Archive for the ‘Surgery’ Category

The real surprise – to me, at least – came more than halfway through Dr. Atul Gawande’s keynote address at the opening session of the American Society of Anesthesiologists’ annual meeting in Boston.

Much of his talk on October 21 celebrated the virtues of checklists and teamwork, topics that have turned into best-selling books for the well-known surgeon and professor of public health. “We are trained, hired, and rewarded to be cowboys, but it’s pit crews we need,” he said.

Then Dr. Gawande posed this question to the packed room: “What are the outcomes that matter?”

He answered his own question somberly. “The most unsafe operation is the operation that shouldn’t be done,” Dr. Gawande said. “Does the operation serve the patient’s goals or not?”

“We’ve all been there,” he continued. “Taking people to the operating room and wondering what we’re doing.”

Those are comments I’ve heard from anesthesiologists many times before, but I never thought I’d hear them from a surgeon.

Flogging the dead

For any of us who practice anesthesiology in a major hospital – doing cardiac, thoracic, or liver cases, for instance – there are days when all our efforts are spent on behalf of a patient whose health is unsalvageable. “Flogging the dead” is a phrase sometimes used to describe prolonged and futile care in the operating room or ICU.

Sometimes aggressive interventions are driven by a family that wants “everything” done, because in their innocence the family members have no idea how terrible and dehumanizing the process of postponing death can be.

In other circumstances, however, the decision of whether to do surgery is driven by the mission and the financial motivation of the health system to provide care. If care doesn’t occur, if the surgery isn’t done, no one gets paid.

If the anesthesiologist walked up to the bedside of an elderly, frail patient who is scheduled for a risky operation, and explained bluntly that the patient might die a prolonged and dismal death in the ICU, there would be hell to pay if the patient or the family decided to back out. The preoperative holding area, five minutes before surgery, isn’t the time or place to have that conversation. Yet that’s often when we meet our patients for the first time.

The “risk of death” is always mentioned in the informed consent documentation, but may be framed by physicians and nurses alike as a theoretical concern rather than a real possibility. The surgeon, the anesthesiologist, and the hospital are incentivized to do cases, not to step on the brakes and stop an operation. This is true even when the operation may fix a specific surgical problem but could lead to worse health, more pain, or loss of independence during the last months of life.

“Our goal is not survival at all costs”

One lesson that Dr. Gawande said he has learned from talking to patients is that people have priorities in life other than just survival. The goals will differ from person to person. If we don’t ask patients these difficult questions, Dr. Gawande said, “the care we provide may be out of alignment with their priorities.” That kind of care may cause more suffering than it alleviates.

One patient told Dr. Gawande that he would be okay with his quality of life so long as he could “eat chocolate ice cream and watch football.”  That’s better than any living will in terms of clarity, Dr. Gawande said.

He advised asking a patient, “What’s your understanding of where you are in your illness? What abilities are so critical to your life that you can’t imagine living without them?” Understanding the patient’s goals and fears can help the patient, the family, and the medical team reach the best decision about a plan of care, Dr. Gawande said.

“Our goal is not survival at all costs,” Dr. Gawande asserted. “Nor is our goal a good death. The goal is for our care to match their goals. To deliver the right care, at the right time, every time.”

For this fundamental change in the culture of healthcare to occur, payment models must change too, Dr. Gawande said. “A switch from fee-for-service to fee-for-value is absolutely critical for us to work successfully as teams. We have to be part of driving the reinvention of how we’re paid.” The team’s success should be linked to an outcome that is optimal in the view of the patient and the family, even if the decision is not to do surgery.

Dr. Gawande praised the many contributions of anesthesiology to improving processes of care and promoting patient safety. But he urged the ASA to “move from safety to outcomes as your priority.”

To achieve the best outcome consistent with each patient’s goals, Dr. Gawande said, “we need to work as teams before and after they come to the hospital. We need to be willing to take part in the experiments and drive the experiments so that we are paid as teams for better outcomes.”

Is it always wrong for a surgeon to book cases that will be done in two operating rooms during the same timeframe?

If you’ve paid much attention to the overheated commentary on social media since the Boston Globe published its investigative report, “Clash in the name of care“, you might easily conclude that the surgeon who runs two rooms ought to be drawn and quartered, or at least stripped of his or her medical license.

John Mandrola, MD, a Kentucky cardiologist who I’ll bet doesn’t spend a lot of time in operating rooms, weighed in on Medscape with a post called “The Wrongness of a Doctor Being in Two Places at Once“, accusing surgeons of hubris and greed.

Respectfully, I disagree.

The Globe’s story tells the dramatic tale of how a prominent surgeon at Massachusetts General Hospital often scheduled two difficult spine operations at the same time. According to the Globe’s reporters, the surgeon typically moved back and forth between two operating rooms, performing key parts of each procedure but delegating some of the work to residents or fellows in training.

On one particular day, a complex case ended with a tragic outcome. The patient, a 41-year-old man, sustained spinal cord injury at the level of his neck, leaving him permanently unable to move his arms or legs. Another prominent MGH surgeon leaked details of the case to the press, and was summarily fired.

Of course, I have no special access to information about what goes on at the MGH, and can’t comment on the specific cases highlighted in the Globe’s report. But I’ve been giving anesthesia for a long time in first-class hospitals. On countless occasions, I’ve seen surgeons run two rooms, and have administered anesthesia to a patient in one of them.

Have I ever seen a patient come to harm because the surgeon scheduled concurrent cases?  No.

Have I ever been annoyed because a surgeon delayed the start of my patient’s case because of the demands of the case in the other room? Yes, but I always agreed with the decision to delay, and the wisdom behind it. If the surgeon is at a critical portion of the first case, we have no business starting the second case until the surgeon gives the go-ahead.

Have I ever been thankful that the surgeon had two rooms? Yes indeed. Here’s why.

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“Twilight” is a movie

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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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 no data prove 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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“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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