Anesthesia opt-out.

This has been quite the year for the practice of anesthesia and medicine as a whole.  The past year saw "Medicare for all" threaten to reduce reimbursement to peanuts, the dangers of propofol thrust into the mainstream media and the term "opt-out" enter our collective vocabularies.

It is the opt out and its issues I'd like to focus on in this post.  The who-provides-best-care-at-lowest-cost debate rages on in many a forum but here I would like to present mostly facts with a smidge of opinion (with sarcastic overtones of course).

The opt out was designed to address the issue of anesthesia care shortages nationwide by giving individual states the right to grant crnas the ability to practice without physician supervision.

This 2001 rule was created to give states “flexibility to improve access to anesthesia services without the burden associated with duplicative regulatory oversight,” said Jeffrey Kang, MD, then director of the Centers for Medicare & Medicaid Services (CMS) Office of Clinical Standards and Quality.

Since 2001, 15 states have invoked the "opt-out" and have granted this privilege.  The ASA, obviously, has opposed and the AANA, obviously, has supported.  The last state to "opt-out" was none other than California.  This came as quite the surprise to many as California has quite a large number of anesthesiologists.  The California Society of Anesthesiologists is in the process of filing a lawsuit to overturn the opt-out.  More info on that here.

From my sources on the ground, most hospitals and surgery centers still require supervision so there hasn't been any major upheavals in the state as far as I know.  I have heard of an anesthesia-trained pain physician fire his MD anesthesia support staff and hire crnas to give sedation in his block shop.  Hmmm.  Updates to follow.

For my opinion I will summarize an excellent lecture entitled "How Might Anesthesia be Delivered?" by
John P. Abenstein, MD, Associate Professor of Anesthesiology, Mayo Clinic College of Medicine, Rochester, MN

Future Impact on anesthesiologists: anesthesia today (is) easier to administer than 30 yr ago, but patients (are) sicker today, with more comorbidities and physiologic changes; result—switch of anesthesiologists’ work effort from administration of anesthetic to providing medical care; in speaker’s opinion, anesthesiologists should leverage knowledge and skills and use technologic advances to increase productivity and improve quality, reliability, and reproducibility of care; will be accomplished through industrial solutions (automated processes overseen remotely by highly skilled operators, with small number of individuals on floor to troubleshoot).  

Thoughts?


Update 2/6/10:  Coverage from the WSJ here.  Note the particularly active comment section.

Famous Anesthesiologists Chapter 1 - Virginia Apgar

Thought I'd use this space to highlight famous anesthesiologists and their contributions to the field.  Number one on the list has to be none other than Virgina Apgar.  Creator of the Apgar score and first full female professor at Columbia University, her contributions are unmatched.

Summary bio here.

The End of Mechanical Ventilation?

As the regular readers of The Anesthesia Blog have noticed, I tend to steer more more towards new technology as it relates to the passage of the gassage.  Its what I enjoy reading about and why I think most of the readership turns to blogs over texts.  Here's one tech breakthrough that knocked my socks off:

From Pulmonary Reviews:

PHILADELPHIA—A lung replacement device that oxygenates blood and removes CO2 was safely tested over a seven-day period in sheep. “Target CO2 removal was achieved,” while daily blood work values were not significantly affected; no adverse effects were found, reported Andriy I. Batchinsky, MD, at the American College of Chest Physicians 2008 Annual International Scientific Assembly. A device of this type potentially could replace currently available mechanical ventilators and thus eliminate the risks associated with their use, Dr. Batchinsky suggested.

We've come a long way from the iron lung.  While this type of technology will undoubtedly take time to pass muster, it is quite the interesting concept.  Not sure it'll replace the LMA or ET tube as the preferred method of CO2 exchange under anesthesia.  It does involve large bore venous access after all.  It could be an addition to the difficult airway algorithim...after surgical airway of course.  You know, the slash trach we all learned how to do in training.  Stay tuned for updates.

Christmas miracle or just another anesthesia save?

It is always interesting to see what personality types are attracted to different fields.  Anesthesia providers always strike me as somewhat-quirky, tech-savy and more commonly...humble.  If glory and ego boosting are your game then anesthesia is not for you.  It is always something I found "nice" about the specialty.  When I do everything right, nobody usually knows except me.  Out of Colorado comes further proof to my thesis:

From ABC News website:

In what is being hailed as a Christmas "miracle," a young mother died during labor with a still-born baby on Christmas Eve but both mom and baby came back to life just minutes later, before the eyes of the nearly heartbroken, stunned father.

They were getting ready to put a catheter in and I closed my eyes and don't remember anything after that," Tracey said.

She had no pulse, no heartbeat, was not breathing and was turning "gray," Dr. Stephanie Martin, director of maternal fetal medicine at Colorado's Memorial Hospital, told CBS News' Colorado affiliate KKTV. "She was dead."

After trying to revive Tracey for several minutes to no avail, doctors ordered an emergency C-section with no anesthesia in an attempt to save the baby. The baby was delivered, but it too was not breathing.

But then Mike and the doctors were astounded when Tracey's pulse returned, just after birth. Doctors quickly wheeled Tracey into surgery to complete the C-section. Then, while the mom was being operated on, other doctors worked to get the baby breathing again and eventually it came back as well.

Not sure what type of catheter.  The epidural kind perhaps?  Either way, no mention of anesthesia except the lack of it during the asystolic c-section.  Whatever the case, most emergency obstetric situations are rarely (if ever) handled by the obstetric team alone.  Kudos on the save to all involved, anesthesia and otherwise.

Postgraduate Assembly in Anesthesiology

The 62nd annual PGA has come to a close in NYC.  I would love to say it was a fabulous exchange of ideas regarding the profound leaps of progress made in the field of anesthesia.  In my humble opinion it wasn't.  I suppose its a sad commentary on the state of anesthesia research but hey who am I to judge, all I contribute is this piddly blog.

The technical exhibits were also less than stellar this year...a few new high tech ways to get the tube in the right hole, a funky new gel LMA, a LOT less swag than in previous years.  Most of the talk seemed to be about capital preservation, exit strategies and how to stick needles in people safely.  


Not the most productive few days, but hey at least we dodged some bullets.  See yall at the ASA.

Anesthesia and Gastroenterology....parasites, greed and symbiosis.

The GI-propofol debate rages on. This week the GI societies presented yet another study regarding the safety and effectiveness of GI supervised-RN-administered-propofol sedation. Summarized nicely here.

This is truly one of the uglier sides of business of medicine. Anesthesia as a whole is in the business of safety under sedation. Not sure anyone can argue that we are the best at it because that is ALL we do...unless you are the CRNA in the previous posting....I digress. If the money involved weren't so enormous there would be no issue. When (and not if) the reimbursements dry up for elective endoscopies the debate will be over.

Couple factoids I've come across about the debate I find disturbing:

• The additional costs of an anesthesia provider to elective endoscopy is estimated to be in the billions every year.
• GI endoscopists nationwide have begun creating corporations which employ anesthesia providers at a low hourly rate and keep the collected reimbursement for themselves...uh conflict of interest anyone?
• Providers who specialize in only propfol sedation for endoscopy are the highest earning anesthesia providers.

Once the biomedical engineers perfect the pill-cam this whole debate will be moot anyway. Or is it the radiologists that'll end it....either way we'll be out of the picture in the not-too-distant future.

Anesthesia providers behaving badly.

I've waxed poetic before about the role we play in keeping our patients safe while under anesthesia. At best we provide an ever-watchful eye while our patients are rendered insensate and helpless. All joking aside, its a role we should be honored to have, a role based on trust. So when that trust us broken, you can and should be held accountable. Your picture on TAB is just my way of doing just that.

From the AP:

ATLANTA — A metro Atlanta nurse anesthetist has been charged with molesting and sodomizing anesthetized patients in dental and medical offices, and police say the videotaped abuses could involve 100 or more victims.

Paul Patrick Serdula, 47, who worked in dental and medical offices across metro Atlanta, was arrested Monday night on child molestation and sodomy charges. The arrest came after authorities found several videos showing him fondling and groping patients who were under anesthesia at various offices, said Cobb County police officer Joe Hernandez.

One less crazy person practicing anesthesia.