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ASA Monitor Today
Monitor editorial board members share “micro” news stories, research studies, and interesting items with the anesthesiology community.
March 28 | March 23 | March 22 | March 21 | March 16 | March 15 | March 14 | March 10 | March 8 | March 7 | March 3 | March 2 | February | January
Fentanyl vaccine could be a game-changer
March 28
A fentanyl vaccine is in development and could be a game-changer in the care of patients with an opioid use disorder. The antibodies are specific to fentanyl and do not alter the pharmacology of morphine and possibly other opioids. The advantage of the vaccine is that, because it prevents fentanyl from entering the brain, the euphoric effects will be absent. I am not sure how this will affect the care of patients who have received this vaccine and are in need of surgery. Perhaps fentanyl will be ineffective in its analgesic effects? Other opioids may need to be used during their surgical care.
The continuing controversy of doctored clinical titles
March 23
“MD,” “DO,” “CRNA,” “CAA,” “ARNP,” “PA-C,” “DNP”: This is just a sample of the alphabet soup of licensed professionals in American health care. The ongoing, increasing fights over titles — most critically around the term “doctor” and the designation “-ologist” — suggest that not everyone plays well in our collective sandbox and further suggest that an uninformed patient population may end up the losers in this struggle. Do patients understand who is actually taking care of them when titles and terms overlap (potentially inappropriately) between the practices of medicine and nursing (and even other fields)?
3-year study of NPs in the ED: Worse outcomes, higher costs
March 22
Like many physicians, I know that my medical education, residency training, and experience allow me to make a difference. This is especially true when the patient presents with more subtle symptoms and complaints. So it does not surprise me that in the VA system, where there has been a policy change to allow for nurse practitioners to work with no physician supervision, researchers found worse outcomes and increased costs for nurse practitioner-provided care.
Mis-Matched: 500 emergency medicine positions left unfilled
March 21
The number of unmatched positions for emergency medicine residency programs doubled this year with over 500 positions left unfilled and a 26% drop in applications to the specialty. This is very concerning as ER colleagues are part of our frontline workforce. Several drivers are suggested, including burnout from the pandemic, violence from patients, the burden of providing primary care in an emergency setting, and cost-cutting from health care corporations, as well as the growing opioid epidemic. As anesthesiologists are first responders on the wards, in the perioperative settings, and in intensive care units, we must learn from these lessons and recognize we are not immune to these very same factors.
Positive life-expectancy trend in Africa threatened by noncommunicable diseases
March 16
Life expectancy in Africa has experienced remarkable increases over the last few decades, a trend now endangered by a growing threat from noncommunicable diseases. Once known for its struggles with infectious diseases such as HIV, tuberculosis, and malaria, the continent now faces different challenges. Globally, seven of the top 10 causes of death are noncommunicable diseases such as ischemic heart disease, stroke, and diabetes. Urbanization, processed food sources, and sedentary lifestyles are all drivers.
Integrity test of a recent Cochrane mask review
March 15
Many were surprised by a recent Cochrane review on masking that concluded, “Wearing masks in the community probably makes little or no difference to the outcome of laboratory‐confirmed influenza/SARS‐CoV‐2.” A similar conclusion was reached for N95 masks, albeit for influenza.
In an interview, the lead author of the study, Dr. Thomas Jefferson (no kidding), also claimed that the evidence for transmission by aerosols was “thin as air” and that the best defense was hand washing. He also claimed in April 2020 that deaths from COVID-19 were just a seasonal viral illness. For what it’s worth, his interviewer, Dr. Maryanne Demasi, had part of her PhD dissertation retracted for image manipulation.
In response to the kerfuffle, the Cochrane Library has issued a statement clarifying the findings. The statement notes that the intent was not to assess mask effectiveness, but to assess interventions promoting mask use. The review only included two studies during the COVID pandemic, and both strongly favored interventions to promote mask use.
The New York Times has an excellent summary of the evidence regarding masks and the misinterpretation of the Cochrane results.
Medical groups launch effort to battle health misinformation
March 14
A partnership of 50 organizations called the Coalition for Trust in Health & Science made its debut earlier this month at the annual meeting of the American Association for the Advancement of Science (AAAS). Members of the coalition announced a two-year plan to develop resources and create a rapid-response platform to help combat what they call health disinformation. This article discusses the coalition. It's time to speculate on what anesthesiologists and the ASA Monitor could do to dispel common myths about anesthesia.
Minnesota Rare Disease Day proclamation
March 10
Rare diseases are not that rare for anesthesiologists anymore because newer therapies for successful treatment are becoming more readily available. This increases the number of such patients requiring anesthesia care. There is a significant gap both in education and the delivery of health care to these patient populations. To improve this situation and bring more recognition to the issue, Minnesota Governor Tim Walz proclaimed February 28, 2023, as Rare Disease Day. The Minnesota Rare Disease Council, along with the University of Minnesota School of Pharmacy and Stem Cell Institute, and many other sponsors including patient advocacy groups, conducted a special symposium on March 2, 2023, to highlight medical issues of concern and reviewed scientific updates to improve the care of such patients. There were many takeaways from this special conference, including new knowledge on a cure for sickle cell disease, gene therapy for Gaucher disease, and translational research suggesting future possibilities for the reversal of adrenoleukodystrophy with medications. The conference concluded with a special quote by Caroline Belden: "Equality is leaving the door open for anyone who has the means to approach it; equity is ensuring there is a pathway to that door for those who need it."
Aren’t you the valet? Tales of Black American surgeons
March 8
Although this piece was written by two prominent surgeons, I am sure that there are anesthesiologists who have experienced this same scenario. Posted just after the end of Black History Month, it is a sobering reminder to me that as a profession and a society, we have much work to do. I, for one, know I am not perfect. I need to ask for forgiveness when I stray from the principle of treating all people with respect. There is so much I need to learn. I urge you to read this and join me.
A world’s first: Scotland bans desflurane
March 7
Scotland becomes the first country to ban desflurane for environmental reasons. Desflurane has a warming potential 2,500 times that of carbon dioxide, so more countries may soon follow suit. Global health care is the fifth largest contributor to greenhouse gases. The elimination of harmful inhalational anesthetics is just the beginning of the many steps needed to curb health care’s impact on climate change.
Why aren’t we making a difference in perinatal medicine?
March 3
As documented this week in The Washington Post, the United States lags well behind other high-income countries in peripartum outcomes (see wapo.st/3ZrKEqa). Quoting the article: “By 2020, nearly all other rich countries saw the number of deaths per 100,000 births dip well below 10, while the U.S. saw a nearly 78% increase to 21 deaths per 100,000 births.” This graph from the WHO shows the rise in maternal mortality rate (MMR) from 2000 to 2020.
My items reported in ASA Monitor Today are in areas where anesthesiologists have little impact. Peripartum maternal mortality is an area where we have profound influence. The past 20 years have seen anesthesiologists bring ever-increasing training, skill, and medical expertise to perinatal medicine. Why aren’t we making a difference? How can maternal mortality have doubled over the past 10 years on our watch?
Minnesota takes practical step to address physician burnout
ASA Monitor staff
March 2
A decision by the Minnesota Board of Medical Practice (MBMP) in support of physician wellness is one that the AMA says can be emulated by all other state medical boards – a nice shout out for a practical approach. Specifically, the MBMP revised a key (and intrusive) question asked of doctors applying for or renewing their license regarding their health and fitness for practice, part of an “encouraging trend” in eliminating barriers to physicians and med students seeking mental health care.
Zoonotic transfer or lab leak?
March 2
As initially reported by The Wall Street Journal, the Department of Energy concluded that SARS-CoV-2 most likely resulted from a “lab leak” at the Wuhan Institute of Virology. The conclusion was reached with “low confidence.” The FBI shares this view, albeit with “medium confidence.” Other intelligence agencies believe it was zoonotic transfer. Confusingly, different government agencies have arrived at different conclusions. Neither the Department of Energy nor the FBI has shared the data that led to a divergent view from other agencies.
The scientific consensus continues to be that SARS-CoV-2 arose by zoonotic transfer at the Huanan Live Animal Market. There is an excellent and authoritative summary in Cell. One of the great pleasures of science is that conclusions are based on data. If either the Department of Energy or the FBI presents convincing data, then scientists will modify their conclusions based on the usual Bayesian approach of weighing new evidence against the prior probability of the conclusion and the quality of the evidence. However, absent either department coming forward with new evidence, quoting Edward Holmes in Cell, “the most parsimonious explanation for the origin of SARS-CoV-2 is a zoonotic event.”
February
‘Unwavering defense of democracy’: Thoughts on Ukraine after a year of war
February 28
If you want to be proud of our government and our unwavering defense of democracy, I urge you to read the interviews published in Politico about the run-up to the Russian invasion of Ukraine. Our top intelligence, military, and diplomatic officials provided on-record narratives of the intense international efforts to persuade Russia to resolve issues through diplomacy rather than military action, as well as the concurrent preparations for the worst-case scenario of an all-out land war in Europe. It’s an inspiring story to read on the anniversary of Russia’s unprovoked assault on a sovereign country.
Drug-resistant P. aeruginosa linked to artificial tears
February 24
There is an extremely rare form of drug-resistant P. aeruginosa that has been found in 58 patients across 13 U.S. states, linked to artificial tears. Five people have lost vision and one has died. The CDC recommends immediate discontinuation of EzriCare Artificial Tears and other products until further notice.
From the CDC website:
As of February 21, 2023, CDC, in partnership with state and local health departments, identified 58 patients in 13 states (CA, CO, CT, FL, IL, NJ, NM, NY, NV, TX, UT, WA, WI) with VIM-GES-CRPA, a rare strain of extensively drug-resistant P. aeruginosa. Thirty-five patients were linked to four healthcare facility clusters. One person has died and there have been 5 reports of vision loss. Dates of specimen collection were from May 2022 to January 2023. Isolates have been identified from clinical cultures of sputum or bronchial wash (13), cornea (12), urine (9), other nonsterile sources (4), and blood (2), and from rectal swabs (25) collected for surveillance; some patients had specimens collected from more than one anatomic site.
Most patients reported using artificial tears. Patients reported over 10 different brands of artificial tears and some patients used multiple brands. EzriCare Artificial Tears, a preservative-free, over-the-counter product packaged in multidose bottles, was the brand most commonly reported. This was the only common artificial tears product identified across the four healthcare facility clusters. Laboratory testing by CDC identified the presence of VIM-GES-CRPA in opened EzriCare bottles from multiple lots; these bottles were collected from patients with and without eye infections and from two states. VIM-GES-CRPA recovered from opened products match the outbreak strain. Testing of unopened bottles of EzriCare Artificial Tears is ongoing to assist in evaluating for whether contamination may have occurred during manufacturing. Patients and healthcare providers should immediately stop the use of EzriCare Artificial Tears pending additional information and guidance from CDC and FDA.
FDA encourages health care professionals and patients to report adverse events or quality problems with any medicine to FDA’s MedWatch Adverse Event Reporting program. Consumers may also report adverse reactions by contacting FDA’s Consumer Complaint Coordinators.
Closed Claims Case Reviews & Anesthesiologist Coverage
February 23
A recent article in the APSF Newsletter about closed claims case review has implications for our profession and I wanted to share it with fellow anesthesiologists. “Non-Operating Room Anesthesia: Closed Claim Review and Analysis” offers two important findings on claims that resulted in indemnity payments, including:
- “Moreover, some NORA environments are prone to heightened scrutiny concerning production pressures and economic incentives, particularly in outpatient facilities with high procedure volumes. When a claim involves a code or another emergency, plaintiffs’ attorneys commonly examine the facility’s staffing and resources to assess whether appropriate personnel, equipment, and rescue medications were readily available. If they uncover any evidence intimating additional personnel or resources could have prevented a crisis or improved the patient’s outcome, they will fold these allegations into a basic yet effective theme: economic gain took priority over patient safety.”
- “Anesthesia professionals are often criticized for failing to appreciate the patient was high risk, or that they tailored the anesthesia plan to the facility’s practice model rather than the individual patient’s needs.”
Furthermore, their first recommendation states, “The easiest decisions to defend are those that are made in the best interest of the patient’s health and safety. To this end, anesthesia professionals should take sufficient time to perform a comprehensive preanesthesia evaluation and develop an anesthesia plan tailored to the patient based on the individual’s medical history and the nature of the planned procedure. Anesthesia professionals should have autonomy to select the anesthesia plan best suited for the patient, and while the proceduralist may provide input, the anesthesia professional should ultimately make the decision.”
But I found the following findings and recommendation important, and in my opinion, another reason that having a CRNA employed by a proceduralist makes implementation much harder than having an anesthesiologist supervising and evaluating each patient before the start of each anesthetic!
Comparing nurses and physicians in the ER
February 21
A working paper published in October by the National Bureau of Economic Research (NBER), titled The Productivity of Professions: Evidence from the Emergency Department, looked at around 1.1 million visits to 44 ERs in the VA, where nurses are able to treat patients without physician oversight. The document received a lot of press in major media outlets. The NBER indicated that treatment by a nurse practitioner resulted in an average 7% increase in costs of care and an 11% increase in LOS, which extended time in the ER by minutes for minor visits and hours for longer ones.
Fighting scope creep in TeXas and beyond
February 17
An article on the Texas Medical Association (TMA) website says organized medicine is banding together to oppose a piece of federal legislation that advocates say would expand the scope of practice for nonphysician practitioners like nurses and physician assistants at the expense of Medicare and Medicaid patients. Another article details the TMA’s larger fight against scope creep and why this issue should be medicine’s top priority.
Getting Paxlovid should not be this difficult
February 16
In the past week, I have heard from anesthesiologists at Stanford and other institutions who were unable to get Paxlovid after testing positive for Covid. Some were healthy. Others had significant risk factors. Some had mild cases. Others became profoundly ill. All were at risk of long-Covid.
Their experiences echo those described in a recent tirade in JAMA “Getting Treated for Covid-19 Shouldn’t Be This Difficult” (Mangurian, 2022). Frustrated by physician reluctance to prescribe Paxlovid, the Department of Health for the State of California issued this advice last December: “The decision to not prescribe Covid-19 treatment should be reserved for situations in which the risk of prescribing clearly outweighs the benefits of treatment in preventing hospitalization, death, and the potential for reduced risk of long Covid.” Restating the above, the only reason to not prescribe Paxlovid is if the risks of taking Paxlovid outweigh the benefits. That assessment is the basis of every therapeutic decision we make as physicians. All of us are at risk from Covid-19.
According to a paper published last week, there were 4,511 excess physician deaths from March 2020 through December 2021 (Kiang et al., JAMA Internal Medicine, 2023). While that is fewer than the rate of excess deaths in the general population during the pandemic, we are nevertheless at risk of serious illness, hospitalization, death, and long Covid.
As I explained previously in ASA Monitor Today, Paxlovid is not in short supply. Nirmatrelvir (the antiviral) has no known interactions with human proteins. It just tastes bad. Ritonavir, the CYP 3A4 inhibitor, has very few potentially consequential interactions with other drugs (e.g., warfarin, beta blockers, possibly anti-epileptics) when taken for just five days. Paxlovid is our only highly effective treatment for Covid-19. If you get Covid-19, get Paxlovid. If your colleagues get Covid-19, prescribe Paxlovid.
Bad outcomes aren’t always negligence
February 15
An article published recently on the AMA website says that physicians in Oregon are telling the Oregon Supreme Court that doctors can’t guarantee good results for every patient they treat – and this is something juries need to be reminded of in court cases, especially ones that may “pull at the heartstrings.”
But if an Oregon appellate decision is allowed to stand, jurors would no longer hear a longstanding piece of the Oregon’s Uniform Civil Jury Instruction that says “physicians are not negligent merely because their efforts were unsuccessful” and that “a physician does not guarantee a good result by undertaking to perform a service.”
Aiding the earthquake victims of Turkey and Syria
February 14
Like many of you watching the news reports about the devastation and loss of life caused by the earthquake in Turkey and Syria, our family is looking for ways to help those affected by the earthquake. Please consider donating to a trusted and verified organization if you are able to contribute. Both the Helping Hand for Relief and Development and the Syrian American Medical Society Foundation are trusted and verified organizations that provide on-the-ground relief (charity navigator ratings of 98% and 100%, respectively). The Syrian American Medical Society has also created a form to gauge interest in deploying as a volunteer on the ground.
Our thoughts and prayers are with family, friends, and their families, and all those affected by the terrible tragedy in Syria and Turkey. May God give them comfort and strength as they go through this ordeal and rebuild their lives.
Can philanthropic agendas worsen health care disparities?
February 14
The World Economic Forum (WEC) concluded last month under the theme “Cooperation in a Fragmented World” and called on world leaders to address immediate economic, energy, food, and health crises “while laying the groundwork for a more sustainable, resilient world.”
Around the same time, Gates Foundation CEO Mark Suzman was interviewed by Reuters and called for increased governmental spending on health care: “It's not right for a private philanthropy to be one of the largest funders of multinational global health efforts.”
Yet large funders continue their obsession with "technology" and "innovation," while most health care systems lack essentials such as oxygen and electricity. Are western-driven agendas worsening the disparity they are trying to address?
For further reading, you might be interested in the article “Ventilators are not the answer in Africa” by an anesthesiologist from Botswana.
Syrians need our help
February 10
The earthquake in Turkey and Syria has been devastating. The official numbers underestimate the extent of the casualties. The president of the Syrian American Medical Society (SAMS) has issued an appeal for anesthesiologists to help care for thousands of injured Syrians. If you are interested, please contact me at steven.shafer@stanford.edu, and I will direct you toward colleagues who are organizing this effort.
January
A call to action on global critical care
January 31
The pandemic has opened an opportunity window for those of us working toward equity in access to critical care. Much like safe surgery, universal health coverage cannot be achieved without it. Unfortunately, solutions remain siloed, and there is a continued obsession with technology when many places lack the very essentials such as oxygen and reliable electricity. This article in Critical Care is important as it represents the perspective of providers living and working in resource-constrained settings. Eleven of the 12 authors are in low- and middle-income countries. All authors have worked together in many capacities over the years to improve critical care capacity for their patients. This narrative outlines several barriers but also offers solutions to make universal critical care a reality.
