measures for desperate diseases   

So, as my co-author, Mike reminds me, I've been absent a looong time. Not without reason, mind you; it has been a tough year, and the clouds are only now beginning to clear. More on this later,( and in another post), but as both a provider and user of the health finance system (and as a beneficiary and victim in both roles, I might add), I have a pretty interested vantage on the healthcare reform ball-game.

So, today's post is about Atul Gawande's gate crashing, delivered suspiciously-on-schedule article, "The Cost Conundrum" which appeared in a recent issue of the New Yorker. You can find it here. Every word is true, (validated by my personal experiences), as far as it goes... 

If you are short on time or attention, link to the article, and skip what I am about to say. What he says is more interesting.

Yo may recall that Gawande, a general surgeon from the midwest, a physician child of physician parents, was a principal in the Clinton Healthcare reform braintrust as a young man. He subsequently completed a surgery residency, published a couple of books of New Yorker essays, and generally manages to nicely write stuff that is interesting to lay readers and medical professionals at the same time. (medical professionals might like his essay "On Washing Hands" which appeared in the NEJM. You can find it here.)

I don't want to critique "The Cost Conundrum" here; rather, I want to justify my post title. I have received links to this article now three times, excluding the one from my co-author, Mike, which was inexplicably lost in the ether (or my untamed gmail account...) That's incredible, exceeded only by solicitations to invest in Nigerian phishing schemes to move large sums money into my bank account, and the stupid morphed picture of the pig-nosed child with "swine flu." To use the term of art, the Gawande article has "gone viral," and will be a powerful influence in the coming reform battle and in Dr Gawande's role in that debate. (Oh, if you don't get the allusion in the title, go find the episode of star trek; it's worth it...)

So, finally and surely as Roosevelt exploited radio and Kennedy, TV, the Obama administration has mastered the web, not only as a tool of campaigning, but as a tool of legislating, which is a fish, as they say, of another garage (sorry). I am reminded as I write this, that much of what the Obama campaign did was based on foundation laid by a physician, Howard Dean, and he deserves an acknowledgement.

I muse, that the pace of technology being what it is, the current Iranian dissident movement is the first full-bore application of the next generation technological socio-political weapon; texting and twittering. I shall leave it to my betters to draw the obvious analogies between politics and war, and the role of new technologies in determining such contests. I will say that, where once I understood technological advance to be primarily physical (faster computers, more powerful weapons) I have come to a broader view which includes less tangible tools, i.e. ideas, logisitical advances, and the like. My more thoughtful colleagues will be saying "well dah," but after all, I was primarily an engineer.

I will not enter the fray on the merits of the current round of healthcare reform. But my initial quotations summarize my opposing feelings adequately, anyway.

Merry BIS-mess to you!

So. Plenty of oxygen was consumed discussing/arguing/debating the merits of the secret-recipe Aspect BIS cerebral monitor at this year's ASA. Isn't this getting old? First, my disclosures. I have no financial interest in or support from Aspect medical (in fact, given the state of the economy, I have no financial interest or support from anything, aside from my ever-shrinking clinical income.) Second, I use the BIS every day, on almost every case I do longer than 15 minutes, paralyzed or not. I even use it on most functional (awake) craniotomies. I have been known to shave the occiput in order to place a BIS array for ACOM aneurysm clippings (yup, we still do them here, now and then). I liiike it. I've used it at least a thousand times.

But it does have its limitations. Like last month, when a young lumbar patient on 2% Sevo and fent with a reading of  42 "BIStles" (that's what I call 'em-why not?) in one epoch, did his best unconscious imitation of upward facing dog the next... (yes Ira, I know-the brain is not the spinal cord.) Do a hundred BIS cases without paralysis and you'll understand in your gut what I mean. But I still like it.

As monitors go, in my practice, the BIS is worth about 1 pulse-ox units (pou). By comparison, the gold standard monitor, the pulse-ox is a perfect 10 pou's.  The Pulse ox is the most perfect anesthesia monitor that ever was, or could be (anybody besides me old enough to remember that feeling in your gut upon hearing a surgeon say "the blood looks dark"?)  Blood pressure, maybe 7 or 8 pou's. Gas monitor, about a 6. The ECG, 2 or 3. This score is obviously my subjective weighting of the sensitivity and specificity of each monitor for keeping my patients (and me) out of trouble, and can certainly vary based upon each individual patient's specific situation (for instance, a person with a history of SVT intuitively derives much more utility from intraop ecg monitoring than a fit 20 something, in whom the ecg almost never tells me anything  I don't know from the plethysmograph.)

Cardiac Transplantation Following DCD Should Be An Oxymoron...

"Cardiac Transplantation following DCD should be an Oxymoron."    -Mike O'Connor.

No matter how cynical you get, it is impossible to keep up.         -Lilly Tomlin

As the saying goes, "you can't make this stuff up." This is in reference, of course, to the recent NEJOM article entitled Pediatric Heart Transplantation after Declaration of Cardiocirculatory Death. In this study, two infants had their hearts harvested following 75 seconds of asystole. The very first post of this blog was titled with a Thoreau quote; "Distrust any enterprise which requires new Clothes." That might be aptly rephrased in the present instance to "Distrust any behaviors which require new ethical language." Obviously, here, Donation after Cardiac Death would be a misnomer, since the heart is nothing like dead, so the designation has been quietly and not-so-subtly modified to cardio-circulatory death. This seems like a further slippery step along the path to a utilitarian transformation of the ethical calculus of donation. Initially, when Beecher et al advanced the definition of brain death, the inevitability of corporal death was a given. Then, in response to a shortage of organs, the line was moved to allow the hastening of death through Donation after cardiac death. Make no mistake, this new designation of cardio-circulatory death, and its ethical rationale represents a fundamental shift again, towards a paradigm of "relative" utility; the implicit argument is that the recipient can make better use of the organ than the donor. This all takes place under the cover of compact between the donor's guardian, the recipient, and the intermediary technicians (transplant surgeon, etc.)

The Inspections Will Continue Until the Quality Improves...

Not-so-long ago, on this continent, one of us was Chief of Staff at a local Columbia Hospital when the Joint Commission for Accreditation of Hospitals (JCAHO or here, JC) appeared for a scheduled survey. Surveys were a little different then; they were announced long in advance, and, if a hospital did exceptionally well, they would receive accreditation with commendation; sort of a gold star. RFI's (recommendation for Improvement) were called  "Type 1" recommendations, and were taken as show-stoppers by all parties, requiring follow-up to ensure correction/compliance. Enough Type 1s and you lost your accreditation, which meant financial ruin. At that time, the Columbia hospital chain owned over 300 hospitals, and had convinced the Joint Commission that their operating practices were so different from other hospitals that they needed their own dedicated surveyors. During the inspection at issue, the physician on that surveying team insisted on a type 1 recommendation based upon his sense that medical staff leadership was marginalized by administration (or some such- the actual wording was never shared with the clinicians). Subsequently, administration announced that this type 1 recommendation had been "rescinded" and that the hospital had received "Accreditation with Commendation." Rumor circulated that said physician was henceforth dis-invited from surveying Columbia hospitals...

The JC was once a consensus building organization that followed the lead of its subscribers and accomplished a great deal. When Congress conveyed "Shall Deem" authority for medicare certification upon the JC, it wrested control of the JC from it’s subscribers and transformed it into a regulatory limb of congress and CMS. While the JC is undeniably under the direction of honorable people, their efforts have become distorted by the politics of money and power which surround them. It's no secret around hospitals that practitioners see no connection between the Joint Commission process and quality of care. Indeed, every practitioner understands that some of the worst hospitals attain JC accreditation almost effortlessly, while some of the best struggle to maintain their certification. Historically, JC inspection was centered on physical plant and policy/procedure. Dreadful care was fine, as long as the policy and procedure manual was up to date and concordant with the most recent guidance. Joint Commission accreditation was, and is, a high stakes game, and unfavorable decisions are very likely to be contested in court (or with the threat of litigation). Consequently, JC regulatory activity has progressively focused on inspection activities that can withstand such litigation. This trajectory has relentlessly uncoupled Joint Commission inspection and accreditation from even a remote relationship to quality of clinical care.  High scores and necessary accreditation have become contingent upon putting up a temporary facade of strict compliance, which frequently obstructs, rather than enhances, care. For the past two decades, the closest thing to a Potemkin village in the American culture has been a hospital preparing for a JC survey.

Donation after Cardiac Death: Is mostly dead slightly alive?

"There's a big difference between mostly dead and all dead. Now, mostly dead ... is slightly alive."

-Miracle Max, The Princess Bride.(1)

In Jainism, a gentle devout sect of Hinduism, the sanctity of life is taken to an extreme. Jains are vegetarians. The most devout Jains will not eat fruits and vegetables that are harvested; they prefer to eat produce that has fallen naturally from the vine or tree.

Which brings us to the euphemistic "Donation after Cardiac Death," or DCD. For those of you who have wandered into this blog, a little history. In 1968 a Harvard committee headed by Henry Knowles Beecher (Harvard Professor of anesthesiology) defined Brain Death. This led naturally to the notion that with proper consent, the organs from such unfortunate ex-individuals (individuality being lost once the person died) could be of utility to society and potential organ recipients. These potential donors are the poor folks who have fallen off the vine of life, but for whom some organs still possess vitality. But, there were problems, the main one being that as the industry advanced, there just weren't enough organs to meet the burgeoning demand.

So, the transplant industry, with transplant surgeons and organ procurement organizations (OPOs) in the lead, set aside decades of careful philosophical and ethical reasoning behind brain death in favor of a utilitarian formulation; they lowered the bar for donation...

We have met the enemy, and he is us....

I'm back...

A year or so ago, I was walking down the OR corridor between cases, and a surgeon I had known for fifteen years pointed at me and said sharply; "come on; what are you doing wandering around? - take the patient back!" I was momentarily confused, since we weren't working together that day. It was good that I was disoriented for that brief moment, because it gave me pause before the anger rose in me; a pause long enough that I suppressed whatever growl would have otherwise erupted. I was four steps away by the time I figured out that he had forgotten who his anesthesiologist was for that day, and he thought I was it... (and I use "it" intentionally). When I passed by a couple of minutes later, he simply said "I thought you were my anesthesiologist." Maybe a little sheepish, but then again, maybe not. And I thought, "he treated me like he treats the nurses..." Here's an amusing account of a sociological study on why surgeons behave like surgeons...

Good Anesthesia Matters!

The anesthesia world is spinning up to a tizzy over the upcoming theatrical release of the movie "Awake." For those of you living "off the grid", Awake is a story about a poor victim who has the extraordinary misfortune to be subjected to cardiac surgery awake/paralyzed. None of us have seen this movie, but advanced word is the anesthesia folks aren't favorably depicted.

I am really, really looking forward to its release. For a lifetime, I have wholly devoted myself to my craft; medicine and anesthesiology. While I have not minded being in the background behind my surgeons, I have, over thirty years, grown tired of the surgical attitude that what I do is trivial; of course it is, because if it weren't, well, they'd be doing it themselves, wouldn't they?  And if I and my colleagues had been made of better stuff, we would have gone into surgery.  What a load of nonsense.

One slip of the surgeon's knife, and a patient's meaningful life is over. Just so, one mistake with a syringe of vecuronium, and a patient is dead, or perhaps, worse than dead... The truth is, if I don't practice smartly and on form, patients will suffer and perhaps die in ways both obvious (aka "Awake") and subtle (ie high blood glucose leading to higher post-op infection rates) It's about time everybody understood it. It doesn't help when colleagues (especially CRNA's, I note over the years) minimize what they and we do; "oh you're going to take a little nap while your (big strong) surgeon operates on you." I even avoid the use of the word sleep to describe what I do. I usually say "sleep is what you do at night. It is free and natural, but if your surgeon were to attempt to operate while you are asleep, you would wake up in great pain. What I provide is drug induced unconsciousness, not unlike a temporary coma. You will not wake up until I reverse the process. It is a safe procedure in my hands, and I will stay with you the entire time to maintain this state and see you safely through." I have no tolerance for anybody who suggests that I am scaring patients like this; it is simple truth, which is the stuff of informed consent.

For every patient that  says "oh, doctor, anesthesia is soooo important," I have ten patients who believe that I belly up to the table with a syringe of clear stuff, inject it, and walk on to the next room, or out for a cup of coffee... ("who was that masked man? I don't know, but he left this bill pinned to my dickie...")

A little patient apprehension about their upcoming anesthetic is a good thing-it's appropriate.  And if the patients get the idea that who is giving their anesthetic; their education, dedication, compassion and diligence,  matter to their outcome, well, then, so much the better. Because it's true.

Where I come from, there' was a saying; "a good surgeon deserves good anesthesia. A bad surgeon needs it." I can't remember all the times I've had to hold a patient together physiologically while the surgeon tried to work his way out of a nasty situation. I have auscultated the hearts of 20000 patients to avoid missing that once-in-a-lifetime patient with critical aortic stenosis who would otherwise die on anesthesia induction (I've found 2). I've sniffed around thousands of diabetics for a whiff of the coronary artery disease that might progress to a fatal perioperative MI. I've sat on the floor of the holding area hundreds of times looking up at anxious three year olds and their parents, quickly forging a rapport that I could leverage into a less scary induction.

I can deal with healthy patient fear; it just takes a little time, some patience and explanation. I hope that every patient for the rest of my career has the good sense to ask me what I'm going to do to keep them alive, and how I'm going to prevent the excruciating agony of their being awake "under the knife", and then I hope they look me in the eye as I explain it all, to be sure they see a soul they can trust.

And if anesthesia leadership on both sides of the aisle (AANA and ASA) settle for some bland reassurances about anesthesia diligence and try to undermine the message of "AWAKE"  by pointing out the inevitable inaccuracies they will find in the movie, than they (and we) ought rightly to be banished to the back benches of the medical pecking order.

And if Aspect medical makes a few more bucks on their BIS monitors along the way, so be it; their box isn't perfect, but it isn't bad, either...

I say, "bring it!" I'll be there on opening night with a big bag of popcorn to assuage my vicarious anxiety...