Archive for the ‘Medical Education’ Category

It’s early May in Los Angeles, and dystopian reality is here – storefronts boarded up; people (if they’re out at all) wearing sinister-looking black facemasks. Inside the hospital, everyone wears a mask all the time, no one gathers in clusters to chat, and even the tail-wagging therapy dogs must be sheltering at home because they’re nowhere to be seen.

One change I didn’t see coming was a metamorphosis in airway management.

Guidelines developed for the intubation of COVID-19 patients are evolving into the new normal whether a patient is infected or not. This is even more remarkable since anesthesiologists consider ourselves experts in airway management, and many of us (how can I put this kindly?) hold firmly to our opinions. Who would have thought old habits could change? But airway management this year is different and scarier. Remember when we didn’t think of it as hazardous duty?

Who still “tests” the airway?

Consider the question of whether to “test the airway” before giving any neuromuscular blocker (NMB) during a routine anesthesia induction. Some of us believe that it offers a measure of safety, because you can back out and wake the patient up if you can’t ventilate. Those (like me) who don’t do it quote studies that demonstrate more effective mask ventilation with larger tidal volumes after NMB, and point out that if you can’t ventilate, most people will give NMB anyway.

That controversy seems to have gone into hiding. Today, the guidelines for intubating a patient with proven or suspected COVID-19 recommend rapid-sequence induction (RSI) to reduce the risk of the patient coughing and spraying the area with aerosolized coronavirus. No one in that situation seems worried about testing the airway.

What about the patient who is asymptomatic, and has a recent negative COVID-19 test result? There is legitimate concern that the patient could still be in the early, asymptomatic stage of infection, and the incidence of false negative results from COVID-19 testing could be as high as 30%. By that logic, we should treat every patient as a PUI, and perform RSI on all comers. It would be interesting to survey anesthesia professionals and see how many now perform RSI as their default approach. Certainly, residents now ask me on nearly every case if the plan is RSI, and I hear from colleagues at other institutions that my experience isn’t unique.

What about extubation?

If we don’t want coughing on intubation in the era of COVID-19, logically we wouldn’t want it on extubation either. Awake extubation, especially in the hands of novices, can include an alarming display of coughing and struggling by the patient, accompanied by cries of “Open your eyes! Take a deep breath!” by the person at the head of the table. More coughing follows as the tube comes out. In contrast, a recent review article on the care of COVID-19 patients advises removing the endotracheal tube “as smoothly as is feasible”. For our colleagues in the United Kingdom who are accustomed to deep extubation, this is routine. In America, it isn’t.

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Elegy for giant conventions

ANESTHESIOLOGY 2019 may have been the last old-school, convention-size, professional meeting I will ever attend. I could be wrong, but it may mark the end of an era. Disruptive change to the convention business model was inevitable, though hastened by COVID-19. On June 5, ASA leadership announced that the 2020 annual meeting will be virtual — for the first time, but perhaps not the last. Does this news herald disaster or opportunity?

When I was a resident attending my first ASA annual meeting, the huge convention center struck me as the mother lode of anesthesiology knowledge, with lectures and workshops that couldn’t be found anywhere else. Today, I wonder why I would travel across the country to attend a refresher course lecture in a freezing-cold meeting room, when I can watch similar content on YouTube or VuMedi for free, in comfort?

Professional associations could take this moment to move decisively into the video/podcast market. Speakers could record their own lectures, pro-con debates, and panel discussions, and societies like ASA and CSA could post all the content on proprietary video and podcast channels for members to access year-round. Think of the money we could save in travel and the cost of renting convention centers. Giant conventions at the ASA level are limited to only a few cities, most of which wouldn’t be my choice to visit.

The future of exhibit halls?

Corporate interest in buying exhibit space at anesthesiology meetings was fading fast, even before COVID-19. Why pay to send people and equipment to exhibit halls when mergers and acquisitions have centralized all the purchasing power? As recently as ten years ago, many anesthesiologists were able to influence which laryngoscopes or epidural kits their departments would order. Today, people who negotiate purchasing contracts typically work in the central offices of health systems, not in operating rooms. Today, most of us can do little more than complain about our inadequate stock of video laryngoscopes or the maddening electronic health record we’re compelled to use.

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“Each man or woman is ill in his or her own way,” Dr. Abraham Verghese told the audience at the opening session of ANESTHESIOLOGY 2019, the annual meeting of the American Society of Anesthesiologists. In his address, titled “Humanistic Care in a Technological Age,” Dr. Verghese said, “What patients want is recognition from us that their illness is at least somewhat unique.”

Though we in anesthesiology have only limited time to see patients before the start of surgery, Dr. Verghese reassured listeners that this time has profound and immense value. He pointed out that there is “heightened drama around each patient” in the preoperative setting. “Everything you do matters so much,” he said. What patients look for are signs of good intentions and competence, and the key elements are simple: “the tone of voice, warmth, putting a hand on the patient.”

Dr. Verghese, a professor of internal medicine at Stanford University and the acclaimed author of novels including the best-selling Cutting for Stone, believes that patient dissatisfaction and physician burnout are the inevitable consequences of today’s data-driven healthcare system, where physicians seldom connect with patients on a personal level or perform a thoughtful, unhurried physical examination. “Our residents average 60 percent of their time on the medical record,” he said.

“It’s the ‘4000 clicks’ problem,” Dr. Verghese said, citing a study in which emergency room physicians averaged 4000 mouse clicks over a 10-hour shift, and spent 43 percent of their time on data entry but only 28 percent in direct patient contact.

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The Hahnemann Disaster

Though the news at first stayed local in Philadelphia and the northeast, it’s gaining traction nationwide. ZDoggMD is on it. Bernie Sanders held a rally.

What happened? The venerable Hahnemann University Hospital, the main teaching hospital for Drexel University College of Medicine in Philadelphia, is bankrupt and will soon close its doors after more than 170 years as a safety-net hospital serving inner city patients.

Why should we care? After all, there are other teaching hospitals in the immediate area with capacity to absorb the patients, and they had several months’ warning to prepare.

We should care for many reasons, but I’ll start with the plight of the 570 residents and fellows who are being displaced from their jobs. Getting a residency position in the first place is a perilous process – there aren’t enough spots for all the graduating medical students who want them. Only 79% of the more than 38,000 applicants in 2019 snagged a first-year or internship position in a residency program.

So the Hahnemann residents – the “Orphans from HUH”, as they’ve started to call themselves – are scrambling on their own to find new jobs at a time when most residents are thankfully settling in to the new academic year. There’s no organized program to help them.

Even for the residents who’ve already found new positions, there are other boulders in the road. To begin with, they haven’t been released yet. They can’t start their new jobs and the Medicare funding for their positions is still tied up in bankruptcy court.

They’re still at work, wandering around a nearly empty Hahnemann with only a handful of patients left. The ER isn’t admitting any new patients and will shut down completely on August 16. The labor-and-delivery ward has closed. The new interns aren’t gaining any real experience and will be lagging behind their peers wherever they go.

“Doctors have been writing notes to update plans of care and people have come in as part of the liquidation to take away their computers,” a third-year internal medicine resident named Tom Sibert, MD, told Medscape reporter Marcia Frelick last week.

Tom Sibert? Any relation? Why yes; he’s my son. You can understand, I’m sure, why I went into full-blown mama lion fury when the Hahnemann situation blew up, and why I was beside myself with worry until he locked in an acceptance to an excellent program where he’ll finish his training.

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Once again, it’s Physician Anesthesiologists Week, and it’s a great time to celebrate our specialty’s many successes and accomplishments.

But we’re wasting an opportunity if we don’t also take this week to consider the state of the specialty today, and what it could or should mean to be a physician anesthesiologist 20 or 30 years from now.

There is no question that a seismic shift is underway in healthcare. Look at how many private anesthesiology groups have been bought out by—or lost contracts to—large groups and corporations; look at how many hospitals have gone bankrupt or been absorbed into large integrated health systems. Mergers like CVS with Aetna are likely to redefine care delivery networks. Where does a physician anesthesiologist fit into this new world?

An even better question to ask is this: Is your group or practice running pretty much as it did 20 years ago? If so, then my guess is that you are in for a rude awakening sometime soon. One of two scenarios may be in play:  either your leadership is running out the clock until retirement and in no mood to change, or your leadership hasn’t yet been able to convince your group that it can no longer practice in the same expensive, antiquated model. As one academic chair said ruefully, at a recent meeting, “They’re like frogs being slowly boiled. They just don’t feel what’s happening.”

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