We guard the privacy of patients in my hospital zealously—we take care of a lot of celebrities since we’re right in the shadow of Beverly Hills.  And of course we live in terror of HIPAA violations, those federally mandated HHS rules that protect individually identifiable healthcare information and could bring down “civil money penalties” upon us if we don’t keep our patients’ medical records strictly confidential.

But for healthcare workers—physicians, nurses, technicians, even medical supply vendors—in LA County, the usual privacy rules don’t apply any more.  Now everybody gets to know at least some of our medical history:  whether or not we’ve been vaccinated against influenza.

How will anyone know whether or not I’ve had this year’s flu vaccine?  Because policy dictates that I must publicly say so, whether I want to “out” that information or not.

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If you live in southern California, you can’t miss the billboards advertising laparoscopic gastric banding at “1-800-GET-THIN” outpatient surgery centers.  They feature happy people who’ve lost 100 pounds or more, and urge you to “let your new life begin” by having a “lap band” inserted.  Fees at these centers are much lower than they are at university medical centers or other major hospitals.

Recently, however, those surgery centers and their owners have been in a lot of trouble.  Patient deaths have been reported in detail by the Los Angeles Times.  Whistleblower lawsuits by former employees have accused the surgery centers of performing gastric banding with unqualified staff and unsanitary, malfunctioning equipment.   Members of Congress are calling for hearings to question the aggressive advertising that failed to disclose “lap band” risks.

Why would anyone believe that cheap surgery is a good choice?  Think about it for a moment.  If you buy a knock-off Rolex watch for a few bucks from a street vendor, are you really surprised if tarnish rubs off on your wrist?

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One of my partners recently sent out a call for an extra pair of hands to help out in the operating room—and with good cause.  The patient on the OR table was a woman in her 60’s whose massive stroke had left her hemiplegic, aphasic, and unable to swallow.  She weighed well over 400 pounds.  Attempts to place a percutaneous endoscopic feeding tube had failed due to her size, and she was now scheduled for open gastrostomy tube placement under general anesthesia.

Even with two experienced anesthesiologists working on the patient, getting vascular access and an endotracheal tube in place wasn’t easy.   She was anemic for reasons that weren’t fully worked up, and her blood pressure was alarmingly labile.  At the end of the procedure, the patient couldn’t be safely extubated so she went to the ICU.  As it turned out, she never left.   The family couldn’t agree on any reduction in the level of life support, and after a stormy five-week stay, she finally expired.  The cost must have reached hundreds of thousands of dollars, and all was spent on sustaining a patient who had no hope whatsoever of meaningful recovery.

This is really the elephant in the room in all the endless talk about health care costs in America, and it’s a subject that often is considered taboo:  the amount of money that we spend fruitlessly on end-of-life care.

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I’m a loyal supporter of the hospital where I work, and I think that we take excellent care of our patients. But when our administrators decided to put in place a checklist for operating room safety, they didn’t get the concept quite right.

We have a multicolored, cluttered form in our operating rooms that is referred to—not affectionately—as the “rainbow form.” It was implemented a year or so ago in an attempt to prevent wrong-side or -site surgery, retained foreign objects in surgical wounds, and other “never” events that could draw the wrath of the Centers for Medicare & Medicaid Services (CMS), state health officials, and The Joint Commission. It has checklists for things that should be done in surgery at different stages: before the patient enters the OR, at the time-out before surgery begins, during the process for counting sponges and instruments, and at the final sign-out before the patient can leave the operating room. All this sounds perfectly reasonable.

But has the “rainbow form” prevented errors? No, it hasn’t.

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They’re part of the game in football and relay races—but are handoffs safe for anesthetized patients?

As resident work hours decreased over the last few years, everyone hoped that hospitals would become safer. That hasn’t happened. No decreases in medical errors or improvements in safety have been demonstrated since residents quit working 36-hour stretches.

Many people think that more frequent handoffs—or handovers, as they’re called in Canada and Europe—may be a big part of the problem. As patient care is transferred between doctors at the end of each shift, vital information must be communicated. In a New York Times Magazine article about resident work hours published on August 7, Dr. Darshak Sanghavi warned that this process often turns into “a real-life game of telephone, where a message is passed from doctor to doctor—and frequently garbled in the process.”

Surely we in anesthesiology do better. Some anesthesiology practices hand off patients more often than others—academic and HMO groups often work according to a schedule with planned relief at the end of the day; private practice anesthesiologists tend to finish their own cases. But there has been little suspicion that handoffs of anesthetized patients were hazardous to their health.

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