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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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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Doctored

Dr. Sandeep Jauhar, a cardiologist, believes with good reason that many physicians have become “like everybody else:  insecure, discontented and anxious about the future.”  In a recent, widely-circulated column in the Wall Street Journal, “Why Doctors Are Sick of Their Profession,” he explains how medicine has become simply a job, not a calling, for many physicians; how their pay has declined, how the majority now say they wouldn’t advise their children to enter the medical profession, and how this malaise can’t be good for patients.

Dr. Jauhar gets it right in many ways, but the solutions he recommends miss their mark completely.

I was 100% in accord with Dr. Jauhar when he argued that “there are many measures of success in medicine:  income, of course, but also creating attachments with patients, making a difference in their lives and providing good care while responsibly managing limited resources.”

The next paragraph, though, I read with astonishment.  Does Dr. Jauhar really believe that publicizing surgeons’ mortality rates or physicians’ readmission rates can be “incentive schemes” that will reduce physician burnout?  Does he seriously think that “giving rewards for patient satisfaction” will put the joy back into practicing medicine?

If so, I’m afraid he doesn’t understand the problem that he set out to solve.

The truth behind “quality” metrics

There is no question that some physicians are inherently more talented, more dedicated, and more skilled than others.  In every hospital, if you speak to staff members privately, they’ll tell you which surgeon to see for a slipped disk, a kidney transplant, or breast cancer.  They’ll tell you which of the anesthesiologists they trust most, and which cardiologist they would recommend to someone with chest pain.  But none of these recommendations are based on simplistic metrics like readmission rates or even mortality rates.  They are based on observations over time of the physicians’ ability, integrity, and conscientiousness–all of which are tough to quantify.

Let’s take, for example, a common operation such as laparoscopic cholecystectomy:  removal of the gallbladder using cameras and instruments inserted through small incisions in the abdomen.  This is a procedure which most general surgeons perform often, with few complications.

When complications occur, there are almost always factors involved other than surgical error.  Patients with diabetes are more likely to develop wound infections, for instance.  Surgery on patients who have had prior abdominal operations may take longer and could cause bleeding or damage to other internal organs because of scar tissue.  Morbid obesity and advanced age are risk factors too.

The surgeon whose mortality rates are higher, or whose patients are more likely to be readmitted to the hospital, may be dealing with a much different patient population from the surgeon with the lowest rates.  An inner-city hospital may admit more patients as emergency cases, in more advanced stages of disease.

It’s difficult for statistics to reflect accurately the dramatic differences among patients that affect surgical outcome.  A noncompliant patient who doesn’t fill prescriptions and follow instructions is more likely to have problems, independent of the experience and skill of the surgeon.  Trying to distinguish among surgeons with “outcomes data” will only result in more surgeons refusing to operate on high-risk patients.

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There’s no mystery about why the July 23 execution of Joseph Wood in Arizona took so long. From the anesthesiologist’s point of view, it doesn’t seem surprising that the combination of drugs used—midazolam and hydromorphone—might take nearly two hours to cause death.

Here’s why.

The convicted murderer didn’t receive one component of the usual mixture of drugs used in lethal injection: a muscle relaxant. The traditional cocktail includes a drug such as pancuronium or vecuronium, which paralyzes muscles and stops breathing. After anyone receives a large dose of one of these powerful muscle relaxants, it’s impossible to breathe at all. Death follows within minutes.

But for whatever reason, the Arizona authorities decided not to use a muscle-relaxant drug in Mr. Wood’s case. They used only drugs that produce sedation and depress breathing. Given enough of these medications, death will come in due time. But in the interim, the urge to breathe is a powerful and primitive reflex.

So-called “agonal” breathing, which precedes death, may go on for minutes to hours. The gasping or snoring that eyewitnesses described would be very typical. People who are unconscious after overdoses of heroin try to breathe in a similarly slow, ineffective way, before they finally stop breathing altogether or are rescued by emergency crews.

More about the drugs

Midazolam is a member of a class of drugs called benzodiazepines. The common “benzos” that many people take include Valium, Xanax, and Ativan. What these drugs have in common is that they produce relaxation and sleep. You might take a Xanax pill, for instance, to help you nap during a long flight.

In anesthesiology, we use benzodiazepines for another important reason: because they produce amnesia. There are stories of people taking a Valium to relax a little before they give an important talk, and the next day panicking because they can’t remember if they actually showed up and gave the talk.

Amnesia can be very helpful in my business. Many of my patients don’t want to remember coming into the operating room and seeing the bright lights and surgical instruments. After I inject one or two milligrams of midazolam into the IV, they’re often smiling and relaxed, and they have no memory later of coming into the operating room at all.  The next thing they know, surgery is over and they’re waking up.

Hydromorphone is a member of a different class of medications: narcotics. These include powerful pain relievers such as morphine, Demerol, heroin, oxycodone, and hydrocodone. These medications, in large doses, will slow or even stop breathing altogether. That’s why the risk of overdose is emphasized so strongly, and why narcotics cause so many accidental overdose deaths.

When you put benzodiazepines and narcotics together, the risk of death by overdose rises sharply. These drugs in combination were implicated in the deaths of actors Heath Ledger and Phillip Seymour Hoffman. There’s no question that if you take enough of these drugs, your breathing will slow and eventually stop if no one steps in to help you.

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Here’s a doctor’s health tip for patients that I’ll bet you haven’t heard before.

If you’re a patient who walks into a hospital for an elective procedure of any kind–surgery, or a diagnostic test–and you find out that Joint Commission reviewers are on site, reschedule your procedure and leave. Come back another day, after the reviewers have left.

Why? Because every single person who works there will be paying a lot of attention to Joint Commission reviewers with their clipboards, and scant attention to you.

The Joint Commission has the power to decide whether the hospital deserves reaccreditation. Administrators, doctors, nurses, technicians, clerks, and janitors will be obsessed with the fear that the reviewers will see them doing something that the Joint Commission doesn’t consider a “best practice”, and that they’ll catch hell from their superiors.

For you as a patient, any idea that your clinical care and your medical records are private becomes a delusion when the Joint Commission is on site. Their reviewers are given complete access to all your medical records, and they may even come into the operating room while you’re having surgery without informing you ahead of time or asking your permission.

Perhaps physicians and nurses have an ethical duty to inform patients when the Joint Commission is on site conducting a review. Right now, that doesn’t happen. Does the patient have a right to know?

Unintended consequences

How did any private, nonprofit organization gain this kind of power? Why do American healthcare facilities pay the Joint Commission millions each year for the privilege of a voluntary accreditation review? It’s a classic tale of good intentions, designed to improve healthcare quality, that turned into a quagmire of unintended consequences and heavy-handed regulation.

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The Institute of Medicine in 2010 famously recommended that nurses should be encouraged to practice “to the full extent of their education and training.” Often, you’ll hear people advocate that every healthcare worker should “practice at the top of their license.”

What this concept is supposed to mean, I think, is that anyone with clinical skills should use them effectively and not spend time on tasks that can be done by someone with fewer skills, presumably at lower cost.

So I would like to know, please, when I’ll get to practice at the top of my license?

As a physician who specializes in anesthesiology at a big-city medical center, I take care of critically ill patients all the time. Yet I spend a lot of time performing tasks that could be done by someone with far less training.

Though I’m no industrial engineer, I did an informal “workflow analysis” on my activities the other morning before my first patient entered the operating room to have surgery.

I arrived in the operating room at 6:45 a.m., which many non-medical people wouldn’t consider a civilized hour, but I had a lot to do before we could begin surgery at 7:15.

First, I looked around for a suction canister, attached it to the anesthesia machine, and hooked up suction tubing. This is a very important piece of equipment, as it may be necessary to suction secretions from a patient’s airway. It should take only moments to set up a functioning suction canister, but if one isn’t available in the operating room, you have to leave the room and scrounge for it elsewhere in a storage cabinet or case cart. This isn’t an activity that requires an MD degree. An eight-year-old child could do it competently after being shown once.

(Just for fun, I sent an email one day to the head of environmental services at my hospital, asking if the cleaning crew could attach a new suction canister to the anesthesia machine after they remove the dirty one from the previous case. The answer was no. His reasoning was that this would delay the workflow of the cleaning crew.)

Then I checked the circuit on the anesthesia machine, assembled syringes and needles, and drew up medications for the case. To each syringe, I attached a stick-on label with the name of the medication, and wrote by hand on each label the date, the time, and my initials. These tasks, as you might guess, don’t require an MD degree either. A pharmacy can issue pre-filled syringes, and clever machines can generate labels with automatic date and time stamps.

It was now 7 a.m., and I moved on to the preoperative area to meet my first patient. I introduced myself, and started to interview her. Then I noticed that no one had started her IV yet. I asked the patient’s nurse if he would set up the IV fluid, which had already been ordered via the electronic medical record. “If I have time,” he replied.

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I give what could be lethal injections for a living.

That’s right. Nearly every day I give someone an injection of midazolam, vecuronium, and an IV solution containing potassium chloride–the three drugs in the “cocktail” that was supposed to kill convicted murderer Clayton Lockett quickly and humanely in Oklahoma.

Here’s the difference between an executioner and me. I use those medications as they are intended to be used, giving anesthesia to my patients, because I’m a physician who specializes in anesthesiology. Midazolam produces sedation and amnesia, vecuronium temporarily paralyzes muscles, and the right amount of potassium chloride is essential for normal heart function. These drugs could be deadly if I didn’t intervene.

My job is to rescue the patient with life support measures, and then to reverse the drugs’ effects when surgery is over. The “rescue” part is critical. When Michael Jackson stopped breathing and Dr. Conrad Murray didn’t rescue him in time, propofol–another anesthesia medication–turned into an inadvertently lethal injection.

When anesthesia medications are used in an execution, of course, no one steps in to rescue the inmate. This gives new meaning to the term “drug abuse”. In my opinion, the whole concept of lethal injection is a perversion of the fundamental ethics of practicing medicine.

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The Dark Side of Quality

Dark side 2

Nobody stands up to argue against quality and value in healthcare. You might as well argue against motherhood, or puppies. Yet many physicians are inherently skeptical of definitions of “quality” that are imposed from above, whether by outside evaluators like The Joint Commission, or (worse) by the government.

There’s good reason for skepticism. Some of the “evidence” behind “evidence-based medicine” has turned out to be flawed, tainted by financial conflict of interest, or outright fraudulent. Any experienced physician knows that there are fads in healthcare just as there are in fashion, and today’s evidence-based medicine may be tomorrow’s malpractice. Let’s take a closer look at what’s really going on in the world of quality metrics, and why it matters if payments to you and your hospital are increasingly linked to how you score.

Surgical Site Infections

The financial toll of surgical site infections (SSIs) is huge, estimated in the U.S. at more than $10 billion a year.(1)  A recent retrospective review from the Veterans Affairs Surgical Quality Improvement Program showed that the majority of SSIs are diagnosed only after hospital discharge, and that 57% will require hospital readmission within 30 days.(2)  The Centers for Medicare and Medicaid Services (CMS) stopped paying for care related to SSIs in 2008 by designating them as “never events”, or non-reimbursable serious hospital-acquired conditions. Now SSIs are part of a long list of hospital-acquired conditions that can result in reduced CMS payments to hospitals, and will bring further reduction in payments over the next several years with the implementation of “value-based purchasing”. More than 1400 hospitals will see their Medicare payments cut by as much as 1.25% this year–a margin that could spell financial disaster for hospitals already struggling.(3)

You may already be among the more than 50% of anesthesiologists who have been reporting performance metrics to the Physician Quality Reporting System (PQRS), which is administered by CMS. When the system started in 2007, CMS offered a bonus payment of 1.5% for successful participation, but that soon shrank to 0.5% and will be discontinued after 2014. Starting in 2015, CMS will impose a 1.5% payment reduction for physicians who do not participate in PQRS, and will push the pay cut to 2% in 2016.

If you participate in PQRS reporting, you know that two of the measures that anesthesiologists report are directly aimed at SSI prevention: perioperative temperature management, and antibiotic timing. PQRS measure #193 specifies that the patient must receive “active warming” or have a temperature above 36C recorded within 30 minutes before or 15 minutes after anesthesia end time. Measure #30 specifies that prophylactic parenteral antibiotics must be administered within one hour before skin incision. Compliance with these two measures isn’t hard to achieve, though no one seems to question the cost to the American healthcare system of all those forced-air warming blankets and machines, or ask why giving antibiotics 61 minutes instead of 59 minutes before skin incision is an automatic “fail”.

But have CMS threats and PQRS compliance done any good? A just-published editorial in Anesthesiology concluded: “Despite early efficacy literature establishing the value of specific antibiotic timing and active warming, repeated large database analyses have not observed robust effectiveness across hundreds of hospitals.”(4)   Simply put, as many of us have noticed in our own hospitals, SSI rates have remained about the same.

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Nepal? I don’t know anyone in Nepal. Yet not long ago I received a courteous email from a physician there, asking my permission to translate an article of mine into Nepali. The topic: advice for older patients who need anesthesia. He wants to distribute it to patients and publish it in his local newspaper.

I asked how he came across the article. He was browsing online among anesthesia blogs, and found mine, “A Penned Point“. Now “blog” isn’t a word Jane Austen would have recognized. It is a lumpish merger of “web” and “log”, and is generally defined today as a website on which an individual records opinions. The proliferation of blogs–like Tribbles–may be seen as a pernicious trend, but it demonstrates the power and reach of the Internet. Business Insider estimates that 22% of the people in the world own smartphones, an increase of 1.3 billion smartphones since 2009. In social media, once you put content out, you have no idea how far it will travel.

Many physicians consider social media a frivolous waste of time. Certainly they can be horribly misused–think of the cyber-bullying that goes on among teenagers. But used wisely, social media can be valuable communication tools. Here follows a brief guide to social media for physicians, admittedly subjective, with caveats included.

The doctor with an opinion

We all have opinions. Occasionally, we want the world to know about them. If you want to publish an opinion column and don’t want to create your own blog, there are online sites where your submission may be welcome. Probably the best-known public site for medical topics is KevinMD, which is curated by Dr. Kevin Pho, a New Hampshire internist. He came early to the game, starting his blog in 2004, and now has over 1000 regular contributors, myself included. You can submit a 500-700 word piece on almost any topic within medicine, aimed at an audience of physicians or at the general public. There’s a good chance that if you can put together a coherent sentence, Kevin will find a place for it. Brace yourself for the comments: Kevin’s readers tend to hold opinions as strongly as the writers do.
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“The creatures cause pain by being born, and live by inflicting pain, and in pain they mostly die.”–C. S. Lewis

The problem of pain, from the viewpoint of British novelist and theologian C. S. Lewis, is how to reconcile the reality of suffering with belief in a just and benevolent God.

The American physician’s problem with pain is less cosmic and more concrete. For physicians today in nearly every specialty, the problem of pain is how to treat it responsibly, stay on the good side of the Drug Enforcement Administration (DEA), and still score high marks in patient satisfaction surveys.

If a physician recommends conservative treatment measures for pain–such as ibuprofen and physical therapy–the patient may be unhappy with the treatment plan. If the physician prescribes controlled drugs too readily, he or she may come under fire for irresponsible prescription practices that addict patients to powerful pain medications such as Vicodin and OxyContin.

Consider this recent article in The New Republic: “Drug Dealers Aren’t to Blame for the Heroin Boom. Doctors Are.” The writer, Graeme Wood, faults his dentist for prescribing hydrocodone to relieve pain after his wisdom tooth extraction. As further evidence of her misdeeds, he says, first she “knocked me out with propofol–the same drug that killed Michael Jackson.” Wood uses his experience–which sounds as though it went smoothly, controlled his pain, and fixed his problem–to bolster his argument that doctors indiscriminately hand out pain medications and are entirely to blame for patient addiction.

But what happens to doctors who try not to prescribe narcotics for every complaint of pain, or antibiotics for every viral upper respiratory infection? They’re likely to run afoul of patient satisfaction surveys. Many hospitals and clinics now send a satisfaction questionnaire to every patient who sees a doctor, visits an emergency room, or is admitted to a hospital. The results are often referred to as Press Ganey scores, named for the company that is the leading purveyor of patient satisfaction surveys. Today these scores wield alarming power over physician incentive pay, promotion, and contract renewal.

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