August 2002
Volume 66 |
Number 8
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| Letters to
the Editor |
Stemp Stumps for Lema
Lema, You got guts. When I first read your stuff, I thought you
were a ham. Now, I'm proud to know you.
Keep dishin' it out.
Leo I. Stemp, M.D.
East Granby, Connecticut
Be Nice, Dr. Lema, or Find Someone Who Will Be
I do value editorials with strong opinions and enjoy reading
your column in the ASA NEWSLETTER, even when I am in disagreement.
The sign of a good leader is someone who can lead others without
being offensive or making enemies for the group. It is easy to
be a condescending. It is harder to acknowledge differences and
to discuss them in a respectful tone. Comments about "flyboy
nurse anesthetists" are not helpful to the collegial relationships
that many of us have worked hard to build with our professional
colleagues.
As part of your responsibility as the editor of the ASA NEWSLETTER,
our membership expects that you treat others with kindness and
respect. This is a sign of wisdom and maturity. If you are not
able to do this, I suggest that you may want to look for another
anesthesiologist colleague to take over the job as editor.
Martha Y. Daly, M.D. Santa Clara, California
Editor's Reply: Clearly, Dr. Daly has not seen the highly
offensive ads sent to Congress or heard the disparaging rhetoric
spewed out by her (certainly not my) "professional colleagues."
Moreover, Dr. Daly is not aware that many of the nurse anesthetists
who are stirring the pot trained in "independent" environments
such as the armed forces, where their respect for anesthesiologists
is virtually non-existent. Also, Dr. Daly is evidently unaware
of the millions of dollars our Society has spent on damage control
for the flagrant lies uttered by the American Association of Nurse
Anesthetists leadership to politicians denigrating our worth in
the operating room. If she had been privy to the many insults
that our leadership and delegates had to endure over the past
years, she would realize that my comments are, indeed, restrained.
Finally, I am not engaged in active negotiations in a leadership
position but serve as a sounding board or lightning rod for current
controversial topics when I write this column. Dr. Daly as an
ASA member has the right to be offended if I insulted her nurse
anesthetist friends and has the privilege of expressing those
feelings. As for this particular editorial, I liked it!
– M.J.L.
Striking at the Heart of the Health Care Crisis
I liked the March
2002 editorial "It's Been a Hard Day's Night" because
it said to me, "Mark gets it!"
Our five veteran board-certified staff anesthesiologists provide
a layered, back-up call coverage for the operating room, the emergency
room, the labor and delivery suite, the intensive care unit and
(in our free time!) cover a surgical center and provide anesthesia
at a small community hospital 60 miles north of us. We regularly
cover more than the 3,500 hours each year that you estimated for
the "average anesthesiologist."
The orthopedic and general surgeons have negotiated contracts
for emergency room on-call coverage while we did the same surgical
cases with them "gratis." We have approached our administration,
quietly seeking some fairness and equity in this situation and
were met with: "We are not interested." We have felt
intimidated by a hospital administration system that regularly
keeps its own people in a state of perpetual uncertainty and fear,
firing the CEO at regular intervals (about every one to two years).
I want to extend the thought of "drawing a line in the sand"
mentioned in the editorial. We recognize that with holding care
is the final and ultimate solution to our problems. This solution
also is exercised in various forms: early retirements, leaving
the specialty and office-based practice. Burnouts, divorces, alcoholism
and suicides strain the demands placed upon us. Each early departure,
each tragic death, results in one more person withholding care
or "drawing a line in the sand."
Orthopedic surgeons have a more effective form of withholding
care by saying, "No!" When they do so, particularly
for emergency room call coverage, their situation improves either
by a stipend for that coverage or a reduced workload. Withholding
care one physician at a time is destructive and fatal to health
care. Withholding care as a group of physicians, although scary
and temporarily disruptive, will both get attention and solve
our problems.
Your editorial mentions a "collapse" and portends a
day when physicians unite in an action of stopping work. Will
physicians have the courage, organization and foresight to take
a "Doc Holiday" in order to prevent a collapse? The
answer can be "yes," just like the anesthesiologists
in northern California who triggered off MICRA legislation by
taking a "holiday" about 25 years ago.
Will your next editorial be for all U.S. anesthesiologists to
take a "holiday" for the next three weeks until the
hours get better and money stops being drained? Unlike the MICRA
situation, which dealt with one problem, we have many problems
that force us to stay divided.
Stephen D. Mulder, M.D.
Templeton, California
4th and 10 With No Time on the Clock
I applaud your football-cum-anesthesiology analogy to the hard
times upon which we practitioners have fallen (April
2002 "Ventilations"). Unfortunately, most members
of our profession already are aware of the frustrations of practice
today. Your message only serves to rub salt into old wounds.
If you were truly interested in shaping up this losing team,
your message should go out on the Internet so that it reaches
an audience of millions of laypeople who remain totally ignorant
of the impending disaster in the delivery of health care in our
country.
Physicians of all specialties have been poorly served by our
constituent societies over the years. (I am 75 and still in practice,
so I know that of which I speak.) If the medical profession as
a whole does not rebel peacefully (as in Texas and New York recently),
we will be lucky to even attend a football game, never mind receive
the accolades of the fans (read patients).
Burton Rubin, M.D.
Alva, Florida
Myth-Shattering References
The review in the April 2002 NEWSLETTER, "Therapy
of PONV: An Overview," written by Ashish C. Sinha, M.D.,
makes the statement "nonuse of an orogastric tube can negatively
impact incidence." Despite its ongoing use by some, the myth
that a gastric tube will reduce postoperative nausea and vomiting
was debunked years ago. An opportunity to disseminate research
findings was missed; instead, anesthesia superstition has been
reinforced. See below for further reading:
1. Trepanier CA, Isabel L. Perioperative gastric aspiration increases
postoperative nausea and vomiting in outpatients. Can J Anaesth.
1993; 40(4):325-328.
2. Hovorka J, Kortila K, Erkola O. Gastric aspiration at the
end of anaesthesia does not decrease postoperative nausea and
vomiting. Anaesth Intensive Care. 1990; 18(1):58-61.
3. Gouzi JL, Moran B. Nasogastric tubes after elective abdominal
surgery is not justified. J Chir. 1998; 135(6):273-274.
4. Cheatham ML, Chapman WC, Key SP, Sawyers JL. A meta-analysis
of selective versus routine nasogastric decompression after elective
laparotomy. Ann Surg. 1995; 221(5):469-476; discussion 476-478.
5. Bauer JJ, Gelernt IM, Salky BA, Kreel I. Is routine postoperative
nasogastric decompression really necessary? Ann Surg. 1985; 201(2):233-236.
6. Jones JE, Tabaee A, Glasgold R, Gomillion MC. Efficacy of
gastric aspiration in reducing post-tonsillectomy vomiting. Arch
Otolaryngol Head Neck Surg. 2001; 127(8):980-984.
Steven Schrenzel, M.D.
Media, Pennsylvania
God Only Knows When This Controversy Will End
It is not the case that only atheists and agnostics feel uncomfortable
with the "Anesthesiologist's
Prayer," which was printed in the "Letters to the
Editor" section of the May 2002 NEWSLETTER. I am a
Unitarian (technically a Unitarian Universalist), which means
I could be atheist, agnostic, a believer in God or a believer
in some transcendent power.
The Unitarian God, however, is not a micromanager but is a giver
of tools and of responsibility. We meditate, we remember, we pray
in a nonspecific sort of way, but we don't think it is God's job
to do the work for us. It has always made me uncomfortable to
see people cross themselves before taking a free-throw. If you
make it, does that mean God recognizes your right to win over
that of your opponent? I recognize that giving anesthesia is a
higher and more difficult calling than taking a free throw. For
me, however, I remain uncomfortable with asking for more help
than I have already been given. I recognize rational people may
disagree, and I am happy to concede that if it is helpful, it
is useful. However, I find it exclusionary to be told that a religious
person must find this prayer helpful, and I know there are many
who feel the same. The belief that one's own religion is the right
one for everyone has caused a lot of trouble in this world. This
country was founded in large part by people seeking religious
freedom.
So go ahead and pray, but please don't ask me to do it with you
or tell me I am not religious if I refuse.
Harriet W. Hopf, M.D. San Francisco, California
Editor's Reply: I said that it helps one to focus on the
tasks of anesthesia. I hardly think that I was proselytizing or
forcing one to pray! One certainly does not need to even read
it if it is not applicable to one's faith. Moreover, greater than
99.99 percent of the membership would find these simple words
either universally applied or not applicable, but hardly offensive.
As a Unitarian, you either believe or do not believe in a "God/Creator,"
so which is it? I think we all need to lighten up just a bit.
– M.J.L.
Créme de la Scam
Dr. Lema, your editorial, "What's
the Name of the Game?" in the May 2002 ASA NEWSLETTER
had just the proper blend of criticism, snark and general disbelief
to appeal to one three-and-a-half years after retirement. I'm
63.5 years old and spent 27 years doing compassionate anesthesia
and keeping my head down. The last 10 years were a pastiche of
inability, disability and unability! How the hell did I do it?
We have a pain group that has offices at a "campus"
complex near downtown. Already it is difficult to get the "pain
doctors" to come in to take night call … there's always
something.
I still think it's only a matter of time until they break away
and do office work. No one wants blood on their bodies, weekends,
nights, epidurals and trauma.
But your worry about finances is very apt, and indeed, how much
Medicare cream will be skimmed (scammed) by "the others"
who'll do the noninvasive stuff first?
Name withheld upon request
Update on Central Line Complications Update
In the article "Central
Line Complications From the ASA Closed Claims Project: An Update,"
in the June issue of the ASA NEWSLETTER, T. Andrew
Bowdle, M.D., recommends transduction and display of a physiologic
waveform "as the most convenient and reliable method for
distinguishing the vein and artery." I would like to recommend
another more convenient and less cumbersome method to achieve
the same goal.1 A 20-gauge catheter placed in the vessel to be
cannulated is attached to 30-inch sterile intravenous extension
tubing without injection ports. A 5 ml syringe attached to the
female end of the extension set aspirates blood into the tubing.
With the extension set held vertically (perpendicular to the floor),
the operator detaches the syringe and observes the resultant "blood
manometer" for a change in the height of the column of blood.
A falling blood column indicates venous cannulation, while a
blood column that continues to rise indicates an arterial cannulation.
Note that the initial column of blood must be greater than the
patient's central venous pressure. Of greatest importance, the
column of blood must either rise or fall; lack of movement indicates
the need to check for patency of the catheter with a syringe and
reposition it if necessary or withdraw more blood into the tubing.
Several versions of introducer kits already contain the sterile
portless extension tubing for this purpose.
Unlike the test described by the author, this method does not
require an electronic transducer or invite a breach in sterile
technique connecting to a transducer not on the sterile field.
1. Bennett JA, Horrow JC. A method to avoid arterial placement
of an introducer sheath. J Clin Anesth. 1996; 8:171-172.
Joel A. Bennett, M.D.
Richmond, Virginia
Simplifying Central Line Complications
In an article by T. Andrew Bowdle, M.D., in the June
2002 NEWSLETTER concerning an update of central line
complications, Dr. Bowdle mentions that there are still instances
of large-bore catheters or introducer sheaths being inserted into
an artery instead of a vein. It is unfortunate that this is occurring
since this should essentially be 100 percent preventable in elective
situations.
Dr. Bowdle writes that examination of the pressure waveform is
the most convenient and reliable method for distinguishing between
vein and artery. In practice, there may be times when a transducer
is not available nor another person capable of managing the transducer.
A simpler, comparably accurate and always available method that
requires no assistance is to attach an extension tubing to the
small catheter and backfilling it with blood to a level above
the central venous pressure. If the blood column falls, it is
venous.1 Additionally, it avoids the possibility of accidentally
flushing an air bubble into an artery.
Another way to increase safety may be to insert central lines
into patients after they are intubated. In my institution, we
have had situations where a carotid artery was entered and a hematoma
developed, which led to the loss of the airway with neurologic
damage and death as the ultimate outcomes. Recent data supports
the idea that central lines can be inserted after intubation more
quickly and without any change in hemodynamic stability or vasoactive
drug use.2
1. Roth JV. Avoiding intra-arterial placement of the introducer
sheath. J Cardiothorac Vasc Anesth. 1993; 7(3):380-381.
2. Wall MH, MacGregor DA, Kennedy DJ, et al. Pulmonary artery
catheter placement for elective coronary artery bypass grafting:
Before or after anesthetic induction? Anesth Analg. 2002; 94(6):1409-1415.
Jonathan V. Roth, M.D.
Dresher, Pennsylvania
Lema Needs Mass Marketing
Your "Ventilations" in the June issue
of the ASA NEWSLETTER, "America
the Suable," is excellent. I am writing this small note
to let you know that this article should be published in every
major newspaper and magazine so that everyone, especially the
public, Congress, senators, etc., will be aware of this grave
problem.
Please continue what you are doing for the service
of all ASA members.
Prabhatsinh P. Mangrola, M.B.
Colleyville, Texas
'Genericide' Killing the 'Language of Shakespeare'
The letter [in
reference to the letter by Malcom T. Klein, M.D., "Catching
Errors Can Be Like Pulling Teeth," in the June 2002 NEWSLETTER]
mentions novocain as "genericidal" when he really means
(I hope) generic. What could genericidal possible signify?
Please try and use the correct term. English is the language
of Shakespeare, Milton, and Jane Austen. It deserves our respect!
Tamara F. Singer, M.D.
Los Angeles, California
Editor's Note: Any errors in this letter, perceived or
real, are included as submitted by the author.
– M.J.L.
The views and opinions expressed in the "Letters
to the Editor" are those of the authors and do not necessarily
reflect the views of ASA or the NEWSLETTER Editorial Board. Letters
submitted for consideration should not exceed 300 words in length.
The Editor has the authority to accept or reject any letter submitted
for publication. Personal correspondence to the Editor by letter
or e-mail must be clearly indicated as "Not for Publication"
by the sender. Letters must be signed (although name may be withheld
on request) and are subject to editing and abridgment.
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