They are coming!! They are here!

Ellis Island stopped it's existence as a gate into this country many moons ago. The immigrant screening process is not centralized anymore and therefore not uniform for everybody. I am sure regulations and rules along with massive amount of forms to fill out suppose to help to screen out potential health problems in people trying to get a permanent residence. And I am quite sure all these measures are very effective in vast majority of cases. I have no inclination to criticize the government on the immigration issue (wrong blog!). What interesting is that with their potential and real diseases people bring their views on how things ought to be run as far as national health care as a policy, obstetrics as far as epidurals, and end of life paradigm as an ethical dilemma. I have just encountered a family of 69 years old gentleman from eastern Europe. Educated back in one of the former Soviet Republics (he was a university biology professor), with good sense of humor, very easy going and nice to interact with he was unfortunately diagnosed with end stage lung CA. Our oncologists were giving him no more then several months to live. And they were about to deliver that terrible news to him, as his family - the wife and two daughters called the oncology office and requested a meeting without his presence. At the meeting they were asking not to tell the patient the truth about his prognosis. As conversation progressed one of the daughters - a US trained radiologist - mentioned the interesting fact that back in their country terminal patient would be lied to - and it was not just a required by the communist government way of things, but rather well established medical and ethical practice. And it probably comes from widespread atheism in that part of the world (although it'd changing now), where death does not bring you to God, or anywhere for that matter. It's nothing less, then the ultimate tragedy. When we mentioned the fact that medico-legally doctors are obligated to tell patients the truth or what they think the truth is about their condition, family (without any hostility) brought up the issue of cultural differences, that must be respected as well from the legal point of view, as we respect some of the religious practices and don't transfuse blood to these patients even when we know it's in the best patient's interest. Go figure..

On call

There is nothing worse then being on call on a Friday. Well.. actually there is - being on call on a Saturday. I am saying this only because my call is half over. But it's Friday night, I am in on call in the Trauma Center and it's nice out there - people are going out, having a good time, drinking (of course, I would love to be one of them), getting into their cars and accidents and then come here. There are some other duties - just got called in to intubate the old guy who got a bad case of pneumonia; put to sleep a young 34 years old woman with a bad case of kidney stones - she was really miserable before surgery; put an epidural in a woman in labor- went in nice and easy, she was very thankful. I love doing epidurals for women in labor - it works right away, great for the whole family, everybody really enjoys the whole experience. For all of you out there screaming your lungs out for "natural labor and delivery" I have only one thing to say: God created the epidural space, not us, it is very natural to use it! Gotta go, new trauma is in the ER

Tragedy

On a nice summer day they went to a movie, 4 year old boy and his young, in their mid thirties, parents. During the movie or right after it, the boy started behaving weird, he stopped talking, fell on the ground and start having seizure. They rushed to the emergency room, where the seizure was stopped with medications. On the head CT scan a huge posterior fossa brain tumor was discovered. Retrospectively, they did acknowledge the fact that in the last month or so, he had been complainig of some headache, and had several episodes of vomiting, their pediatrician was thinking about some possible stomach flu kind of problem.
When I was called the neurosurgeon was very concerned on the phone - usually a bad sign- our guys are pretty calm here, so if there is a problem it's a real deal, not "just a test". I rushed to the ICU, the kid looked very sleepy, his pupils were reactive but uneven, blood pressure was normal, but heart rate was somewhat slow - pending brain herniation! We took him down to the operating room right away, and put an EVD - a draining device to decrease build up of brain fluid - his massive tumor obstructed normal passage of the brain fluid and it had nowhere to go, as a result pressure on the brain itself kept on building up and there was a point where it was high enough to cause his seizure and other symptoms. Unfortunately that how it is in kids - no any signs until it's huge. We brought him back still asleep. The MRI was done the next day, there are already metastasis into the spinal cord, he is having big surgery tomorrow, and then it is going to be a long sessions of chemo and radiation. Just wanna go home and hug my kids...

Should I watch "Sicko"

Her is my case: 43 years old gentleman was scheduled to undergo a simple laparoscopic hernia repair. It does not look like anything I have to worry about - simple, straightforward case, good surgeon I have done a million like this with. So, not a big deal, right? Wrong! The guy happened to be 377lb, a smoker - 2 packs a day since high school, severe sleep apnea, high blood pressure poorly controlled with meds that he takes sporadically, diabetes again poorly managed. Not bad. Hah..! I came in for an easy case! On top of all of this, he is quite demanding and somewhat obnoxious. The first thing he tells me after I have introduced myself was how great the movie "Sicko" was. How much better health care people get in Cuba. And after I told him that he was a seriously higher risk for surgery and anesthesia he was genially surprised and became angry with me, he started mumbling something about "greedy doctors" - is that also in the movie? I have not seen it yet, and now have no intentions. The fact that this "greedy" doctor is trying his best to get him through his surgery, that he had complicated this otherwise pretty straightforward process by years and years of abuse escaped him completely! Of course, I didn't argue, patients have different ways to cope with the stress of anticipating surgical procedure. But this situation does bring up a valuable point of personal responsibility. Maybe in Cuba or elsewhere health care is accessible to everybody. It was in my former home country - Soviet Union - it was equally shitty for everybody. The real challenge here is to make it equally great for everybody, because just making everybody covered does not make it better. The concept of universal health care has a great danger to make it significantly worse for people who do have coverage right now! If somebody finds the solution, plus general public assumes more responsibility for maintaining healthy life style, then and only then we will be on the right track.
And by the way, my patient did fine. He woke up coughing like crazy, we had to give him breathing treatment in the recovery room. Because of his sleep apnea issue I sent him to the special close monitoring unit overnight and consulted hospitalist doctor to take care of his diabetes after surgery. I don't think I am gonna see "Sicko", not soon anyway.

Robot in the OR

Technology is great! Progress is good! And misusing it is inevitable! We've been doing robotic surgery here for some time. And my feelings are mixed. Apparently urologists have enough data to support robot use in surgery, as for other surgical sub specialties I don't know. In some way it's a marketing tool, and some surgeons are pushed to start doing it, before all the data is in. I just don't see how surgery that usually is done in 2 hours now is stretched out to 8-10 hours is good for you. From anesthesia prospective it cannot be good - surgery over 3 hours may increase patients' chances for the heart attack in immediate postsurgical period. So, in my humble opinion, unless there is a STRONG evidence that robot gives us better outcomes, we should be more careful to use it. Of course, these surgeons will get better - our urologists now take the same time to do a robotic prostatectomy (removal of prostate) as they used to do it the old fashion open way. But today I have an 85 years old lady scheduled for a robotic GYNE surgery by the surgeon who has not done as many, and I just wander how beneficial it will be for her to stay under anesthesia 2-4 times longer.

No pain, no gain

Greetings, everybody! Hope your weekend is going great!
I have just finished my pain rounds and am on the way home. Nobody gave me any trouble today, except one kid - 16 year old after Nuss procedure. This surgery has changed the pectus repair forever. It is a defect in one's chest when the sternum (middle bone) grows inwards - does not look very good and may result in serious health problems. With Nuss, (name of the guy who came up with this procedure) a metal bar is inserted under the chest wall, and it's a bent bar, so after it is placed the chest wall kind of pops out and it does look much better right away. The problem is it hurts like there is no tomorrow. One of the most painful surgeries we do. The solution - high thoracic epidural along with some IV supplementation. Since we've started using epidurals we have much better postoperative course.
But this kid even with his epidural going full speed, even with IV Toradol (ibuprofen type of pain medicine), and occasional IV narcotics continued to rate his pain at 7-8 on 10 point scale. When I walked into his room, he was peacefully sleeping, he woke up, saw me and started grimmacing right away. Teenagers..I do belive he has pain, but it is not 7 or 8 or 5 for that matter. I guess, the common misconception that we can comletely avoid pain associated with surgery, and of course, that would be ideal, but it's not always possible. This kid is not properly informed and therefore prepared to this or any kind of surgery. I don't blame him or his surgeon (who is excellent, by the way), but the system. To buy a car we go through tons of research, we check multiple websites, blogs, we stop at different dealeships, we do our homework. But our health care is in the hands of others - insurance companies and hospitals. It's time to take personall responsibility - do your homework! Work with your doctors, know what to expect. www.surgerytomorrow.com

Friday at last

Eight cases at the SurgiCenter and I am done by 6pm, not bad at all! My first guy was a nice young, i think about 20 years old, kid. He had fallen on his shoulder while playing basketball. It took two sport medicine orthopads, three hours of anesthesia and a solid shoulder nerve block to fix him. It will probably take another 4-6 months until he is back to his regular activities. A lot of work on his part, but we did ours today - he is fixed and comfortable. The rest of the patients were routine knee scopes - nothing exciting. And I am glad, this week was full of excitement, enough is enough, Miller Time! I still have to see pain patients tomorrow, but no OR duties till next week. www.surgerytomorrow.com.

outpatient surgery day

I don't think i would like to get into all the political discussions about outpatient surgical centers that are popping up all over the place, but this one is really nice! Brand new, no big administration, things are done efficiently, and I think it is really nice for patients.
I had a couple of shoulder scopes today. First, was a healthy construction guy, he fell off the ladder, hurt his shoulder. I did a brachial plexus block (put some numbing medicine around the bundle of nerves that supply the shoulder), he did great - no narcotics, no hangover, no nausea, he left the center 40 min. after the end of his surgery. Makes you feel good!. I hope his block will last for 15 or maybe 18 hours.
The second patient was an older lady with arthritic shoulder problems. The same block for her. She did stay a little longer, but overall was very happy - she had complained prior to surgery that she always has problems with nausea after all her surgeries. Yepp..but not today! Nice short day for a change. Going for a run!

surgerytomorrow.com

I didn't realize that our website was down for a few days. Well, sorry if any of you tried to get in. Now it is up and running. anybody can come in and go through our survey if you are getting ready for any kind of surgery. It is free, and secure (you don't have to use your real name, or email, or whatever), and it will give you some info to read regarding your upcoming surgery and recommend tests and studies you might need. Check it out.

scoliosis is the summer surgery

Summer is a time for big spine surgeries in our OR. Teenage kids are out of school, so they come in to get it done during their summer break. Recovery is long and may be painful. Usually they are healthy otherwise, and although it is a huge surgery they do very well. But today it's a different story - 12 years old girl with severe cerebral palsy and tons of problems - seizure, post heart surgery (Fontan), G-tube (permanent feeding tube) and no veins. Dad was very nice and actually helpful in preop area. Initially I thought of getting IV access in preop, but after i talked to him and looked at her veins (rather on the absence of them) it became obvious that it would be better to put her to sleep with a mask and then look for a vein. So she got some Versed through her G-tube, and became really mellow with that. Mask induction was easy enough, and then one of those "better be lucky then good" just happened! I got an IV in, not a big one, just 22g, but it's a good start. The arterial line followed. Central line went into the neck - left IJ (internal jugular Vein) and we were ready to roll.
What I learn over the years about scoliosis surgery is that it is really surgeon dependent. When I was in my training, residency and fellowship, it would be whole day adventure with tons of blood loss. Patients would stay intubated (asleep with a breathing tube) at least overnight, we had to do all these (seemed advanced at the time) anesthesia techniques to slow down blood loss as much as possible (we would keep patients'blood pressure intentionally low, or take some blood from them in the beginning of the case, replace it with Ringer solution and give the blood back at the end of the case). When I started working on my own, with private surgeons, these cases stopped being as big of a deal anymore. We still get ready for a serious blood loss - large bore IVs, blood in the OR, ICU admission after surgery, but It takes only 4-5 hours, blood loss is there, but nothing unmanageable, and there were a few times when i didn't have to give blood at all.
We did transfuse our patient today, I think we lost about 900cc, and I did keep her intubated (it was more conservative approach then usual). Surgeons put epidural catheter in her back, for pain management after surgery, I have to take care of it now - they work in most of the scoliosis kids, but some require a little more attention. OK, gotta go now - my next challenge for today - 3 year old for an MRI study.

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Big people on OR table

I showed up today in the hospital looking forward to a fun day. My first patient is a pleasant 64 years old guy with severe shoulder arthritis. He is going for a total shoulder reconstraction. He's got pretty usual array of medical problems: high blood pressure, smoking (although he quit 3 years ago), enlarged prostate, that he had unenetfull surgery for, and last but not least - he is 340lb. And this is his (and now mine)real problem. We have to get him through this pretty extensive surgery. Fat people do present a real problem for anesthesiologists. They may have tons of hidden, underline medical conditions, such as heart disease, high blood pressure, sleep apnea, diabetis, etc. Specifically related to anesthesia, they may have, what we call, a difficult airway, - a situation where putting a breathing tube may be difficult or even impossible and sometimes will require additional instruments and techniques. I thought, my guy would definitly benefit from the nerve block - a technique where i would inject a nubming medicine near a bundle of nerves and his shoulder would be.. well, numb for 12-18 hours. That way, we may avoid General Anesthesia altogether, or at least he will require a significantly less amount of it, plus, after he wakes up, he will not feel any pain for long time and therefore will have no needs for strong pain medicine (narcotics) with serious side effects, especially in overwieght patients.
And that's what I did. The block went great, although took some time because it was difficult to identify the landmarks on his heavy, many times folded neck. And then I did put him to sleep - not a very fast surgeon, sitting position for surgery, i thought it would be easier to take care of his airways (put a breathing tube)while i still had access to him, before the surgery had started rather then struggle under the drapes, if urgent situation developes.
I had to delay the surgery again, since i did not have a full information on his heart status. He had claimed that he did have a stress test done - a test that evaluates heart functional status in patients with high risks factors (being fat, history of smoking), but we didn't get any information on that from his primary doctors office, so we waited for them to fax it to us - could've been avoided through our algorithm - www.surgeytomorrow.com

surgerytomorrow: today's cases

surgerytomorrow: today's cases

today's cases

The little kid did great! He is one of two, a twin, his sister stayed home - her head is normal! He was not pleased to see me in the morning, i was not upset - it was his feeding time, but we had to keep him hungry. There was some delay and confusion with his presurgical blood work - another proof of inefficiency of the current system, where anesthesiologist meets his/her patient in the morning of surgery; a short phone conversation with me would have been enough to avoid all that stuff, plus, the Mom was understandably anxious, so I had to take some time dealing with all that. But the case went great! Of course, we lost about half of his blood volume in the first hour or so, i was ready - two large IVs and an arterial line, so it was pretty easy to keep up. My fellow surgeons kept me on my toes, but that was expected. These are very special cases, it is easy to fall behind, and then it becomes nothing but trouble. We took him to the Intensive care still intubated, but he was awake and pretty comfortable 2 hours later. I did enjoy that.
Tomorrow a couple of big shoulders - scopes, rotator cuffs, etc..should be fun, I love doing those nerve blocks.
www.surgerytomorrow.com

cases for tomorrow

I got a big day tomorrow! First, 3 months old for a huge craniofacial advancement, those cases can bleed, and bleed fast, i hope kid got nothing else wrong with him. Hope, it is a full term boy with a funky looking head, and that's it. We can fix that. There are going to be two surgeons: a peds plastic guy and a peds neurosurgeon. Thank god, these guys are good and fast! From my, anesthesia, stand point, I will need a good access - a couple good IVs, It will be nice to get a 20g in the foot, will see..
Yes, these guys are fast. When I was just starting out I heard this from an old heart surgeon: "Not every fast surgeon is a good surgeon, but every slow surgeon is a bad one". Some may disagree, but there is some truth in it - hours under anesthesia is not good for you, unless you need it.
Then I got a couple of spine fusions. Those could be easy, or hard, depending on how big the fusion is, if it is just a couple levels, should not be a big deal, unless patient is sick or fat or both.
So I should be done by 7-8 at night. Not great, but can be worse.
If you are to have surgery soon please check out www.surgerytomorrow.com

solution

If you read the first post, I would like to let people who are savvy health care consumers know: There are solutions! As a matter of fact several.., If you have to have a surgical procedure, try to contact your Anesthesiology Departement several days prior. You may discuss your anesthesia options with your surgeon or primary care doc, OB/Gyne, pediatrician, and they may give you some good ideas, but, again, it's not their area of expertize, and when they start ordering tests specifically to prepare you for this surgery, I am almost sure, you will end up having done tests you don't need, and missing those you do need. The best case scenario: you will have done some extra studies, spent few extra $$$ and your surgery and anestheia will be uneventful, but there is another possibility: If your anesthesiologist decides in the morning of surgery, that those tests are not enough, your procedure maybe delayed or even canceled. If one or two or more tests just happen to be out of the customary "normal" range you will need more tests and consultations - surgery delayed or canceled. I don't want to scare people dead, but it has been many cases like that, frustrated patients and family members. Lots of wasted resources.
We (myself and my fellow partner anesthesiologist with tons of help from our computer/ web wizards) have developed an algorithm to help patients and their docs to get ready for surgeries and educate them along the way. It's free and will be soon available on www.surgeytomorrow.com. Please come in and use it, let me know what you think. We put a lot of thoughts and efforts into it. And it does work! You don't have to use your name or Social Security Number or credit card number. It's secure and private and FREE. It will give you recommendations on possible tests you might need before your surgery and also give you an article to read regarding your surgery. So it is www.surgerytomorrow.com

if you have to go to OR

If one has to have surgical procedure done what does it mean to be ready for it? I, medical doctor, mind you, have just underwent surgery. I am an anesthesiologist. So I do know some things about it. First of all i picked the surgeon, an orthopad i work with all the time, so i knew he was good, really good, then i asked one of my patners to do anesthesia for me. Things went very smooth with no problems, and I am recovering well, thank you very much. And then I started getting bills! Still not a lot of suprize there, i knew they were coming. But sitting at home it got me thinking: to prepare me - a healthy 40 year old with no medical problems, active, athletic (runnig 15-20 miles a week, playing ice hockey - that how I got hurt in the first place), my primary care doctor along with my surgeon ordered bunch of blood tests, Chest X-Ray, and even ECG, I did know prior to surgery - i didn't need any of that to "prepare" a patient like me to the type of surgery i was about to have, All these test ate most of my didactible, and they all were normal! What did they expect? Why would Chest X-Ray be abnormal in a healthy 40 year old with no symptoms or complains. As an anesthesiologist i constantly see this happen - surgeons, primary care docs order absolutely useless tests and studies to "prepare" their patients for surgeries. The problem is not that they are bad docs, but rather they don't know, it's not their field! It's mine! I do know! I was trained to do just that. The current system does nor allow patients to meet their anesthesiologist right before the surgery, so we are stuck to what other doctors order and most of the time it's tests that are not necessary, or sometimes the ones that would be useful are missing. We delay, postpone or cancel surgeries altogether. We did work hard to develop policies, to educate doctors and nurses, but although policies are useful they are not a panacea, medicine is not math, sometimes 2+2 is not 4! I saw some crazy numbers recently - about$2billions is wasted in this country on the unnecessary presurgical testing! Plus, let's say, one of the tests comes back abnormal, now what do you do? More tests! More time, more money, and possibly more complications. Surgery is not an indication for routine blood tests, X-Rays, ECGs, CTs, colonoscopies, etc..My advice - contact your anesthesiologist before your procedure, express your concerns ask for his/her opinion.