Archive for the ‘Politics’ Category

Author’s note: This article was written in late March, 2020, for publication in the American Society of Anesthesiologists’ monthly magazine, the ASA Monitor. It was published online ahead of print on May 8, 2020.

As you read this, we will be at least six weeks further down the road of the COVID-19 pandemic than we are today. We may have answers to the questions that are causing us sleepless nights. With the benefit of that hindsight, what should we have done differently if we had known in March what we know today, in May?

There are two ways to look at this: the “macro” view and the “micro” view. The first refers to national policy, and the second looks at what we are doing as physicians, in our own hospitals. Let’s start with “micro”, as that’s what we have the most ability (perhaps) to influence.

Did we get serious about personal protective equipment (PPE) too early or too late? Did we waste it on asymptomatic, healthy patients before the pandemic really got started? Or did we fail to take it seriously enough, endangering ourselves, colleagues, and patients?

As I write, some hospitals are still working under a policy of using standard droplet precautions (regular surgical masks and eye protection) for asymptomatic patients, though guidelines are evolving rapidly with recognition that intubation and extubation are aerosol-generating procedures that warrant N95 mask protection. For hospitals with supplies of N95 masks that will only last a few more days, this is a looming problem, not easily solved. Manufacturers can’t meet even the current demand, and at least here in Los Angeles, the surge hasn’t peaked.

Other hospitals have already moved to using enhanced PPE for routine intubation and extubation in asymptomatic patients: for example, otherwise healthy patients presenting for breast cancer surgery. This practice is based on the fear that asymptomatic patients may be coronavirus carriers. Depending on the aggressiveness of the anesthesiology leadership, the recommended precautions may include head-to-toe coverage – what Atul Gawande, MD, MPH, referred to, in his March 21 New Yorker article on protecting healthcare workers, as “full Wuhan”. Will they regret this later, if supplies are exhausted? Was this ethically the right call when so many other hospitals lack basic supplies? Will they incur hostility from ICU or ED staff who arguably need enhanced PPE more urgently for critically ill patients? Or will they be very glad they did because their personnel escaped COVID-19 infection altogether? We just don’t know.

Dr. Gawande concluded that coronavirus transmission “seems to occur primarily through sustained exposure in the absence of basic protection or through the lack of hand hygiene after contact with secretions.” In other words, wash your hands and don’t touch your face. The best PPE in the world won’t help you if you contaminate your hands while taking it off, and then touch your face without washing your hands. He believes the “standard public-health playbook” can still manage this epidemic:  basic hand hygiene and cleaning; targeted isolation and quarantine of the ill.

Perhaps by May, all personnel in every hospital will be wearing standard surgical masks for patient interactions, as the best way to protect us all from droplet transmission by coughing. That seems sensible, but again, we don’t know if we’ll have enough masks. Perhaps by May, the enduring standard of care will be always to use N95 masks and tight-fitting goggles for intubation and extubation, even after the worst of the COVID-19 surge has ebbed. We’ll see.

The “macro” view

There are so many questions, and so few answers.

Was it the right call to close schools? Did this help to reduce coronavirus transmission? Or did it slow the rate of acquiring herd immunity among children, the population least likely to develop serious COVID-19 complications? Michael Osterholm, MD, MPH, a public health and infectious disease expert, argued in the Washington Post on March 21 that there has been no real difference in the rate of transmission between Hong Kong, where schools closed, and Singapore, where they didn’t. Meanwhile, the stress on the healthcare workforce is worse because of childcare worries on top of all else.

Chandra Ellis, MD, a plastic surgeon and burn expert, says she is seeing new cases of small children with burn injuries suffered at home from hot coffee spills and open oven doors, and she believes there will be more. Parents trying to work from home aren’t used to watching active toddlers at the same time. Is working from home really the best approach, or would healthy parents be better off at work with their work stations further apart, consistent handwashing, and support for generous sick leave policies so that they can stay home if they’re ill?

Why are some young, previously healthy adults ending up on ventilators from inflammatory complications of coronavirus? Could the severity of COVID-19 illness correlate with peanut allergy and asthma, which are more common in younger adults, or with vaping?

We understand – or think we do – why older patients are more susceptible to severe COVID-19 illness:  their immune systems aren’t as robust, and they have more underlying diseases. Does the severity of disease in older patients correlate (or not) with taking angiotensin-receptor blockers, whose biology has complex interactions with COVID-19?

What about East Asian patients who have a facial-flushing reaction to alcohol intake – do they survive COVID-19 better than others? We’ve never completely understood why there is a 30-50 percent frequency of the ALDH2*2 (acetaldehyde dehydrogenase) allele in East Asian populations (Chang, 2017). That allele is known to raise the risk of certain cancers (esophageal, stomach), but could it also confer resistance to zoonotic coronaviruses, which may have been a recurring source of viral illness in Asia for centuries?

How long can the lockdown last before the economic consequences become so severe that the public mutinies? Will “speakeasy” restaurants and hair salons start to open surreptitiously? It’s obvious that the economic hardships are greatest among the lowest-paid workers – restaurant employees, hotel cleaners, ride-share drivers. Will we see families lining up at food banks as they did in the breadlines of the Great Depression?

While major medical centers may be swamped with patients, and some anesthesiologists find themselves pulled from the OR to serve as intensive care physicians, ambulatory surgery centers aren’t calling in their usual per diem anesthesiologists to do cases. Many anesthesiologists aren’t working at all as elective cases dry up. All of us are seeing a horrifying drop in the value of our retirement portfolios. What will the economic outcome be for our profession as a whole?

Probably the most important remaining question is the one posed by Neil Ferguson, MA, DPhil, and his colleagues at the Imperial College of London: Can non-pharmacological interventions reduce COVID-19 mortality and healthcare demand? The authors believe that intensive intervention – social isolation, business shutdown – would have to continue until a vaccine is developed, which could be as long as 18 months away (Ferguson, 2020). We think these measures work, judging from the experiences in China, South Korea, and Singapore. It’s too early to tell yet about Italy, Spain, Germany, and England. The curve can be flattened, but what happens if interventions are relaxed? Will case numbers rebound? The authors conclude:

“While experience in China and now South Korea shows that suppression is possible in the short term, it remains to be seen whether it is possible long-term, and whether the social and economic costs of the interventions adopted thus far can be reduced.”

Dr. Ferguson tested positive for COVID-19 on March 18. Will he survive? What about U.S. Senator Rand Paul, who also has tested positive? Will COVID-19 go on to decimate the highest echelons of government worldwide? Will we conclude after the fact that America relaxed our own restrictions too early or too late?

As the great Danish physicist Niels Bohr said, “it is very difficult to predict – especially the future.” Will the month of May bring warmer weather, reduced viral activity, and a return to normal? Or will the new normal be worse than it is today? Right now, in March, no one knows.

Do you think I went too far in my last blog post, calling out some journalists as “pontificating parasites” who love nothing more than to slam physicians and blame us for the cost of healthcare?

If you do, then you must not have read Elisabeth Rosenthal’s latest salvo in the Feb. 16 New York Times, where she says physicians are in “a three-way competition for your money” with hospitals and insurers, as if we’re all equally well-funded players at a craps table.

Even National Public Radio, often no friend to physicians, acknowledges that physician pay adds up to a mere eight percent of total US healthcare costs.

What stings even more, hearing that kind of accusation from Ms. Rosenthal, is that she used to be a physician herself before she quit emergency medicine to edit Kaiser Health News. I’m sure it’s a better gig: no nights, no weekends, no holidays. But, as Julius Caesar noted, it’s always worse when the stab in the back comes from someone you thought of as a colleague, if not a friend.

Surprise medical bills

The topic of Ms. Rosenthal’s one-sided op-ed is out-of-network billing, also known as “surprise” billing. Emergency physicians (along with anesthesiologists) may be the doctors most often accused of not being “in-network” with insurance companies and sending patients large “surprise” bills after the fact.

However, the American College of Emergency Physicians (ACEP), which represents Ms. Rosenthal’s former colleagues, is no happier than anyone else about out-of-network bills. “Much of this conflict over surprise billing is playing out in the media,” ACEP notes, “and insurers have been trying their hardest to paint emergency physicians in a bad light.”

ACEP is right. The facts about out-of-network bills, and the history behind them, differ from what Ms. Rosenthal would have the public believe.

What is a narrow network?

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If physicians are “muggers” and co-conspirators in “taking money away from the rest of us”, then journalists and economists are pontificating parasites who produce no goods or services of any real value.

I don’t think either is true, but the recent attacks on physicians by economists Anne Case and Angus Deaton, and “media professional” Cynthia Weber Cascio, deserve to be called out. You could make a case for consigning them permanently, along with the anti-vaccination zealots, to a healthcare-free planet supplied with essential oils, mustard poultices, and leeches.

My real quarrel with them — and with the Washington Post, which published their comments — is that they have the courage of the non-combatants: the people who criticize but have no idea what it’s like to do a physician’s work. More about that in a moment.

Ms. Cascio was enraged by the bill from her general surgeon, who wasn’t in her insurance network at the time she needed an emergency appendectomy. She doesn’t care — and why would she? — that insurance companies increasingly won’t negotiate fair contracts, and it isn’t the surgeon’s fault that Maryland hasn’t passed a rational out-of-network payment law like New York’s, which should be the model for national legislation. She doesn’t care that Maryland’s malpractice insurance rates are high compared with other states, averaging more than $50,000 per year for general surgeons. She just wants to portray her surgeon as a villain.

The two economists are indignant that American physicians make more money than our European colleagues, though they don’t share our student loan debt burden or our huge administrative overhead for dealing with insurance companies. They resent that some American physicians are in the enviable “1%” of income earners. But do they have any real idea what physicians do every day?

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We’re very fortunate in anesthesiology. We’re seldom the physicians who have to face families with the terrible news that a patient has died from a gunshot wound.

But all too often we’re right there in the operating room for the frantic attempts to repair the bullet hole in the heart before it stops beating, or the blast wound to the shattered liver before the patient bleeds to death.

Despite all the skills of everyone in the operating room – surgeons, anesthesiologists, nurses, technicians – and all the blood in the blood bank, we’re not always successful. A death on the OR table is a traumatic event and a defeat; we remember it decades later.

So yes, this is our lane too. Memories haunt me of the times when mine was the last voice a gunshot victim heard on this earth, telling him he was about to go to sleep as he went under anesthesia for the last-ditch, futile attempt to save him.

I use the pronoun “he” intentionally, as every one of those cases in my professional life has been a young man. My experience is representative; most gunshot victims aren’t the random targets of mass shootings. They are overwhelmingly male (89 percent), under the age of 30 (61 percent), and over half are from the lowest income quartile.

The National Rifle Association (NRA) is way off base in telling physicians to mind their own business as it did in its infamous November 7 tweet. Human life is our business. Pediatricians have every right to remind parents that gun security, and keeping guns out of the hands of children, are vital to their well-being right up there with getting them vaccinated.

At my house, we’ve always kept our guns padlocked in a safe that our children couldn’t have broken into with a crowbar. We’re not NRA members, but we enjoy going to a shooting range on occasion. I learned gun safety during my officer training in the Army Reserve Medical Corps. My husband and I are firmly in the category of gun-owners who take both the right and the responsibility with the utmost seriousness.

Physician opinions on gun control and gun ownership vary just as much as the opinions of the rest of the population. What doesn’t vary is our collective sense of responsibility for public health and our support for better, more readily available, mental health care.

The solutions to America’s horrific rate of gun-related deaths aren’t easy or obvious. But the NRA isn’t helping matters with its thoughtless and incendiary social media message.

When you tell anyone in healthcare that “sedation” to the point of coma is given in dentists’ and oral surgeons’ offices every day, without a separate anesthesia professional present to give the medications and monitor the patient, the response often is disbelief.

“But they can’t do that,” I’ve been told more than once.

Yes, they can. Physicians are NOT allowed to do a procedure and provide sedation or general anesthesia at the same time – whether it’s surgery or a GI endoscopy. But dental practice grew up under a completely different regulatory and legal structure, with state dental boards that are separate from medical boards.

In many states, dentists can give oral “conscious” sedation with nitrous oxide after taking a weekend course, aided only by a dental assistant with a high school diploma and no medical or nursing background. Deaths have occurred when they gave repeated sedative doses to the point that patients stopped breathing either during or after their procedures.

Oral surgeons receive a few months of education in anesthesia during the course of their residency training. They are legally able to give moderate sedation, deep sedation or general anesthesia in their offices to patients of any age, without any other qualified anesthesia professional or a registered nurse present. This is known as the “single operator-anesthetist” model, which the oral surgeons passionately defend, as it enables them to bill for anesthesia and sedation as well as oral surgery services.

Typically, oral surgeons and dentists alike argue that they are giving only sedation – as opposed to general anesthesia – if there is no breathing tube in place, regardless of whether the patient is drowsy, lightly asleep, or comatose.

The death of Caleb Sears

Against this backdrop of minimal regulation and infrequent office inspections, a healthy six-year-old child named Caleb Sears presented in 2015 for extraction of an embedded tooth. Caleb received a combination of powerful medications – including ketamine, midazolam, propofol, and fentanyl – from his oral surgeon in northern California, and stopped breathing. The oral surgeon failed to ventilate or intubate Caleb, breaking several of his front teeth in the process, and Caleb didn’t survive.

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