EHR

“I’m here to say ‘Yes, they can,’ which is different from ‘Yes, they always do,’” says James Moore, MD, President-Elect of the California Society of Anesthesiologists (CSA).

To the contrary, enthusiasm for electronic medical records (EHRs) is part of a “syndrome of inappropriate overconfidence in computing,” argues Christine Doyle, MD, the CSA’s Speaker of the House.

The two physician anesthesiologists (and self-identified “computer geeks”) squared off in a point-counterpoint debate in New Orleans as part of the American Society of Anesthesiologists (ASA) annual meeting, with Dr. Moore defending the benefits of EHRs and Dr. Doyle arguing against them. Dr. Doyle chairs the ASA’s Committee on Electronic Media and Information Technology, while Dr. Moore leads the implementation of the anesthesia information management system (AIMS) at UCLA.

Legibility, accuracy, quality

Dr. Moore defined safety in anesthesia care as “minimizing patient injury resulting from or occurring during anesthesia, and keeping surgeons from harming patients any more than they have to.” He said that computerization contributes to safe anesthesia care by improving legibility, offering clinical decision support with readily available reference information, and providing alerts and reminders.

Computer tracking of the anesthetized patient’s vital signs is more accurate, Dr. Moore said. It prevents the “normalization” of blood pressure that tends to appear on the paper record. Quality reports are easier to generate and outcomes are easier to measure with EHRs in place, he noted. “Postop troponin levels and acute kidney injury are easy to track.”

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3 COMMENTS

Jnelson

I can only speak as a patient. My eye doctor never seems to know anything about me because to find out about my past history requires that he search his computer rather then just flipping back through a paper chart. More and more I finding him to appear ill prepared and downright incompetent as he never seems to follow up on past issues; in fact even though I come once a yr or more , its like he doesnt even know who I am. This is something which my doctors never did in the past.
A friend of mind said that her doctor told her she had to hire a scribe because paperless charting required her to talk and type at the same time which required her to pay more attention to her hand held pc then to her pts.
It seems to me that more and more we are taking the pt out of medicine and caring more about following the rules or making things more systematic. The pt is already somewhat objectified and treated as just another diagnosis. I think there needs to be some happy medium here where we can be efficient and be REAL at the same time.

karen

Actually, both Dr. Doyle and Dr. Moore talked about distraction, but they (naturally) made opposing points. On the one hand, it can be distracting to have to try to keep up with a paper record when there are other tasks to be done. It can be nice to have all the vital signs automatically charted for you. On the other hand, as you point out, particularly in the learning stages it can be all to easy to get caught up in the EHR and forget everything else. On the one occasion when my EHR wasn’t cooperating at the start of the case, I felt it was best simply not to put my patient to sleep and wait for it to be fixed first. I thought it would be much too distracting to have someone working on fixing the EHR in the middle of the case.

Best,

Karen Sibert

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The anesthesia care team has a long-standing record of safety

“Fighting against those who want to change things is a futile strategy,” declared Jason Hwang, MD, MBA, keynote speaker at the opening ceremonies of the American Society of Anesthesiologists’ annual meeting in New Orleans on Saturday, October 11. “You can’t defend a profession by putting up regulatory and payment barriers to stop the barbarians at the gates.”

Dr. Hwang is a co-author of  The Innovator’s Prescription: A Disruptive Solution for Health Care, the winner of the 2010 Book of the Year award from the American College of Healthcare Executives. An expert on the subject of disruptive innovation, Dr. Hwang told the audience of anesthesiologists from more than 90 countries that the Perioperative Surgical Home (PSH) concept offers an integrated solution to healthcare that can help the profession of anesthesiology adapt, survive, and prosper.

He used the example of Apple Inc. to illustrate how a company can thrive while other huge competitors failed because they yielded to “the irresistible temptation to keep doing what they already did best.”

Faster horses, bigger hard drives

If Henry Ford had asked customers what they wanted, Dr. Hwang said, they would have answered “faster horses”. If you asked people what they wanted from their computers 10 years ago, they would have answered bigger hard drives, more memory, and faster processors. Nobody would have said they wanted a phone. But Apple redefined the business with smartphones and tablets that created their own market, and Apple controls the entire integrated product.

Anesthesiology’s chief problem has been complacency with the status quo, Dr. Hwang said. Profitability has been greatest in the operating room, while the areas of preoperative and postoperative care were ripe for encroachment by hospitalists and other practitioners.
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2 COMMENTS

Wonderful article! This is so insightful about anesthesia, and it really gives an overview about the future of anesthesia. With so many current advances in technology, the future of anesthesia is certainly open. Thanks so much for sharing this info!

Great article, thanks for sharing. You are a gifted writer and a true physician advocate. I’m currently reading your latest stuff on Kevin MD. Thanks for doing what you do and sharing your insights.

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Joan Rivers 3

The ear, nose and throat specialist who treated comedian Joan Rivers on August 28 has been identified as Dr. Gwen Korovin, a prominent New York physician who is known as a voice doctor to many entertainers and Broadway stars including Hugh Jackman and Julie Andrews.

With a physician who is an expert in airway anatomy at her side, and all the technologic advantages of a modern clinic in Manhattan’s upper east side, the 81-year-old Ms. Rivers must have anticipated an uneventful procedure. Instead, she stopped breathing and suffered cardiac arrest. The question remains:  What went wrong?

Credentials questioned

Several sources have reported that Dr. Korovin had not completed usual credentialing procedures at Yorkville Endoscopy, and did not have privileges to do anything but observe on the day Ms. Rivers was treated.

In fairness, the credentialing process at a hospital or ambulatory surgery center (ASC) simply reviews documentation that the physician is qualified to perform procedures, and grants the physician privileges to practice there. Physicians choose where they want to work, and don’t necessarily maintain privileges at more than one hospital or ASC.  A lack of privileges doesn’t imply a lack of experience or training; it simply means that the physician hasn’t gone through credentialing steps at that facility.

In Dr. Korovin’s case, her attorney’s statement notes that she “maintains privileges at one of the city’s most prestigious hospitals.” Her prominence in Manhattan may have led to an assumption that her credentials at Yorkville Endoscopy were in order, although it is the responsibility of each facility and its medical director to make sure.  Dr. Lawrence Cohen, Ms. Rivers’ gastroenterologist, was the medical director of Yorkville Endoscopy at the time of Ms. Rivers’ treatment, and has since resigned.

Critical lack of oxygen?

Ms. Rivers suffered cardiac and respiratory arrest while at Yorkville Endoscopy for evaluation of why her voice was getting raspier. She was resuscitated and transferred to a nearby hospital, but died a week later after discontinuation of life support.

Initial autopsy results were inconclusive, according to CNN’s report of a statement from the medical examiner’s office, meaning that no obvious cause of death was clear, and more tests will be done.  This information appears to rule out some causes of sudden cardiac arrest such as pulmonary embolism, the formation of a large clot that stops blood flow through the lungs.

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2 COMMENTS

John Snow MBBS

As always for Dr Karen, fair, factual, and illuminating.

There are two kinds of surgical interventions: 1) Minor Surgery 2)Major Surgery.

There is no such a thing as Minor Anesthesia.

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Vocal folds

Since the death of comedian and talk-show host Joan Rivers, more information has surfaced about the events on the morning of August 28 at Yorkville Endoscopy. But key questions remain unanswered.

News accounts agree that Ms. Rivers sought medical advice because her famous voice was becoming increasingly raspy. This could be caused by a polyp or tumor on the vocal cords, or by acid reflux irritating the throat, among other possible causes.

So Ms. Rivers underwent an endoscopy by Dr. Lawrence B. Cohen, a prominent gastroenterologist, to evaluate her esophagus and stomach for signs of acid reflux. At the same time, a specialist in diseases of the ear, nose, and throat (ENT) reportedly examined her vocal cords (also known as vocal folds).

We don’t know exactly how much or what type of sedation Ms. Rivers’ may have received, though several news sources have reported that she was given propofol, the sedative associated with the death of Michael Jackson. No physician who specializes in anesthesiology has been identified on the team taking care of Ms. Rivers, and we don’t know who was in charge of giving her propofol.

It seems clear that at some point during Ms. Rivers’ endoscopy and vocal cord examination, there was a critical lack of oxygen in her bloodstream.

Was laryngospasm the cause?

Giving sedation for upper endoscopy is tricky, as any anesthesia practitioner will tell you. A large black endoscope takes up space in the mouth and may obstruct breathing. Any sedative will tend to blunt the patient’s normal drive to breathe. But most patients breathe well enough during the procedure, and go home with no complaints other than a mild sore throat.

News reports have speculated that the root cause of Ms. Rivers’ rapid deterioration during the procedure could have been laryngospasm. This term means literally that the larynx, or voice box, goes into spasm, and the vocal cords snap completely shut. No air can enter, and of course the oxygen in the bloodstream is rapidly used up.

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6 COMMENTS

[…] Any facility that offers propofol for its patients, the AAAASF says, should stock neuromuscular blocking agents.  These medications, such as succinylcholine, could be life-saving in the event of laryngospasm as discussed in my previous post. […]

sad

It is sad but these sort of problems are more a result of arrogance, overconfidence or complete ignorance of how badly things can go wrong for the simplest of procedures. In this case things would have been more complicated because of her celebrity status and her advanced age. Under such conditions a cautious, experienced and good doctor would have taken extra precautions. Despite all the very best care sometimes patients do develop complications and die. Joan Rivers RIP. She has become an unfortunate victim of badly managed endoscopy procedure.

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Joan Rivers

There are minor operations and procedures, but there are no minor anesthetics.  This could turn out to be the one lesson learned from the ongoing investigation into the death of comedian Joan Rivers.

Ms. Rivers’ funeral was held yesterday, September 7.  Like so many of her fans, I appreciated her quick wit as she entertained us for decades, poking fun at herself and skewering the fashion choices of the rich and famous.  She earned her success with hard work and keen intelligence–she was, after all, a Phi Beta Kappa graduate of Barnard College.  Ms. Rivers was still going strong at 81 when she walked into an outpatient center for what should have been a quick procedure.

So when she suffered cardiac arrest on August 28, and died a week later, we all wondered what happened.  I have no access to any inside information, and the only people who know are those who were present at the time.

But the facts as they’ve been reported in the press don’t fully make sense, and they raise a number of questions.

What procedure was done?

Early reports stated that Ms. Rivers underwent a procedure involving her vocal cords.  A close friend, Jay Redack, told reporters at the NY Post, “Her throat was bothering her for a long time. Her voice was getting more raspy, if that was possible.”  In a televised interview, Redack told CNN that Ms. Rivers was scheduled to undergo a procedure “on either her vocal cords or her throat.”

However, the Manhattan clinic where Ms. Rivers was treated, Yorkville Endoscopy, offers only procedures to diagnose problems of the digestive tract.  All the physicians listed on the staff are specialists in gastroenterology.  Any procedure on the vocal cords typically would be done by an otolaryngologist, who specializes in disorders of the ear, nose, and throat.

So it may be that acid reflux was considered as a possible cause of Ms. Rivers’ increasingly raspy voice, and she may have been scheduled for endoscopy at the Yorkville clinic to examine the lining of her esophagus and stomach.  Endoscopy could reveal signs of inflammation and support a diagnosis of acid reflux.

Upper gastrointestinal (GI) endoscopy involves insertion of a large scope through the patient’s mouth into the esophagus, and passage of the scope into the stomach and the beginning of the small intestine.  It’s a simple procedure, but uncomfortable enough that most patients are given sedation or, less commonly, general anesthesia.

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1 COMMENT

Neal Koss

You were very kind in not being overly critical. I can’t believe that they did not even have a pulse oximeter in place, since that would have given an early warning. And without that simple device, procedures should never be done. It will be interesting when all the facts are known, but I am betting that no pulse ox was present.

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