Of cats and termites

Tigger 4

How an eleven-pound cat precipitated domestic chaos and delayed surgery

Termites are endemic in southern California, and we’ve had spot treatments several times over the years at various sites in our house where little piles of sawdust have appeared as evidence of termite activity. Finally it became clear that the termites were winning and more aggressive treatment was in order: tenting. This is the process of hoisting a big, brightly-colored tent over the whole house and putting an end to the termites with a poisonous gas called Vikane, or sulfuryl fluoride.

Tenting is a major project. All food and medicine has to be put in special non-porous plastic bags, sealed tightly with tape. All the people, animals and plants have to be evacuated. Natural gas must be turned off. The house is sealed in the tent for 24 hours, then aired out with big industrial fans. On the third day, you can go home.

The fumigation was scheduled to begin on Monday. Over the weekend, we put the food and medicines in bags, or most of it anyway. I arranged for our three tabby cats to be boarded at the vet. Our dog-walker agreed to board Milo, our 100 lb. Rottweiler-mix dog, at her house. My husband Steve complained continuously, as though I had bought bags of termites and sprinkled them around the house on purpose to annoy him.

On Monday morning Steve and I both went to work, to our day jobs as anesthesiologists, and I came home at 11:30 to take the cats to the vet and hand off the dog. The exterminators were expected to arrive between 1:30 and 3:30 pm. I had the presence of mind to lock all three cats in the family room before I went to work. Now my task was to get all three into their carriers and off to the vet.

Going three rounds with Tigger

I decided to tackle Tigger, the five-year-old male, first. He is strong, sinewy and sleek, and we’ve nicknamed him the “stealth cat” because he is very good at eluding capture. I thought he would be the biggest challenge to put in the carrier, and I was right.

Round 1. I caught Tigger, shoved him into his carrier, and tried to hold him down while I zipped it up. He turned into a writhing yowling clawing dervish and fought his way out.

Round 2. I think he got out even faster that time.

Round 3. Met the definition of insanity, as I hoped for a different outcome from the same sequence of actions. Same cat, same outcome.

I considered my options, and decided to get Joe and Tabitha into their carriers and drive them to the vet. This, I thought, would give Tigger time to calm down. Joe is a placid 17-year-old senior cat, and while he doesn’t like to go anywhere, he can’t be bothered to put up much fuss. Tabitha is a 10-month old kitten. It took some doing to catch her, and she was very unhappy, but she was still too small to win the contest. I drove Joe and Tabitha to the vet and came back home. As I came in the house, I caught a brief glimpse of Tigger, still locked in the family room. I put some more food in bags and waited for Krys, the dog-walker, to arrive and help me with Tigger.

1 pm: Krys arrived. We discussed the plan to put Tigger in his carrier. Only problem: we couldn’t find Tigger. We looked all over the family room and kitchen. We searched in the coat closet, under furniture, and behind the washing machine and dryer. No Tigger. It was as if he had evaporated. Milo (the dog) at this point was becoming anxious, trotting around after me and panting, sensing a disturbance in the force. I decided it would be best to let Krys and Milo leave.

1:30 pm: A fair amount of stuff still needed to be put in bags, but I couldn’t find the cat anywhere. Rising anxiety. I called my husband. A veteran of married life, he recognized the tone of desperation in my voice, and promised to come home as soon as he could arrange coverage. Cat clearly more important (for the moment) than heart surgery.

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5 COMMENTS

Dear Dr. Sherling, My goodness! I don't recall chastising anyone; merely expressing an opinion which the New York Times found of sufficient interest to publish. As for holding an OR case--anyone who works in the OR would understand what really happened. I was going to be delayed briefly, on account of my wayward cat. The surgeons certainly had the option of working with another anesthesiologist, as someone is always free for emergencies, flat tires, or other delays. As it happens, the surgeons ...Read More

Dawn

You held an OR case for a cat, but in the New York Times chastise female internists who work "part-time"? How horrible on so many levels. I would encourage you to spend some time with female PCPs who are also mothers. I extend an invite to you from Florida and there are certainly many members of the Physician Mommy Group who would do likewise closer to you. While you have likely taken a lot of heat for your misguided opinions of female physicians, I am ...Read More

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A Call for Civility

cats & dog

Why can’t physician anesthesiologists, nurse anesthetists, and anesthesiologist assistants just get along?

American anesthesiology reached a significant milestone last year, though many of us probably missed it at the time.

In February, 2014, the number of nurse anesthetists in the United States for the first time exceeded the number of physician anesthesiologists. Not only are there more nurses than physicians in the field of anesthesia today, the number of nurses entering the field is growing at a faster rate than the number of physicians. Since December, 2012, the number of nurse anesthetists has grown by 12.1 percent compared to 5.8 percent for physician anesthesiologists.

The numbers—about 46,600 nurse anesthetists and 45,700 physician anesthesiologists—reported in the National Provider Identifier (NPI) dataset for January, 2015, probably understate the growing disparity. Today, more and more physicians are leaving the front lines of medicine, many obtaining additional qualifications such as MBA degrees and embarking on new careers in hospital administration or business.

Physician anesthesiologists can expect that fewer of us every year will continue to work in the model of personally providing anesthesia care to individual patients. Clinical practice is likely to skew even more toward the anesthesia care team model, already dominant in every part of the US except the west coast, with supervision of nurse anesthetists and anesthesiologist assistants.

So why does the level of animosity between physician anesthesiologists and nurse anesthetists seem to be getting worse, even as the care team gains greater prominence? Does the anonymity of the Internet bring out the worst in everyone and make civilized discourse impossible?

Anesthesiologist assistants (AAs), of course, are to anesthesiologists what physician assistants are to physicians in other specialties. They are under the jurisdiction of medical boards, not of nursing boards, and are firm supporters of anesthesiologists. In contrast, the website of the American Association of Nurse Anesthetists (AANA) states that nurse anesthetists “collaborate with other members of a patient’s healthcare team: surgeons, obstetricians, endoscopists, podiatrists, pain specialists”—a list which pointedly excludes physician anesthesiologists.

Perhaps increasing downward pressure on payments and tough competition among hospitals are worsening the strain on anesthesia practitioners of all stripes. But in an era where healthcare professionals are faced with onerous new rules and regulations on a daily basis, and report alarming levels of burnout, does it make sense for groups with so much in common to be permanently at odds? Wouldn’t they do better as allies? In the field of anesthesia, why can’t physicians, nurses, and AAs just get along?

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24 COMMENTS

If you think "physician anesthesiologist" is cumbersome, wrap your tongue around "Physician Assistant in Anesthesia". How many patients do you think have a clue what all these titles actually entail?

norwood

So I'm an anesthesiologist - or call me an MDA, it really doesn't matter to me. I know what my credential is. Anyone else think that the great majority of both anesthesiologists and CRNAs just wants to get along and get the job done, and that maybe 5% of each group needs to switch to decaf already? I've worked alongside militant anesthesiologists, and also alongside militant CRNAs. To me, they're equally painful. There are opportunities for MD-only practice and opportunities to be an unsupervised CRNA... so the ...Read More

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“Twilight” is a movie

Propofol bottles

How the advent of propofol — the drug associated with the deaths of Joan Rivers and Michael Jackson — changed the meaning of the term “sedation”

“Twilight! She has to have twilight,” insisted the adult daughter of my frail, 85-year-old patient. “She can’t have general anesthesia. She hasn’t been cleared for general anesthesia!”

We were in the preoperative area of my hospital, where my patient – brightly alert, with a colorful headband and bright red lipstick – was about to undergo surgery. Her skin had broken down on both legs due to poor circulation in her veins, and she needed skin grafts to cover the open wounds. She had a long list of cardiac and other health problems.

This would be a painful procedure, and there would be no way to numb the areas well enough to do the surgery under local anesthesia alone. My job was to figure out the best combination of anesthesia medications to get her safely through her surgery. Her daughter was convinced that a little sedation would be enough. I wasn’t so sure.

“Were you asleep the last time your doctor worked on your legs?” I asked the patient. “Oh, yes,” she said. “Completely asleep.”

“But she didn’t have general,” the daughter interrupted. “She just had twilight.”

Propofol revolutionized anesthesia care

Though “twilight” isn’t a medical term, people often use it to mean sedation or light sleep as opposed to general anesthesia. Most patients don’t want to be awake, even if their operation doesn’t require general anesthesia. They prefer an intravenous “cocktail” to make them oblivious to pain and unaware of anything that’s happening. Today, the main ingredient is likely to be an anesthetic medication called propofol.

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2 COMMENTS

BradJohnSnow

Karen: I wish you would do all the writing in public relations blurbs for the ASA. ou make it clear! B

Dr.Srivalson Kozhipparambil

Propofol alone can be often hazardous when the pain levels suddenly increases. Hence I use it in combination with very small doses of isoflranre.

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Joan Rivers 3

New York Post reporter Susan Edelman revealed on January 4 the name of the unfortunate anesthesiologist allegedly present on August 28 at Yorkville Endoscopy, during the throat procedure that led to the death of comedian Joan Rivers. She is reported to be Renuka Reddy Bankulla, MD, 47, a board-certified anesthesiologist from New Rochelle, NY.

Having her name made public will be a nightmare for Dr. Bankulla, as investigators will certainly target her role in Ms. Rivers’ sedation and the management — or mismanagement — of her resuscitation.

When the news of Ms. Rivers’ cardiac arrest and transfer to Mt. Sinai Hospital became public, many of us guessed that there might have been no qualified anesthesia practitioner — either anesthesiologist or nurse anesthetist — present during the case. The gastroenterologist and then medical director of the clinic, Dr. Lawrence Cohen, argued famously that the sedative propofol, which Ms. Rivers received, could be safely given by a registered nurse under his supervision, and that no anesthesiologist is necessary.

However, with the publication of the Centers for Medicare & Medicaid Services (CMS) report of September 5, it became clear that an anesthesiologist was definitely present. The anesthesiologist was identified only as “Staff #2″ in the report. She was interviewed by the CMS surveyors four days after the event, but said she was “advised by her legal representative not to discuss the case.”

Key pieces of information about what happened still haven’t been made public. Nonetheless, the surveyors gathered enough information to reach this conclusion:  “The physicians in charge of the care of the patient failed to identify deteriorating vital signs and provide timely intervention during the procedure.”

By any standard of care, the anesthesiologist clearly would be one of the physicians in charge.

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15 COMMENTS

Dr Venkatramana

Sad and tragic for all involved. The rush to get things done in operating room particularly in free standing surgery centers is one of the main reasons why things get missed. Providing anesthesia for ENT cases is highly risky because of the shared airway. Surgeons as a bunch never listen until you yell. However when your surgeon and or patient is a VIP, the anesthesiologist is expected to put up the nicest behavior and that means not asking too ...Read More

Regina santamaria

I hate going to Endo. I wish we would institute a policy to intubate ERCP's. We even do spiral enteroscopys under Mac which is even more dangerous because it takes the GI doc at least 2 minutes to pull the spiral scope out because it is all the way down the duodenum and they have to twist it out. I think it's a disaster waiting to happen.i told the powers of be where I work that they should be intubated and I don't feel comfortable ...Read More

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Party animals 11:21

No one wants a hospital-acquired infection—a wound infection, a central line infection, or any other kind.  But today, the level of concern in American hospitals about infection rates has reached a new peak—better termed paranoia than legitimate concern.

The fear of infection is leading to the arbitrary institution of brand new rules. These aren’t based on scientific research involving controlled studies.  As far as I can tell, these new rules are made up by people who are under pressure to create the appearance that action is being taken.

Here’s an example.  An edict just came down in one big-city hospital that all scrub tops must be tucked into scrub pants. The “Association of periOperative Registered Nurses” (AORN) apparently thinks that this is more hygienic because stray skin cells may be less likely to escape, though there is no data proving that surgical infection rates will decrease as a result.  Surgeons, anesthesiologists, and OR nurses are confused, amused, and annoyed in varying degrees.  Some are paying attention to the new rule, and many others are ignoring it.  One OR supervisor stopped an experienced nurse and told to tuck in her scrub top while she was running to get supplies for an emergency aortic repair, raising (in my mind at least) a question of misplaced priorities.

The Joint Commission, of course, loves nothing more than to make up new rules, based sometimes on real data and other times on data about as substantial as fairy dust.

A year or two ago, another new rule surfaced, mandating that physicians’ personal items such as briefcases must be placed in containers or plastic trash bags if they are brought into the operating room.  Apparently someone thinks trash bags are cleaner.

Now one anesthesiology department chairman has taken this concept a step further, decreeing that no personal items at all are to be brought into the operating room–except for cell phones and iPods.  That’s right, iPods, not iPads.  This policy (of course) probably won’t be applied uniformly to high-ranking surgeons or to people like the pacemaker technicians who routinely bring entire suitcases of equipment into the OR with them.

What’s particularly irrational about this rule is that cell phones likely are more contaminated with bacteria than briefcases or purses, even if they’re wiped off frequently.  And I have to ask how an iPhone 6+ meets eligibility criteria while the barely-larger iPad mini doesn’t.  Again, please show me the data demonstrating that this will reduce infection rates, unless someone is making it a habit to toss briefcases and iPads onto the sterile surgical field.

Show me the money

I wish I could say that the driving force behind hospitals’ fear of infection is simply the wish for patients to get well. Unfortunately, it’s probably driven as much by financial motives as benevolent ones.  Today, Medicare won’t pay for care related to surgical site infections, and it fines hospitals whenever too many patients need to be readmitted within 30 days of discharge.  In 2014, a record 2610 hospitals–including 223 in California–were penalized, and will receive lower Medicare payments for all patients over the next year, not just those who were readmitted.

What does this mean at the grassroots level?

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8 COMMENTS

Kyle Bunker

"Surgeons, anesthesiologists, and OR nurses are confused, amused, and annoyed in varying degrees." I literally laughed out loud, great article! I always enjoy reading your posts.
I hate to repeat myself (not really); but once you understand that much of this is about breaking physicians to someone's saddle, it all makes sense. It's a lot more about power and control than it is about patient-care improvement. Ever notice how deeply the nursing profession is imbedded in this sort of busy-bodying? It's a great chance for groups of non-physician colleagues who've traditionally felt "oppressed" by doctors to get a little payback by nipping at our heels like snarly terriers. What they can't achieve ...Read More

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