CSA Bulletin - California Society of Anesthesiologists

Transcription

CSA Bulletin
California Society of Anesthesiologists
Vol. 59 No. 2
Spring 2010
CSA BULLETIN
The California
Society of Anesthesiologists
Periodicals Postage Paid
San Mateo, California
ISSN NO. 0745-7723
Spring 2010
Volume 59, No. 2
Editor ..................................... Stephen H. Jackson, M.D.
Associate Editors
Jason A. Campagna, M.D., Ph.D. ....... Patricia A. Dailey, M.D.
J. Kent Garman, M.D., M.S. ........ Arthur O. McGowan, M.D.
Kenneth Y. Pauker, M.D. ................Michele E. Raney, M.D.
Karen S. Sibert, M.D. ................. Mark A. Singleton, M.D.
Earl Strum, M.D. ....................... Mark I. Zakowski, M.D.
Chief Executive Officer .................... Barbara Baldwin, MPH
Managing Editor ................................. Andrea de la Peña
Business, Subscription and
Editorial Office:
E-mail Address:
CSA Web Site:
951 Mariner’s Island Blvd., Ste. 270
San Mateo, California 94404-1590
csa@csahq.org
http://www.csahq.org
Telephone: 650-345-3020
FAX: 650- 345-3269
Frequency:
Quarterly: Winter, Spring, Summer, Fall
All views expressed are those of individual authors.
2009-2010 Officers
President . . . . . . . . . . . . . . .................................. Linda B. Hertzberg, M.D.
President-Elect . . . . . . . ..................................... Narendra Trivedi, M.D.
Immediate Past President ......................... Michael W. Champeau, M.D.
Secretary . . . . . . . . . . . . . . . ...................................... ...... Earl Strum, M.D.
Assistant Secretary . . ................................... Christine A. Doyle, M.D.
Treasurer . . . . . . . . . . . . . . . ...................................... Peter E. Sybert, M.D.
Assistant Treasurer . . ................................... William W. Feaster, M.D.
Speaker of the House of Delegates ................ Johnathan L. Pregler, M.D.
Vice Speaker . . . . . . . . . . .................................... James M. Moore, M.D.
ASA Director for California ............................. Mark A. Singleton, M.D.
ASA Alternate Director ............................ Michael W. Champeau, M.D.
Chair, Educational Programs Division .................... . Adrian Gelb, MBChB
Chair, Legislative and Practice Affairs Division ...... Kenneth Y. Pauker, M.D.
Vice Chairs . . . . . . . . . . . . ..................................... Stanley D. Brauer, M.D.
. . . . . . . . . . . . ........................................... Paul B. Yost, M.D.
Contents
2
Editor’s Notes Move Aside, Clifford: Medicare/Medicaid is the
Biggest Red Dog Stephen Jackson, M.D.
6
President’s Page The CSA: Coming of Age Linda B. Hertzberg, M.D.
8
From the CEO Mis-Interpretive CMS Guidelines Barbara Baldwin,
MPH, CAE
Ê
11
Legislative and Practice Affairs
Ê UÊÊÊA California Political Update William E. Barnaby, Esq., and
Ê
Ê UÊÊÊCalifornia Hospital Association—Medication Safety Committee
Ê
Ê UÊÊThe 2009-2010 GASPAC Honor Roll Kenneth Y. Pauker, M.D.
William Barnaby III, Esq.
Jeffrey Uppington, MBBS
21
The “Hellhole” That is Haiti … CSA Was There!
25
Haiti Medical Assistance—A Life Changing Experience
30
ASA Director’s Report March 2010 Mark Singleton, M.D.
33
Data Exchange in the Information Age: Creation of the
Anesthesia Quality Institute Richard P. Dutton, M.D., MBA
37
2010 CSA Annual Meeting and Clinical Anesthesia Update
45
Dr. Rebecca Patchin Offers the AMA’s Perspectives on
Health Care Reform Rebecca J. Patchin, M.D.
49
In Memoriam: Gilbert E. Kinyon, M.D. 1921-2010
51
Gil Kinyon has passed away… Peter L. McDermott, M.D., Ph.D.
53
Peering Over the Ether Screen When is the Best Time for
55
Arthur E. Guedel Memorial Anesthesia Center Impact of
61
District Director Reports
75
California and National News
78
New CSA Members
79
Mark Your Calendar
Thomas H. Cromwell, M.D.
J. Kent Garman, M.D.
John Hattox, M.D.
Mistakes? Karen S. Sibert, M.D.
Published Manuscripts Merlin D. Larson, M.D.
Spring 2010
1
%DITORlS .OTES
Move Aside, Clifford:* Medicare/
Medicaid is the Biggest Red Dog
By Stephen Jackson, M.D., Editor
E
very year, the ASA Office of Governmental
Affairs becomes more important to the
future economic viability of our specialty.
Their tenacious campaign moved Congress to
rectify the egregiously unfair and illogical academic anesthesia teaching rule
and enabled many of our respected but economically suffering residency
programs to continue to operate with their customary excellence. Now,
however, we must focus on Medicare’s illogical and inexplicable RBRVS
formula, with its 33 percent reimbursement rate for our specialty, one that
continues to threaten to undermine the future of anesthesiology. The ASA’s
lobbying efforts will attempt to ensure that any healthcare “reform” somehow allows,
at a minimum, negotiated payment rates.
Even though our fractious and caustic, partisanship-engulfed Congress
abandoned attempts to lower the Medicare eligibility age to 55, we still
must confront the undeniable realities of our healthcare “reform” and what Medicare and Medicaid are becoming. The California HealthCare Foundation reports
that California has the largest number (4.5 million) of Medicare beneficiaries of
any state, and as California’s population ages, the percentage of Medicare
recipients will continue to trend upward. Under the national healthcare “reform”
bill, as many as two million low-income, previously uninsured Californians
will be newly enrolled in Medi-Cal and other public coverage programs, and
an additional two to three million would be able to obtain private healthcare
insurance. Indeed, the bill does raise reimbursement for primary care physicians
(PCP) to levels approximating those of Medicare, and this might encourage
PCPs to treat existing and newly insured Medi-Cal beneficiaries. Our elderly
population (those over 65) will more than double between 2000 and 2030,
and that scenario is independent of any healthcare “reform.” Medicare’s payments
*“Clifford the Big Red Dog” is a beloved American children’s book series written by
Norman Bridwell, initially published in 1963. As the storyline unfolds, the runt of a litter,
Clifford, is a tiny and frail red dog who is selected by a little girl named Emily Elizabeth
as her birthday gift. Her love for Clifford “enables” him to grow into a large (25 feet tall)
dog, ultimately forcing Emily Elizabeth’s family to have to move from their city home
into the country. The size of this big red dog unquestionably dominates the story lines.
2
CSA Bulletin
Editor’s Notes (cont’d)
in California are $600 higher per beneficiary than the national average. In 2004
and 2005, total annual medical payments for Medicare beneficiaries in this
state averaged about $11,300, of which $7,000 was paid by Medicare, and
$1,300 was paid by the beneficiaries as “out-of-pocket” expenses. Add to this
simmering cauldron the fact that in 2005, almost 80 percent of these beneficiaries
suffered from two or more chronic conditions, and almost 40 percent had four or
more. Given California’s already-existing overwhelming budgetary challenges,
and the fact that the national healthcare “reform” bill’s infusion of federal funds
will not fully offset the additional costs now heaped upon our state, California’s
public health programs will encounter grave difficulty in funding this major
coverage expansion.
The March 2010 issue of the journal Health Affairs reports the actuarial
prediction that in 2011, for the first time in history, federal government
programs will account for more than half of all United States healthcare
spending. While federal funds accounted for 47 percent of the $2.34 trillion
of national health spending in 2008, that figure is projected to reach 50.4
percent by the end of next year, and this represents more than 17 percent
of the Gross Domestic Product (GDP). Indeed, government healthcare programs
constitute an increasing portion of the federal budget, which is laden with
annual deficits exceeding one trillion dollars. National health spending grew
5.7 percent in 2009 (it had increased 4.4 percent in 2008), reaching the total
of $2.5 trillion, despite a projected decrease in the GDP. Accordingly, the
resultant projected rate-of-rise of the health share of the GNP is the highest
one-year increase since it was first calculated in 1960! Our weak economy with
its high unemployment rate is pushing more citizens into Medicaid programs,
and this represents a leading driver of the acceleration of the public payers’
health spending that is projected to rise 8.7 percent to $1.3 trillion.
And then, in the other corner, we have the inadequately regulated pharmaceutical
and profiteering private healthcare insurance industry, our poster boys for
healthcare capitalism run amuck. Private health insurers plead dramatically
increased costs and payouts as they cover new expenses by raising premiums,
deductibles and copayments in order to preserve their all important medicalloss ratio, which, in turn, produces enormous payouts to their executives and
dividends to their stockholders. And, bear in mind that there has been federal
subsidization of premiums made available by the Consolidated Omnibus
Budget Reconciliation Act (COBRA) to bolster private insurance. Assuredly, the
decrease in private healthcare insurance enrollment will suffer further as
unemployment maintains its depressing numbers and COBRA coverage threatens
to expire.
Spring 2010
3
Prior to passage of the new federal legislation, national spending was predicted
to grow more slowly in 2010 (5.2 percent), this in large part being attributable
to a drop in Medicare spending growth from 8.1 percent to 1.5 percent. Under
the mantle of the Sustainable Growth Rate (SGR) now in place, that Medicare
figure would be significantly influenced by the mandated 21.3 percent reduction
in Medicare reimbursement to physicians, while Congress continues to equivocate
by pushing the implementation date for such a drastic cut further into the
“near” future. Indeed, if this SGR “hit” were to occur, then national health
spending would decelerate from the 2009 figure of 5.7 percent to 3.9 percent
in 2010. Then again, organized medicine is working on the assumption that
the 21.3 percent SGR hit will never be put into play, but the Fed’s continuous
threats of such a massive cut places organized medicine in an endless defensive
mode to protect an otherwise unacceptable status quo, essentially weakening
and postponing any concerted offence to advocate for a meaningful increase
in physician payments. As we can see, organized medicine has its hands full
of challenges, including the absence of any tort reform in our newly adopted
healthcare “reform.”
By the end of this decade, unless some cost-savings healthcare reform is
enacted, approximately one in five dollars spent in the United States will be on
healthcare, a magnitude not to be found in any other industrialized nation. The
Congress then would face the options of reducing benefits (read this as rationing),
neglecting quality of care issues, ratcheting down payments to physicians,
hospitals, nursing homes, vendors and such, and/or finding new or expanded
vehicles (read this as more taxes, even a federal sales tax) to raise revenue to
cover health costs. It is projected that a decade from now, healthcare spending
will be closing in on $4.5 trillion. And, be alerted that the first baby boomers
become eligible for Medicare as they turn 65 in 2011.
Yes, folks, Americans (sorry, Emily Elizabeth**) now own the biggest red
dog of all—Medicare!
The House of Medicine is fractionated amongst its warring ideological,
specialty and mode-of-practice interests. As it struggles to regain its
former preeminence as the single voice for American physicians, the
AMA’s influence within the halls of Congress could soon falter. I strongly
recommend that you read the article by Dr. Rebecca Patchin, fellow
California anesthesiologist and current chairman of the AMA Board of
Trustees, beginning on page 45. Moreover, if you have not yet done so, I
urge you to read the two valuable articles on healthcare reform as it applies
to anesthesiologists in the March 2010 ASA Newsletter by ASA’s
** Emily Elizabeth is Clifford’s friend.
4
CSA Bulletin
Immediate Past President, Roger Moore, M.D., and ASA’s Executive Vice President
in Washington, D.C., and general counsel, Ronald Szabat, J.D., LL.M.
I also encourage you to read the fascinating Guedel article on the history of our
specialty by Dr. Merlin Larson in this issue of the Bulletin (see pages 55-60).
Following upon the spirit and essence of that article, your editors are calling
upon all of our readers to consider contributing to a column that we had
initiated over 13 years ago called “Tips From The Top.” These short articles
are written by you, giving you, our CSA members, an opportunity to publish
what you believe to be your uniquely innovative and successful techniques or
maneuvers that enhance the anesthetic management of your patients. These “Tips”
also can focus on improving physician well being, decreasing physician stress,
increasing efficiency/productivity, or containing costs. They even can challenge
conventional wisdom that you might believe to represent nothing more than
unsubstantiated “pseudoscience.” Of course, these “Tips From The Top” refer
not only to the “top” of the operating room table, but also being at the “top”
of your specialty. Don’t hesitate to share your gems with your CSA colleagues,
even if you are concerned with writing form, grammar, figures (if necessary), or
any imagined or real barrier. Your Bulletin editors (we’re truly a special breed of
editors, a friendly lot) will help “perfect” your presentation for publication.
Finally, I am saddened to note the passing of Dr. Gil Kinyon, former editor
of this Bulletin, President of the CSA, Assistant Secretary of the ASA, and
beloved friend and sage advisor to so many of CSA and ASA leadership over
the past half century. With his understated quick wit, “can-do” optimism, and
seemingly boundless energy and enthusiasm, Gil inevitably was a joy to be
around. We all shall miss him, and we wish his wonderful wife, Mary, and his
family our sincere condolences. Please see the wonderful memorials to our
beloved Dr. Kinyon by former CSA and ASA presidents, John Hattox and Peter
McDermott, on pages 49-52.
CSA Bulletin Cover for Volume 59, Number 2
“McWay Falls”
This is a photograph taken of McWay Falls in Julia Pfeiffer Burns State
Park in Big Sur. The image was taken from the trail to the falls on April 5,
2008. A digital Nikon D80 using a Nikon 18-200 VR zoom lens was
used without a tripod.
© Copyright 2008. This photograph was taken by Irving Olender,
M.D., and is reprinted on the Bulletin cover with his permission.
Spring 2010
5
0RESIDENTlS 0AGE
The CSA: Coming of Age
By Linda B. Hertzberg, M.D., President
I
n the last Bulletin, I discussed the possibilities
for the future of the CSA. As president this
year in particular, it often seems that one
reacts to problems or crises rather than moving
forward on a given agenda or strategic plan.
President Obama’s proposed health care reform
and Governor Schwarzenegger’s opt-out decision certainly created challenges
of that sort. As I write this, the House of Representatives is considering a
reconciliation bill for health care reform, and we are awaiting Governor
Schwarzenegger’s response to our lawsuit. Despite this aspect of the position
to which I was elected, it is important that decisions made by the president or
the board of directors and organization as a whole reflect the long-term strategic
goals and vision of the society.
The CSA celebrated its sixtieth anniversary two years ago, quite an accomplishment for a state society in a specialty which itself has existed only for little
over a century. Over time we have developed bylaws, policies, procedures, and
processes for the governance, structure, and work of the CSA. These guidelines
detail how our board of directors (BOD) and office should function to fulfill the
mission of the CSA: “The California Society of Anesthesiologists is a physician
organization dedicated to promoting the highest standards of the profession of
anesthesiology, to fostering excellence through continuing medical education,
and to serving as an advocate for anesthesiologists and their patients.” At the
heart of any programs that the CSA leadership initiates is this mission and the
benefit accrued to the CSA members.
In earlier times the role of the CSA was to promote the art and science of
the specialty of anesthesiology. The development of the specialty, educational
opportunities, collegial relationships with our colleagues, and the places
(primarily hospitals) where anesthesiologists practiced was the primary focus
of the CSA. That changed in the mid-1970s with the malpractice crisis.
Anesthesiologists were at the forefront of the demonstration at the state Capitol.
We played an integral role following the demonstrations in the negotiations
that led to the development of MICRA. From these origins of political activism,
we can trace the development of the CSA’s Legislative and Practice Affairs
Division and its advocacy efforts on behalf of our members. Obviously, as
times have changed, so has the CSA. Legislative and political advocacy is
now a primary focus of CSA activity throughout the year.
6
CSA Bulletin
President’s Page (cont’d)
However, with aging also comes the possibility of institutional inertia and the
unanticipated obsolescence of internal processes. In my speech to the CSA
House of Delegates at the 2009 Annual Meeting, I discussed the concept of
“the way we do it here” as limiting the ability of individuals and organizations
to adapt and change when necessary. Two things happened just recently that
again led me to think about how mature organizations react to new ideas. The
first was that my daughter Rachel turned 21 and “came of age.” Rachel has
not really changed; she remains a bright, enthusiastic college student with
lots of projects and boundless enthusiasm for the future and its possibilities.
Several weeks after that, a few of the members of the BOD and I had the
opportunity to visit the CSA office and spend some time interacting with the
office staff. Our staff members are enthusiastic and energetic, with ideas about
how we can make the CSA better. It was wonderful to be exposed to the
diversity of personnel, personalities, ages, and thoughts about our projects.
Clearly the newer members of the CSA office cadre have had an effect on
the entire office. They have spoken up and promoted new ways to improve
efficiency and perform office functions. The concept of continuous change, and
the ability of the CSA to use that process to move forward with new initiatives,
engages and energizes the office staff and makes them excited about the direction
of the CSA. We in leadership should learn from that energy and enthusiasm
and apply it to how we help manage the CSA of the future.
Like most medical societies, CSA leadership tends to remains fairly traditional
in its attitudes about how the organization should function. As noted before, we
have bylaws, rules and processes to guide us. However, none of these should
limit our ability to embrace change when it is beneficial to the membership and
function of the society. We need to think more like some of our younger office
staff members and more recent residency graduates who have become CSA
members. Examine the possibilities. Look for diverse ways of accomplishing
goals or projects. Use the electronic and other tools at our disposal to engage
CSA members, as well as members of the public. To fully come of age in the
twenty-first century will require that we adapt to a 24/7 culture, society and
news cycle. A slow, deliberative committee and board process has worked for us
in the past. In today’s rapid paced society, it may no longer be so effective. The
CSA of twenty-first century can come of age by finding innovative ways to move
in a manner that fits our goals and meshes with the pace of today’s society.
CMA Physician’s Confidential Assistance Line
(650) 756-7787 or (213) 383-2691
Spring 2010
7
&ROM THE #%/
Mis-Interpretive CMS Guidelines
By Barbara Baldwin, MPH, CAE
In December 2009 the Centers for Medicare
and Medicaid Services released revisions of the
anesthesia services sections of the Interpretive
Guidelines for Hospitals and for Ambulatory
Surgery Centers. Without any fanfare or foreknowledge of the ASA, several changes in
requirements for anesthesia services in both
types of facilities went into effect. How important are interpretive guidelines?
CMS’s description is informative.
“Survey protocols and Interpretive Guidelines are established to provide
guidance to personnel conducting surveys. They serve to clarify and/
or explain the intent of the regulations and all surveyors are required
to use them in assessing compliance with Federal requirements. The
purpose of the protocols and guidelines is to direct the surveyor’s
attention to certain avenues for investigation in preparation for the
survey, in conducting the survey, and in evaluation of the survey
findings.”1
In essence, Interpretive Guidelines instruct surveyors what to look for to
determine whether a hospital or ASC complies with the applicable Medicare
Conditions of Participation. Interpretive guidelines are developed at the staff
level within CMS and are not subject to public notice and hearing requirements;
hence, the perception that the new guidelines came out of the blue.
The new guidelines are based on existing Medicare conditions of participation.
Using existing regulatory language, several additions to both the hospital and
ASC guidelines established significant changes for anesthesia practice and facility
procedures.
Interpretive Guidelines for Hospitals2
Some of the modifications to the hospital guidelines are positive for anesthesiologists and patients, and a few are highly objectionable. On the positive side,
other than Critical Access Hospitals, hospitals are now required to organize all
anesthesia services throughout the hospital and in off-site locations under one
anesthesia service under the direction of a qualified Doctor of Medicine (M.D.)
or Doctor of Osteopathy (D.O.).
8
CSA Bulletin
From the CEO (cont’d)
Hospitals are required to establish policies and procedures defining
provision of these services that are consistent with State scope of
practice law.
The anesthesia service (department) must develop policies and
procedures on provision of ALL anesthesia services (including analgesia)
and minimum qualifications for each practitioner permitted to
provide ALL anesthesia services.
The interpretive guidelines draw a distinction between anesthesia (medication
to produce a loss of pain, movement, function and memory and/or consciousness)
and analgesia (relief of pain by blocking pain receptors).
Two guidelines go beyond current interpretations, seemingly expanding the
scope of practice for CRNAs and narrowly defining the term “immediately
available,” creating an onerous requirement. In addition, time requirements for
pre- and post-evaluation of patients are specified.
Ê
UÊ Ê
, ÃÊ>ÀiÊÃ«iVwV>ÞÊ«iÀÌÌi`ÊÌÊ>`ÃÌiÀÊ>LÀÊi«`ÕÀ>ÃÊvÀÊ
the purpose of analgesia without physician supervision. However, if
anesthesia effect is necessary for delivery, supervision is required.
Ê
UÊ Êºi`>ÌiÞÊ >Û>>Li»Ê ÃÊ Ã«iVwV>ÞÊ ìwi`°Ê ÕìiÃÊ ÜÊ
define immediately available to mean that the anesthesiologist must
be physically located within the same area as the CRNA or AA—for
example, in the same operative suite, same labor and delivery unit,
or same procedure room, and not otherwise occupied in a way that
prevents the anesthesiologist from immediately conducting handson intervention, if needed.
Ê
UÊ Ê*Ài>iÃÌiÃ>ÊiÛ>Õ>ÌÃÊÕÃÌÊLiÊ«iÀvÀi`ÊÜÌÊ{nÊÕÀÃÊ«ÀÀÊ
to any surgery (administration of first dose of anesthesia marks end
of 48 hours) with general, regional, or monitored anesthesia.
Ê
UÊ Ê*ÃÌ>iÃÌiÃ>Ê iÛ>Õ>ÌÃÊ ÕÃÌÊ LiÊ V«iÌi`Ê >`Ê `VÕiÌi`Ê
within 48 hours of any surgery involving general, regional, or
monitored anesthesia in both inpatient and outpatient settings.
Time begins when the patient is moved into the designated recovery
area.
Evaluation cannot begin immediately upon arrival to the designated
recovery area and cannot occur until after patient has sufficiently
recovered from the effects of anesthesia so as to participate in the
evaluation (e.g., answer questions and perform tasks).
For outpatients—must be completed prior to discharge even if 48
hours is later.
Spring 2010
9
From the CEO (cont’d)
Interpretive Guidelines for Ambulatory Surgery Centers
In May 2009, CMS issued a modification of the Conditions of Participation
for ASCs.3 Following that release, significantly revised interpretive guidelines
became effective December 30, 2009.4
Section 416.52(b) details requirements for post-surgical assessment and
discharge. A physician or anesthetist (depending on scope of practice)
must assess the patient’s recovery from anesthesia following surgery. Overall
assessments, also required, may be performed by a physician or other
qualified provider, including a registered nurse with experience with postoperative care.
A new guideline at 416.52(c) specifies that the operating physician must sign
the discharge order and that the patient is expected to leave the facility within
15–30 minutes after the order. This rule varies from standard practice in many
ASCs, where the anesthesiologist writes the discharge order with the operating
physician off-site.
ASA Response
ASA President Dr. Alex Hannenberg sent a letter to CMS Acting Director Charlene
Frizzera5 protesting the lack of transparency in developing the guidelines,
which lacked an opportunity for input by interested parties. In
addition, he addressed the benefits and shortcomings of the rules, noting the
positive effects of consolidating all anesthesia services under one department,
establishing policies and procedures and minimum requirements for all
personnel providing all anesthesia services. The change in requirements for
CRNAs administering labor epidurals without physician supervision was
challenged with questions about patient safety, particularly when complications
occur or a cesarean section is needed. He also addressed the logistical
complications created by the narrow time requirements for pre- and postanesthesia evaluation.
New information will be posted on the ASA Web Site and distributed to CSA
members. Members who are experiencing the practical effects of the changes
are urged to inform the CSA at csa@csahq.org.
http://www.cms.hhs.gov/GuidanceforLawsAndRegulations/08_Hospitals.asp
http://www.asahq.org/Washington/12-11-09%20RevisedANHospitalInterpretiveGuidelines.pdf
3
http://www.asahq.org/Washington/narules.pdf
4
http://www.cms.hhs.gov/transmittals/downloads/R56SOMA.pdf
5
http://www.asahq.org/news/asanews011810.htm
1
2
10
CSA Bulletin
/N 9OUR "EHALF a
Legislative and Practice Affairs Division
A California Political Update
By William E. Barnaby, CSA Legislative Counsel,
and William E. Barnaby III, CSA Legislative
Advocate
J
udging from the news media, voters
throughout the nation and California are
angry and eager to “throw the bums out.”
Elected incumbents, both legislators and
executive officials, see their approval ratings
spiraling downward. “Change” was the watchword in the 2008 elections but now “change,”
especially in health care, has become extremely
controversial and subject to strident opposition. At the same time, government
at all levels increasingly seems incapable of dealing effectively with chronic, longstanding problems. The “good old days” when partisan differences could be set
aside and problems resolved through compromise are only a distant memory.
Aside from mere partisan differences, the slumping economy with high
unemployment and increasing demand for costly public services presents a
huge challenge. However, the extreme partisanship of recent years, no matter
whether it merely reflects deeply held convictions, or is trotted out simply to
make the other side look bad, has undermined problem-solving. Throw into
the mix the constant change of decision-makers mandated by term limits, and
the ability to find solutions becomes all the more difficult. Office holders come
and go while the same chronic conditions persist and usually get worse.
The 2010 Elections
Voters in the upcoming June 8th primary will face another lengthy ballot.
Lacking the intense interest of the 2008 Presidential Election and the general
unhappiness with government, turnout is expected to be low. The biggest
draw usually is the race at the top of the ticket—in this case, for Governor.
Since former Governor and current Attorney General Jerry Brown is
unopposed for the Democratic nomination, the major contest will be on the
Republican side between State Insurance Commissioner Steve Poizner and
former eBay CEO Meg Whitman. Both are personally wealthy and are spending
millions to face Brown in the fall. Also on the ballot, but not likely to draw
much interest, will be the other constitutional offices—Lieutenant Governor,
Spring 2010
11
Legislative & Practice Affairs (cont’d)
Attorney General, Controller, Treasurer, Secretary of State, State Schools
Superintendent, plus five seats on the Board of Equalization and 10 to 15 ballot
propositions.
Legislative Term Limits
For the Legislature, change is built into the system because of term limits.
Of the 100 state legislative seats up for election (80 Assembly, 20 Senate),
37 will change hands even if there is not a single change in the party of the
office holder. Of the 37 districts, 11 termed-out Assembly incumbents will be
running for the Senate. The remaining 26 Assembly districts will be filled by
individuals who have no prior state legislative experience. The constant turnover prevents continuity of purpose and full understanding of the nature of
underlying problems. Continuity of patient care is an important factor in quality
medical treatment. Continuity is also important in governance, but it has been
severely weakened in California by term limits.
Even with all the public anger and disdain for politicians, there is no dearth of
candidates for “open” legislative seats. Primaries frequently are crowded with
three, four or five candidates seeking the dominant party’s nomination.
For our lobbying activities, an election year means numerous candidate
interviews. Candidates seek interviews with lobbyists who represent politically
visible clients, such as CSA, that have political action committees, such as
GASPAC. These interviews offer an opportunity to learn the views of candidates
and also an opportunity to educate them on the issues and concerns of clients.
This enables us to be acquainted and have some idea of the political views of
most of the newly elected lawmakers when they take office.
Of particular interest this year are the Assembly candidacies of three
physicians.
Dr. Richard Pan, an Assistant Professor of Pediatrics at UC Davis and former
Chairman of the California Medical Association’s Council on Legislation, is
running in the Democratic primary in Assembly District (AD) 5. It is an uphill
battle for Dr. Pan. The district is comprised mostly of suburban Sacramento
County and has been represented by Republicans for the past two decades. Its
voter registration is trending Democratic, however, and Dr. Pan is waging an
aggressive and broad based campaign.
Dr. Linda Halderman, a general surgeon specializing in breast cancer
treatment, is seeking the GOP nomination in the 29th AD located in the central
valley counties of Fresno and Madera. For the past two years, she has been
a top advisor to State Senator Sam Aanestad (R-Grass Valley). She sought a
12
CSA Bulletin
health policy position in the Capitol after her practice in an impoverished area
was not viable financially due to low Medicare and Medi-Cal payments.
Dr. Halderman entered the race after returning from volunteer medical service
in typhoon-devastated American Samoa last fall.
Dr. Don Kurth, an Associate Professor at Loma Linda Medical School and
President-Elect of the American Society of Addiction Medicine, is running for
the Republican nomination in AD 63 which is located in western San Bernardino
County. He is Mayor and a City Councilman in Rancho Cucamonga and previously
served on the Cucamonga Water District Board.
All three physician candidates have opposition in their respective primary
contests. All three are supported by CSA’s GASPAC, CMA’s CALPAC, and
other medical specialty societies. Their election would bring a solid physician
perspective to many of the health care controversies before the Legislature.
California Hospital Association—
Medication Safety Committee
By Jeffrey Uppington, MBBS, Director, District 8
I
represent the CSA on this recently formed
committee of the California Hospital
Association. It meets quarterly and has so
far met twice. It is composed of representatives
of a number of California hospitals, mostly
pharmacists and nurses, representatives from the
California Board of Pharmacy and the Department
of Public Health, representatives from the
regional association of hospitals, the Association
of California Nurse Leaders and the CEO (an ex-anesthesiologist) of the
California Hospitals Patient Safety Organization—CHPSO.
The first meeting began a discussion of the committee’s mission and purpose—
finalized at the second meeting—and a determination on how to proceed
practically. It was decided that three topics would be addressed initially by
separate workgroups within the committee. They were:
Ê
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Spring 2010
13
The mission of the Committee is to provide leadership within the health care
community to promote the highest standards in the safe and effective use of
medications for the population of California. The purpose of the Committee
is to provide a forum for diverse multidisciplinary health care organizations
which include regulatory agencies, patient safety organizations, disciplinespecific professional associations/organizations and health care delivery
organizations. The Committee will act as a source of medication safety expertise,
provide a venue for coordination of medication safety activities, and make
recommendations related to legislation and regulation related to medication
safety. At the second meeting, reports from the workgroups were presented.
MERP: There was consensus that every hospital is approaching MERP
differently, and there is high anxiety about what is expected. The California
Department of Public Health is struggling with the same issues. The workgroup
felt it important to try and standardize the MERP surveys. A draft survey tool
has been produced, and the workgroup will ask if it can provide input to the
survey tool.
EMO: More data is needed on where hospitals are vulnerable, mistakes made,
and potential remedies in this area. A survey could help collect this data. Best
practices need to be collected, vetted, and disseminated. The group decided
to restrict itself to Emergency Department patients for now and divided drugs
into three broad categories where review by a pharmacist before administration
could be helpful.
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Ê >`Ê ÃiÊ «ÃÌÊ «iÀ>ÌÛiÊ i`V>ÌÃ]Ê i°}°]Ê >«ÀÃÞ]Ê
antibiotics, Tylenol
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The group felt that each hospital could develop its own policies, the focus of
the group being to help hospitals tailor their own individual programs.
HR/HAD: The group—of which I am a member—did not meet before the last
full meeting of the committee. However, it has met, via telephone, since. It will
focus on various California hospitals and health systems to establish recommendations for high risk/high alert medications. While most hospitals have a
list of such drugs, there is not a universal list. The group could act as a repository
of high risk/high alert drugs resources, including a standardized list and
suggested protocols.
The CDPH uses All Facility Letters (AFL) to educate institutions about high
risk drugs, emergency medications and storage requirements. The HR/HAD
group could supplement these efforts, and it will ask the various hospitals
14
CSA Bulletin
for their list of high risk/high alert drugs. There is likely to be an effort to
standardize all IV infusions.
If anyone in the CSA has questions or suggestions for input to this CHA
Medication Safety Committee, please contact me at juppington@ucdavis.edu.
The 2009-2010
GASPAC Honor Roll
By Kenneth Y. Pauker, M.D., Chair,
Division of Legislative & Practice Affairs
It was the best of times, it was the worst of times,
it was the age of wisdom, it was the age of foolishness, it was the epoch of belief, it was the epoch of
incredulity, it was the season of Light, it was the
season of Darkness, it was the spring of hope, it
was the winter of despair, we had everything before
us, we had nothing before us …
— A Tale of Two Cities by Charles Dickens, 1859
T
he confusion, clarity, turmoil, hope, incongruity, and especially the
cognitive dissonance that was so pervasive in London and Paris during
the Age of the French Revolution was distilled and captured by Dickens
150 years ago. There is a curious parallel to our world today. The guillotine has
been retired, but politics endures.
As clinical anesthesiologists, we always have strived to safeguard our
patients from the “slings and arrows” of medical misfortune. ASA Past President
Dr. Mark Lema lamented that in addition to primary duties as regards
patient care, we have had “to protect and defend” our patients from “dabblers,
poachers, and charlatans” in recent years. We are fortunate indeed to have
many colleagues in the CSA and ASA who labor tirelessly on our behalf to
defend our patients and our profession, all the while holding a focus on
advancing the art and science of anesthesiology. It’s a big job, and it takes
expertise, time, energy, and money to do it, but your CSA and ASA are up
to the task. Who else understands you and speaks for you?
We live in a representative democracy and this is an election year. We
are engaged on many fronts in our struggle to defend our patients and to
advance our profession, but right now we absolutely must carry our messages
about who we are, what we do, what we want, and what we need to those
Spring 2010
15
who are elected to write the laws, to administer the government, and to
appoint the regulators. Most judges are appointed, but some, indeed, are
elected, while others must be confirmed at the ballot to continue in office
after being appointed, and/or after serving for a time. There is no mistaking
that each branch of government, even the judiciary, exercises its authority in
a political context.
Political Action Committees (PACs) are constituted to elect candidates
and advance the political agendas of various organizations. CSA’s Greater
Anesthesia Service and Political Action Committee, GASPAC, raises and then
disburses funds as campaign contributions to candidates running for state and
local office. GASPAC’s objectives are to promote and advance the practice of
anesthesiology, quality patient care, and public health. GASPAC encourages
anesthesiologists to be more engaged, active, and effective in government
affairs.
Simply stated, our PAC’s money (as well as that from individual donors and
candidate’s own resources) helps elect those who appear most sympathetic
to our objectives and to our philosophy on the issues most important to
us as anesthesiologists, regardless of party affiliation. GASPAC is the CSA’s
vehicle to have a voice in the political and policy-making arena. GASPAC can
accept donations from virtually any individual or entity in the United States,
personal or business, even corporations. National PACs that contribute to federal
campaigns have a very different set of rules and requirements such that
solicitations for ASAPAC are prohibited in this publication.
The general election is to take place on November 2, 2010. All state constitutional
officers, including a new governor, who has the authority to opt in or opt out
and to appoint members to many regulatory boards, and moreover all of the
state Assembly and half of the state Senate are up for grabs. Some judges will also
appear on the ballot. Some of the issues related to anesthesiology that may be
on the table include health insurance and Health Care Service Plans regulation,
Medi-Cal payment rates, scope of practice for ancillary health care professionals,
payment for non-contracted services, the bar against the corporate practice
of medicine, medical peer review, retaining MICRA, licensing of physicians
and facilities, and diversion, just to name a few. Every one of these could affect
our practices adversely and seriously. CSA must be visible and integral to the
discussion whenever these matters rise to the surface. GASPAC enhances our
visibility and advocacy and offsets interests pushing a contrary agenda.
GASPAC needs your help and is pleased with each contribution, but is
especially appreciative of those who have stepped up to lead in our efforts
to strengthen GASPAC, either by giving at the Gold level of support (*$500
16
CSA Bulletin
or more donation), or who have convinced their own groups to contribute a
group donation on behalf of all members.
I would like to extend a special thanks to Dr. James Buese, who not only
contributed at the Gold level himself, but also arranged a very substantial
additional contribution on behalf of his group, and to Drs. Jeffrey Parks and
Marvin Covrag, whose personal levels of support were beyond even our Gold
level. Thank you, doctors.
The 2009-2010 GASPAC Honor Roll is:
Audrey L. Adams
Emmanuel J. Addo
David N. Aguilar
Virgil M. Airola
Peter W. Allen, Jr.
Glenn W. Alper
Eric R. Amador
Rasheed Amireh
Clarita G. Amurao
Jeffrey L. Anderson
Ruth K. Anderson
Joseph J. Andris
Eduardo E. Anguizola
Christian C. Apfel
Anthony Arellano-Kruse
Kelly Asan
Gus G. Atkins
Merrill P. Bacon
Edward R. Baer
Eugene L. Bak
Barbara Baldwin
Brian J. Bane
Paul E. Banta
Alan R. Bargman
William E. Barnaby
William Barnaby III
Bruce Baumgarten
John W. Beard
Kevin P. Becker
Catherine J. Bell
Lawrence Bercutt
Dean B. Berkus
Craig D. Berlinberg
Mark H. Berman
Gerald Berner
Donald P. Bernstein
Spring 2010
Matthew G. Bertram
Ronald S. Bierma
Michael W. Bigelow
Lars L. Bjorkman
David K. Black
William A. Bode
Lowell A. Boehland
Bryan D. Bohman
Thomas P. Booy
Michael Borges
John B. Bornstein
Walter S. Brannan
Stanley D. Brauer*
Terrance W. Breen
David Brewster
Heinrich A. Brinks
Arne J. Brock-Utne
John G. Brock-Utne
Kamran H. Broukhim
James V. Buese*
Igor Bulatov
Rick R. Bushnell
Jerrold C. Bustos
Selma H. Calmes
Jason A. Campagna
Carol I. Capener
James W. Carlin
Paul D. Carlton
Timothy H. Carpenter
Sung M. Chae
Howard I. Chait
Ian Chait
Michael W. Champeau*
Patalappa Chandrashekar
Anthony H. Chang
Calvin Chang
Chai Jie Chang
Katherine A. Chang
Taposh Chatterjee
Anthony K. Chen
Tino Chen
Jason C. Cheung
Tony Chiang
Wonjae E. Choi
Stanley Chou
Nazia R. Choudhury
Harrison S. Chow
Todd W. Christensen
Peter E. Chu
Paul A. Chuljian
Byung J. Chung
Yueh-Han W. Chung
Matthew K. Cirigliano
Rodney D. Clark
Jeffrey P. Clayton
Henry Cola
Paul B. Coleman
Mark E. Comunale
William J. Conard
Antonio H. Conte
Gary P. Coppa
John F. Corbin
Daniel M. Cosca
Marvin D. Covrig*
Harry J. Cozen
Thomas H. Cromwell
James L. Crook, Jr.
Brian L. Cross
Giovanni Cucchiaro
Brandt R. Culver
Jason W. Cunnan
Frederick J. Curlin IV
17
Patricia E. Curtis
Gary L. Cutter
David P. D’Ablaing
Patricia A. Dailey
Martha Y. Daly
Pavan K. Davuluri
Maria A. De Castro
Michele C. Dee
Jeanette Derdemezi
Robert P. DeVoe
Annie T. Diego
Ralph S. Diminyatz
Donald B. Dose
George G. Doykos
Christine A. Doyle*
Monty Dunn
Ross A. Dykstra
Samir Dzankic
Steven A. Ecoff
George F. El-Khoury
Donna J. Ellis
Richard C. Engel
Paul Englund
David L. Estep
William Etiz
Douglas A. Etsell
William J. Evans
Arthur C. Ewers
Mark R. Fahey
Robert T. Falltrick
William W. Feaster
Jason Fellows
Neal E. Feuerman
Kevin J. Fish
James A. Flanigan
Cort P. Flinchbaugh
Richard P. Fogdall
Craig J. Fong
Wayne A. Foran
Brandt A. Foreman
Robert A. Frantz
Peter E. Frasco
Patrick M. Fujimoto
Kenneth T. Furukawa
James W. Futrell, Jr.
Jeffrey D. Galland
Donald J. Galligan
J. Kent Garman
Adrian W. Gelb
18
Steven J. Gerschultz
Bruce H. Gesson
Ernesto P. Gidaya
Russell Gilbertson
Gurdarshan S. Gill
Ted F. Gingrich
Gary M. Glaze
John C. Glina
Stefany W. Gluzman
Paul Goehner
Steven D. Goldfien
Randall L. Goskowicz
Amitabh Goswami
Mark T. Grabovac
Ryan B. Green
Michael A. Greenberg
George A. Gregory
Philip A. Greider
Jeffrey Grewal
Raman S. Grewal
Gary T. Guglielmino
Edward F. Gunz
Jaehong Gwag
Ali Habibi
Gordon R. Haddow
Derek P. Haerle
Klane L. Hales
Timothy W. Hansen
Mark E. Harlacher
Brian P. Harney
David C. Harris
John M. Harris
Richard E. Harris
Johnny R. Harrison
Richard D. Hauch
William L. Hazard
Daniel W. Heflin
Judith Hellman
Gordon L. Heminway
Michael G. Hernandez
George P. Herr
Linda B. Hertzberg
Robert E. Hertzka
William H. Hess
Nicole B. Hlava
Eric M. Hodes
David R. Holtzclaw
Victor J. Hough
James D. Howard
Kirk G. Howard
Joan E. Howley
John Hsu
Gary T. Hum
Ty W. Hutchins
Joel L. Hutchinson*
Kha K. Huynh
Kenneth A. Ikemiya
Kenneth Imanaka
Shale F. Imeson
David H. Irwin
George G. Izmirian
Stephen H. Jackson
Uday Jain
Robert M. Jarka
Todd I. Jen
William Jenkins
Harry Joe
Paul W. Johnson
Clyde W. Jones
Robert K. Jones
Peter C. Jong
Hasmukh G. Joshi
Patricia A. Kapur
Alireza Katouzian
Jeffry A. Katz
Ronald L. Katz
Wayne A. Kaufman
John L. Keating
Paul B. Kennedy
Mark E. Kenter
Randall H. Kerr
Robert T. Keszler
Leonard D. Kim
Sung-Hwan Kim
Kenneth Y. Kimura
Arthur C. Klein
Irv Klein
Wayne M. Kleinman
Michael S. Klemm*
Andrew A. Knight
Robert L. Kogan
Jonathan M. Kohl
Ronald D. Kolkka
Brian N. Kopeikin
Ali Korkorian
Thelma Z. Korpman
Rebecca K. Krisman
Sally V. Krueger
CSA Bulletin
Daniel A. Kuiken
Pramod Kulkarni
Sumangala Kuramkote
Hannah Kwon
Michael J. Laflin
Clinton J. LaGrange, Jr.
Ellis C. Lai
Michael Lam
George H. Lampe
Laurence A. Lang
Lance G. Larsen
Todd D. Lasher
Nathaniel C. Law
Brian B. Lee
George I. Lee
Kee Y. Lee
Steven E. Lee
Gary A. Leopold
Norman Levin
Leonard N. Lewenstein
David M. Lewis
Samuel Li
Yih-Chang Li
Michael J. Lillie
Dennis M. Lindeborg
Susan Loghmanpour
James F. Lourim
Jason P. Lujan
Stanton W. Lum
Philip D. Lumb
John A. Lundberg
Kevin Luu
Nelly K. Mac
Sean C. Mackey
Anthony H. Maister
Ann Marie Mallat
Susan R. Maloney
Douglas K. Mandel
Steven Lee Mandel
Steven J. Mandelberg
Gerard Manecke
Steven R. Marcum
Edward R. Mariano
Norma O. Marks
Rosemarie M. Johnson
Douglas J. Martin
Jonathan D. Maskin
Linda J. Mason
Rima Matevosian
Spring 2010
Elisa O. Maxwell
William G. Maxwell
Freddie D. McClendon
Peter L. McDermott
John S. McDonald
Michael D. McGehee
Jennifer L. McGinley
Theodore McKean
Fred J. McKibben
Roger S. Mecca
Joshua D. Meezan
Byron R. Mendenhall
A. Duane Menefee
Lonnie W. Merrick
Harry M. Miller
Kevin M. Miller
Ronald D. Miller
Anushirvan Minokadeh
Julian M. Mirman
LeRoy Misuraca
Avery C. Mittman
Daniel Y. Mochizuki
Joseph D. Mollner
Jack L. Moore
James M. Moore
Patrick A. Moore
Friedrich Moritz
Randall D. Morton
Mark G. Mulder
Michael J. Murphy
Steven Naleway
Ricardo F. Navarro
Marco S. Navetta
Daniel H. Nelson
Jesse L. Neubarth
Lindsay Newcomb
Philippa Newfield
Ethan A. Nicholls
Peter M. Nickel
Alan K. Nirady
Aidan P. O’Brien
Mary C. O’Keeffe
Norichika Okada
Vincent R. Okamoto
Deborah B. Olson
Gerald D. Pacelli, Jr.
Pamela P. Palmer
Gurnam S. Pannu
Joe L. Paredes
Cynthia Parenti
Jeffrey D. Parks*
Narendra L. Parson
Meenal S. Patel
Elena O. Patterson
Kenneth Y. Pauker*
Ronald G. Pearl
John J. Peckham
Daniel R. Perlov
Kenneth P. Peterson
Sonya D. Pettus
Gail P. Pirie
Jeffrey A. Poage
Grete H. Porteous
Gregory J. Porter
Jeremy B. Poulsen
Johnathan L. Pregler
Todd O. Primack
Alexander F. Pue
Ned Radich
Darrell W. Randle
Michele E. Raney
David A. Raskin
David Raybould
Danielle M. Reicher
Debra Reinking
Bruce J. Reitman*
Jalil Riazi
Mark J. Richman
Phillip C. Riddle
Mark L. Rigler
Miguel A. Rivera
Beverly B. Roberson
H. Douglas Roberts
Brian C. Robertson
Lawrence M. Robinson
Scott L. Robinson
Susanne C. Roessler
George G. Romero
William J. Rose
Jonathan B. Rosenthal
Richard W. Rowe
David J. Ruderman
Scott M. Rudy
Richard L. Ruffalo
Christopher G. Rumery
Kenneth R. Sacks
Nicholas G. Sakellariou
Jeffrey K. Sakihara
19
Robert H. Sanborn
Surinder Sandhu
Ned T. Sasaki
Stanley J. Scheurman, Jr.
Randal Schlosser
John C. Schmidt
Michael S. Schneider
John C. Scoles
David A. Shapiro
Thomas E. Shaughnessy
James J. Shea
Owen F. Shea
Jian-Cheng Shen
Youssef Shenouda
Harvey C. Shew
Benjamin Shwachman
Karen S. Sibert
Thomas Sinclair
Parvinder Singh
Mark A. Singleton
Stephen J. Skahen
Kristin N. Smith
Steven V. Snyder
Mitchell Solomon
Karl M. Sorensen
Steven J. Soule
Howard D. Spang
Thomas C. Specht
Selvarajah Sriharan
Carla M. St. Laurent
Stanley W. Stead
Richard M. Stearns
Charles R. Stevens
William R. Stevens
Sara E. Stewart
Gary R. Stier
Rodney Strachan
Ernest G. Strauss
Earl Strum
Jeffrey S. Stuart
Daniel E. Sucha
Kanwarjit Sufi
Richard M. Sugar
Robert G. Sugar
CSA Web Site
20
Young Suk
R. Lawrence Sullivan, Jr.
Rajeshwary Swamidurai
Kent A. Swanson
Peter E. Sybert
Frank A. Takacs
Chee-Ken Tan
David Y. Tang
Edward Tang
Afton C. Taylor
Bradley J. Thomas
Sydney I. Thomson
Jeffrey C. Thue
J. David Thurston
Jae E. Townsend
Thanh K. Tran
Narendra S. Trivedi*
Curt N. Tsujimoto
Gerald E. Tull
Judi A. Turner
Ted H. Tuschka
Jeffrey Uppington
Senen T. Uyan
Clifton O. Van Putten
Margaret N. Van Wyk
Christopher J. Vasil
Alva T. Verde
Jerrold A. Vest
David J. Vierra
H. Hugh Vincent
Steven G. Vitcov
Sivasai B. Voora
Oleg Vosicher
Mark E. Vukalcic
Barry L. Waddell
Gerald H. Wade
Brian L. Wagner
Samuel H. Wald
Wayne T. Walker
Michael J. Wallace
Michael A. Walter
Henry C. Walther
Brian W. Wamsley
Natalie Y. Wang
Steven Wang
Clarence F. Ward
Eric A. Wardrip
Randall W. Waring
Thomas D. Webb
Malcolm J. Wehrle
Paul M. Weidoff
Robert A. Weiss
Marc L. Weller
Douglas A. Wemmer
Stephen Y. Wen
Cornelis G. Wesseling
Jerrin M. West
Charles Westover, Jr.
David P. Whalen
Michael Whitelock
Harry C. Wiese, Jr.
Michael H. Wiggins
Steven R. Wilbur
Lancelot L. Williams
Michael S. Winston
Heidi L. Witherell
Robert J. Wood
David G. Woodward
Cho-Ying D. Wu
Robert B. Wudrick
Dwight A. Wymore
Eileen T. Wynne
Thormason M. Yanagi
Stephen P. Yeagle
Julie Y. Yeh
Larry Yip
Paul B. Yost*
Vian Younan
Anni Yue
Tim Y. Yuen
Mark I. Zakowski
Eric J. Zeeb
Ramin Zolfagari
www.csahq.org
CSA Bulletin
4HE m(ELLHOLEn 4HAT )S (AITI a
#3! 7AS 4HERE
By Thomas H. Cromwell, M.D., CSA Past President
T
hat may seem like a bit of an exaggeration. But to those of us who were
there it is right on!
“Beyond Mountains there are Mountains” is an old Haitian proverb and title
of a recent book by Harvard-trained Dr. Paul Farmer, who has been involved
in Haiti for years. It is a metaphor for the 200 years worth of struggles that
Haiti has lived through since Haiti became the first black nation to declare its
independence.
Haiti comprises the western half of the island of Hispañola and was discovered
by a person whose name is quite familiar to us, Christopher Columbus, and
thus became a Spanish protectorate. Years later, it was deeded to the French,
who enslaved the indigenous population and denuded the landscape to plant
sugar cane, which eventually supplied 60 percent of Europe’s sugar. The sugar
plantations have long since been abandoned, and Haiti has been subjected
to a series of malevolent dictators seeking personal fortune at the expense
of Haitian citizens, who then flee the country into exile. Most recently, these
include Papa Doc Duvalier, credited with the most oppressive and corrupt
regime in modern times. In 1990, he was replaced by a charismatic priest,
Jean-Bertrand Aristide, who brought a glimmer of hope to Haiti, but only for
a brief moment, as he quickly abandoned his priestly ways, stole the farm, and
escaped into exile in South Africa. Recurring military coups then gave way to
the current president, René Préval, who has required UN troops to maintain
even a semblance of order in this impoverished county. I was in Haiti seven
years ago, and conditions then were absolutely deplorable! No public sanitation
existed, forcing Haitians to dump raw sewage in the streets. Clean water was
accessible to only a few and medical care was virtually nonexistent. This meager
existence relegated Haiti to the status of the third-poorest country in the Western
Hemisphere.
All that changed at 4:59 p.m. on January 12th of this year when a magnitude
7.0 earthquake, the first major quake in 200 years, not only erupted in Haiti
but dead-centered under Port-au-Prince, which was home to 20 percent of
the country’s 9 million population. In less than 60 seconds, Haiti crumbled to
become the poorest nation on earth, and it appears destined to remain so for
years to come.
CSA was well represented in Haiti’s relief effort. Four members of the
anesthesia department at California Pacific Medical Center in San Francisco
Spring 2010
21
The “Hellhole” That Is Haiti … (cont’d)
responded, as well as CSA Past President Kent Garman from Stanford and Judy
O’Young from Piedmont. The CPMC group consisted of Steve Younger, CSA
District 6 Director, and Barry Rose, who arrived soon after the event in Jimana,
just over the border in the Dominican Republic, to assist with anesthesia
and critical care. Also included was Steve Lockhart who led a group from
Sutter Health (including Vernon Huang from Mills-Peninsula Health Services,
Burlingame) that found themselves in Saint Marc, some 80 miles to the north of
Port-au-Prince. Of course, the fourth member from CPMC was me.
Kent Garman, Judy O’Young, and I all deployed with a Disaster Medical
Assistance Team which I had been with in the Superdome during Katrina.
A federal team, we were one of a network of 30 such teams nationwide,
making up the National Disaster Medical Service. Our experiences were quite
different. Kent and Judy left the Bay Area within hours of the earthquake and
spent three days staging in Atlanta, then several days in the U.S. Embassy in
Haiti. During that time, the U.S. Government conducted needs and damage
assessments and moved 17,000 troops from the 82nd Airborne in Fort Bragg
to provide much needed security, in view of the fact that Haiti owns the
second highest homicide rate in our half of the world, even during the best
of times. Judy was then asked to join a Boston-based surgical team associated
with the DMAT system, setting up a field operation in Gheskio in downtown
Port-au-Prince. Gheskio is a walled two-acre compound in a low-lying
flood plain in a designated “high crime area” in which some 1,000 or so
prison inmates had been freed by a collapsed central prison. Kent’s team finally
was allowed to set up its treatment area on a golf course in Peytonille, one
of only a few relatively prosperous areas of the city, and treated some 1,400
patients in the remaining four days that they were there. Unfortunately, a large
helicopter flying an errant approach caused substantial downdraft injuries to
several members of the team, including Kent, who suffered three fractured ribs
from which he is now recovering.
I relieved Judy 10 days after the earthquake. Upon leaving for Haiti, we were
warned by the federal government that conditions would be “extremely austere,
including a breakdown of civil order, no assurance of basic sanitation, privacy,
communications, adequate food or water, or timely evacuation in the
event of injury or illness.” Disease exposure included malaria, multi-drug
resistant TB, hepatitis, AIDS, and anthrax. That will get your attention!
Every bit of it turned out to be true. The conditions were indeed “austere.”
Our accommodations consisted of seven tents in 90 to 100 degree heat,
with no running water or air conditioning. Two of the tents were
40-person sleeping tents with double bunking on World War II-vintage
cots, and electricity was supplied by six mobile generators running 24/7 to
22
CSA Bulletin
power the ICU and OR tent. Navy helicopters spiraled down to a landing
zone just beyond a “tent” city, more accurately a bed-sheet city, just over the
wall, contributing to an ever-present noise pollution. An area outside one of
the tents was designated as an “expectant” area, a brutal fact of triage in a major
disaster. Meals were MREs (meals ready to eat), if you could find time, and
water was bottled. Sleep was interrupted frequently by aftershocks during
which we had to assemble in the courtyard for roll call.
Dr. Thomas Cromwell and Bill Mayberry, CRNA from Florida,
at the Gheskio Compound.
Operating conditions were equally nasty and exhausting with 12- to 14-hour
days in our tent-turned-sauna by the midday sun. Our 13 surgeons, many
from Massachusetts General, would rotate cases, but due to acuity of cases
and questionably functioning anesthesia machines, the anesthesiologist,
CRNA, and three OR techs had to be present for every case, making for very
long arduous days, one after another. The field model anesthesia machine
had several essential parts missing, including a pop-off valve and airway
pressure gauge. This was in addition to what clearly became obvious—an improperly
calibrated isoflurane vaporizer, all in all making each and every case a seat-ofthe-pants undertaking. The ventilator could have been powered by compressed
air had we been fortunate to find any, but we were forced to use precious
oxygen from a nearby welding shop to power it on abdominal cases. We
periodically ran out of syringes, needles, and oxygen. No regional needles or
drugs had been included in the cache, and so our anesthetic of choice was lowflow oxygen delivered by an LMA and with minimal relaxants, so the patient
could be spontaneously ventilating and survive on room air at the end of the
case. Intubation was reserved for major abdominal cases—of which we did
Spring 2010
23
see quite a few, including gunshot wounds and stabbings with liver injuries,
dehisced post C-section uteruses (which eventually dehisced the abdominal
wound) and long strangulated hernias with dead bowel. The majority of cases
were, of course, post crush injuries with amputations, stump revisions, and
external fixators. In addition, we saw a variety of sepsis and tetanus patients,
fungating breast cancers, severe dehydration, and profound anemias. On a
positive note, not once did I hear a “time out.”
Wrap Up: Haiti’s earthquake will rank as one of the worst disasters in
modern history. Eventually, in excess of 250,000 Haitians will be counted
among the dead, surpassing the Banda Ache Tsunami three years ago. Most
disturbing is that on the day I left Haiti, February 1st, 4,500 Americans were
unaccounted for, and most likely remain entombed in the rubble—more
Americans than we lost in 9/11! Many, perhaps most, of the thousands of
Haitians treated by volunteer medical personnel most certainly would not have
survived without the care provided.
But now the DMAT teams have returned to the United States, the USS Carl
Vincent has long since departed, and the USN Comfort will soon do likewise,
so it is up to the Haitians and whatever meager assistance they are able to garner
from the rest of the world, as they shift from rescue to recovery. That will be the
heavy work, and it will go on for years, given the history of that poor country.
How many tragedies can one population be expected to endure? Beyond
Mountains, there are Mountains!
As for those of us who went to Haiti, statistics tell us that 30 percent will suffer
symptoms of post-traumatic stress disorder. Fortunately most of that will be
transient. When those who went were asked if they would do it all over again,
the vast majority said that they would —a shining example of man’s humanity
to his fellow man!
24
CSA Bulletin
(AITI -EDICAL !SSISTANCEp
! ,IFE#HANGING %XPERIENCE
By J. Kent Garman, M.D., M.S.,
Professor Emeritus, Stanford University
O
n January 12, 2010, at 4:30 p.m. EST,
a 7.1 magnitude earthquake struck
Haiti, centered under the capital city,
Port-Au-Prince. This is one of the poorest
countries in our hemisphere, with approximately
nine million inhabitants. The damage was
horrendous. Dr. Tom Cromwell has covered the
history and social condition of Haiti in his article that accompanies mine. One
reason for this article is to help folks who may have to participate in these
missions in the future. None of us was totally prepared for the situation, despite
our training, including having detailed lists of required equipment.
On January 13 at 5 p.m., I was given seven hours notice to be on a midnight
flight to Atlanta as a member of DMAT CA-6 (Disaster Medical Assistance Team
California 6). This is a federal medical team set up to deploy a 35-40-person,
self-sufficient team to render “austere” medical care in cases of disaster situations.
It usually consists of 35 physicians, physician assistants, advanced nurse
practitioners, paramedics, and logistic and administrative personnel. DMATs
are designed to be deployed for two weeks, at which time they are relieved by
another team. We are federal uniformed employees under the DHHS (Department
of Health and Human Services). In the case of the Haiti earthquake disaster, five
DMATs were deployed within three days of the earthquake.
I quickly re-packed my gear—consisting of two bags, one weighing 50 pounds,
and a backpack weighing 25 pounds. We are supposed to have everything
in our backpack to subsist for 24 hours until our main gear bag arrives. This
includes a uniform, personal hygiene gear, rain gear, flashlight, food and
water. Our main bag has a sleeping bag and inflatable mattress pad, two more
uniforms, underwear, more personal hygiene gear, more food and water,
flashlight, et cetera.
After one night in Atlanta, we boarded a charter jet to Haiti. We arrived in the
late afternoon in Haiti on January 15 (three days after the earthquake) at the
overwhelmed airport. It was crowded by refugees seeking to leave the country
and assistance teams seeking to enter the country. We had been combined with
one other DMAT, NJ-1. We now totaled around 80 people.
Spring 2010
25
Haiti Medical Assistance (cont’d)
The airport was very small, with a tarmac for only around 15 airplanes to
park. The terminal building was structurally damaged and deemed unsafe
for occupancy, so everyone simply stood on the tarmac with the noise of jet
engines, waiting for either a plane flight out or a ride into the city. Toilet
facilities consisted of a cardboard box with a plastic bag liner. In our case,
we sat on the tarmac for around six hours until four large dump trucks pulled
up in front of our area. Then, we all threw our gear into the back of the dump
trucks, climbed aboard, and were driven to the U.S. Embassy. It was dark, so
we could only see numerous groups of people with cooking fires burning along
the streets.
Upon arriving at the embassy, we learned that our equipment cache (team
support equipment including cots, medical equipment, tents, drugs, etc.) had
not arrived with us and so, for the moment, we had to make do with what we
carried on our backs. It was four days until our equipment arrived, local transportation and security were arranged, and an appropriate site from which to
operate was determined. This delay was extremely frustrating.
Unfortunately, the arrival of hundreds of relief workers, including DMATs,
a surgical team (IMSuRT, or International Medical Surgical Response Team),
and several FEMA Urban Search and Rescue (US&R) teams overwhelmed the
embassy facilities, and we ended up with one working male shower per 300
people and one working male bathroom. The women’s facilities were in only
slightly better shape.
The difference between DMAT and IMSuRT teams are that DMATs establish
general austere medical and minor surgical services, and IMSuRTs enhance a
DMAT with operating room capabilities with primitive anesthesia capabilities—
well described by Dr. Tom Cromwell who worked with the IMSuRT.
So, we ended up sleeping on the ground for several nights with our mats and
sleeping bags. Haiti is a tropical island, and temperatures and humidity were
excessive. Also, malaria is endemic and critters liked very much to crawl onto
something warm. For some reason, 2-inch long millipedes took a liking to me
and repeatedly woke me up by crawling on exposed skin. We did not have
access to the mosquito nets in our equipment cache, so we relied on bug
repellant. All of us were given malaria prophylaxis for the trip and a month
afterwards. We were also immunized with typhoid vaccine. We experienced
aftershocks daily, with a 6.1 shock being the largest.
Meals were MREs (military rations, or Meals Ready To Eat) and bottled water.
There was no running water, and all structures were uninhabitable because of
damage. We discovered that only one MRE out of six had instant coffee in it.
26
CSA Bulletin
Those of us who were coffee drinkers and with caffeine withdrawal headaches
hunted these coffee packets down. My favorite mixture was to dump two or
three instant coffee packets, one creamer packet and one sugar packet into a
partially empty bottle of cold water. Shake well and drink, and your caffeine
headache went away. The new Starbucks Via instant coffee packets were like
gold for those who had thought to bring them.
After the four-day delay, we were loaded onto trucks from the 82nd Airborne
Division and driven 10 miles to our new base. This was located on a hill overlooking the city, on a golf course in the nearby town of Petionville. We were
located with an 82nd Airborne element (1-73rd) of about 300 soldiers that was
assigned to food and water distribution. We slept on a tennis court. There were
no showers or latrines except for open-air bucket toilets. At least the women
in our group got a small tent with toilets for privacy. One’s sense of propriety
disappears quickly in these situations. We attempted to keep clean using baby
wipes in the mid-90 degree temperatures (actually hotter inside our medical
treatment tents.) Without belaboring the point, my first shower was in Atlanta
on return to the U.S. six days later.
A word about our friends, the U.S. Army: We always go into situations that can
be somewhat dangerous, from a security perspective. On this deployment, we
heard gunshots daily, and treated some victims of violence. Our “force protection”
was the U.S. Army unit with which we were co-located. These people were
extremely competent, very well-armed, polite, and all-in-all nice to have around,
considering the 50,000 refugees nearby. The Haitians respect the military,
especially because they set up a major distribution point for food and water
at our location. We had long, well-controlled lines of refugees lining up to get
some of the meager supplies that the Army was handing out.
We set up our two medical treatment tents and tried to engineer a reasonable
patient flow with appropriate supplies available. Then we had an interesting
incident that set us back several hours. A Navy CH-53 Sea Stallion heavy-lift
helicopter from the USS Carl Vinson landed at our LZ (landing zone). These
helicopters can generate well over 120 knots of downdraft (rotor wash). It
came over our medical tents and supply dump at around 30 feet altitude. I was
moving boxes into the tent from our supply dump. I heard the helicopter and
immediately was blown 10 feet through the air onto the ground. Then a series
of heavy supply boxes, blown into the air by the downdraft fell on me. I ended
up with broken ribs on the left, a minor concussion, and cuts and bruises.
In total, we had eight injuries, none requiring Medevac. Also, two large trees
about 20 yards away from where I was standing were broken in half. And, even
worse, the roof of our just constructed medical tent was completely blown
Spring 2010
27
off and all the supplies we had so carefully arranged were scrambled. We all
pitched in and got things straightened out.
Then we started to see patients. I acted as an ER doc (granted, not fully trained),
doing a lot of debridements of grossly-infected wounds. Unfortunately, many
of my patients had their crush injuries and lacerations sutured shut by someone
prior to seeing us. My previous experience as a Marine Corps Flight Surgeon in
Vietnam had taught me that dirty combat wounds rarely should be sutured. In
every case, the wounds I saw in Haiti required removal of the sutures, debridement of non-viable tissue, irrigation, and dressing. In severe cases, we asked
the patient to return for follow-up. Usually they did so.
We saved every piece of “disposable equipment,” such as scalpels, scissors,
forceps, syringes, etc., for washing and reuse (remember that Haiti is a high-risk
AIDS population). Our operating conditions were noisy, very hot (my gloves
would accumulate several ounces of sweat), and dusty due to the constant
helicopters landing nearby.
One remarkable case: I took care of a patient with a large fluctuant (4 X 4
inch) abcessed scalp wound. The original injury, two lacerations, was sutured
shut. We removed the sutures and opened the lacerations, which gushed pus.
We then made two more incisions in the abcess to aid drainage. Then, as we
probed the wound with a hemostat, we encountered something soft. We pulled
on it and out came a six inch piece of gauze. Someone had packed this wound
with gauze and sutured it shut; pretty stupid care. We irrigated the wound with
a peroxide solution and dressed it (all without any anesthesia). After a day on
oral antibiotics, I saw the patient again; the wound was no longer fluctuant and
appeared to be draining well. I hope he did well.
A word about anesthesia in this situation: I read a quote from the Wall Street
Journal from a trauma surgeon in Haiti. He said, “We were practicing Civil
War surgery.” What he meant was that we did not have the ability to provide
decent anesthesia other than local infiltration and an occasional extremity
block, and amputations were the major treatment for many of the wounds
we saw. In most cases, I debrided without any anesthesia; the patients were
remarkably stoic in most cases. We also had no x-ray or ultrasound equipment.
If a patient had an open extremity fracture or crush injury, the correct treatment
was amputation prior to gangrene and sepsis setting in. We could not do
amputations, so we simply dressed and splinted these wounds, informing the
patient to return for follow-up when we could transport them to a surgical site.
Many did not return.
28
CSA Bulletin
One happy note: we delivered several healthy babies.
We had extremely limited ability to Medevac patients to a higher level of care.
Every surgically capable facility was maxed out with patients within two days
of opening. This included the hospital ship Comfort (650 beds), the Israeli
field hospital (200 beds), and the USS Carl Vinson (100 beds). For most days,
we were told that no Medevacs were possible. I personally clinically diagnosed
two pelvic fractures in young females and could do nothing for them except to
fashion pelvic splints and explain through interpreters how to use them.
And some personal notes:
UÊ ÊÊÜìÀi`ÊÜÞÊÊ>`ÊÃÊÕVÊivÌÃì`ÊÜiÀÊÀLÊV>}iÊ«>Ê>vÌiÀÊÌiÊ
accident; the question was answered on return home after x-rays and
exam. Fractured ribs hurt. Vicodin is a wonderful drug until you get
hooked on it. I think I had withdrawal symptoms several weeks later.
UÊ ÊÃ]Ê ÃÜ}Ê ÛiÀÞÊ «ÀÊ Õ`}iÌ]Ê Ê ÜiÌÊ ÌÊ >ÌÊ ÌÀiiÊ ÜiiÃÊ ÌÊ >Ê
case of shingles (right side, cervical 2, 3, and 4). I did take anti-virals and
steroids and do not think they did any good. I am now at eight weeks and
can say that shingles is a very debilitating and demoralizing disease. The
constant itching and pain can drive you crazy. If you have not had the
shingles vaccine and are over 60, run to your doctor to get it.
All in all, I am glad I went. I find myself waking up at night thinking about
this experience; I have never been a real believer in post traumatic stress
disorder, but there actually may be something to it. I have frustration and guilt
for not having been able to do more for these poor people, who in every case
were polite, well dressed, clean, and very stoic. I must thank my fellow DMAT
members and the Army who worked until they dropped. We all acted as a
team, supporting each other through this experience.
According to the Wall Street Journal, “Haiti’s recent earthquake was the most
destructive natural disaster that a single country has experienced … It killed
an estimated 200,000 to 250,000 people, claiming more lives as a percentage of
a country’s population than any recorded disaster.” It probably injured another
300,000 people. Our DMAT facility treated over 1,200 patients in four days.
We did the best we could.
Spring 2010
29
!3! $IRECTORlS 2EPORT
-ARCH ASA Positioned to Confront
an Uncertain Future
By Mark Singleton, M.D., ASA Director
for California
F
ollowing the dramatic election in January
of Scott Brown in Massachusetts to fill
Ted Kennedy’s former U.S. Senate seat,
an enormous power shift has taken place
in the tumultuous healthcare reform debate. Like the winter snowstorm’s
effect on Washington, this event paralyzed the Democrats’ healthcare
reform juggernaut, until the President’s recent resuscitation attempts. ASA
has continued to pound the message that the Medicare program treats
anesthesiologists outrageously, that continuation of the present formula is
unacceptable, and any expansion of the current programs is perilous. March 1,
2010, passed without any congressional action to halt the scheduled SGR
21 percent cut to physician payments, but just a few days later, another bill
temporarily forestalled it. At the time of this writing there is what appears to be
a final push to pass “some kind of” healthcare reform legislation. What comes
out of this battlefield is unlikely to be significantly reformative and more likely
to create a whole new landscape of problems. Meanwhile we are clinging to
the precipice. I keep asking myself how long anesthesiologists will continue to
participate in programs and contracts that systematically undermine and degrade
our profession.
On March 6-7, 2010, the ASA Board of Directors met for its interim meeting
in Chicago, and in addition to myself, representing California were:
Drs. Linda Hertzberg, CSA President; Narendra Trivedi, CSA President-Elect;
Ken Pauker, CSA Legislative and Practice Affairs Division Chair; Johnathan
Pregler, CSA House Speaker; and Barbara Baldwin, CSA CEO. Of course,
Dr. Linda Mason filled out the California group as the ASA’s new Assistant
Secretary. The meeting traditionally begins early Saturday morning with the
regional caucuses conducting a generally informal discussion of the current
issues of interest. The Western Caucus is a vibrant and informative arena and
often is the origin of momentum in developing initiatives and policy for the
organization. Following the caucuses discussions, four Review Committees
(Administrative, Professional, Scientific, and Financial Affairs) conduct open
hearings where testimony is invited from any ASA member on all the reports
and items of business submitted to the Board.
30
CSA Bulletin
ASA Director’s Report (cont’d)
The following items were considered and approved by the Board at this interim
meeting. They now will become part of the eventual “handbook” of materials
presented for consideration by the ASA House of Delegates in October 2010.
UÊ Ê iìÌÃÊ ÌÊ ÌiÊ `ÃÌÀ>ÌÛiÊ *ÀVi`ÕÀiÃÊ ÌÊ v>VÌ>ÌiÊ iiÀ}iVÞÊ
(electronic) meetings of the ASA BOD, and to determine the amount of
member fees for the ASA annual meeting.
UÊ *
Ê À«Ãi`Ê iLiÀÊ viiÃÊ vÀÊ ÌiÊ -Ê >Õ>Ê iiÌ}Ê ÌÊ LiÊ ÃiÌÊ >ÌÊ fÓÇxÊ
(advance registration) and $480 (on-site), and $100/$175 for registration
on a daily basis. Fees for all non-member categories also are increased.
Registration in the past has been a free “member benefit,” although
charges for individual lectures, panels and workshops have increasingly
been instituted. The new fee structure will be inclusive.
UÊ Ê Ê Û>ÀiÌÞÊ vÊ i>ÃÕÀiÃÊ vVÕÃi`Ê Ê -Ê i«ÞiiÊ V«iÃ>ÌÊ >`Ê
member volunteer reimbursement, with the goal of decreasing cost and
improving efficiency in the organization.
UÊ Ê Õ`}ÊfÈ]äää®ÊvÀÊ>ÊÌÀ`Ê>`Êw>ÊÞi>ÀÊÌÊ,ÊvÀÊLÀ>ÊvÕVÌÊ
monitoring studies.
UÊ ,
Ê iVi`>ÌÊ "/ÊÌÊÃÕ««ÀÌÊ-Ê}ÕìiÃÊÊ*" 6ÊÀiµÕiÃÌÊ
of SAMBA to ASA) because of concerns about conflicts of interest of the
authors, and strength of evidence.
UÊ Ê ÀÊ ÞÕÀÊ vÀ>Ì\Ê º-Ê ,"
-»Ê >VVÀ`}Ê ÌÊ *ÀiÃìÌÊ iÝÊ
Hannenberg because ASAPAC is officially the largest health-related PAC
in the nation, including the AMA.
UÊ Ê i`Ê ÌiÊ ºÛiÌ>ÌÊ iÌ`Ã»Ê ÃiVÌÊ vÊ ÌiÊ -Ì>`>À`ÃÊ vÀÊ >ÃVÊ
Anesthetic Monitoring to mandate “monitoring for the presence of
exhaled CO2 unless precluded or invalidated by the nature of the patient,
procedure, or equipment” during moderate or deep sedation.
UÊ Ê VÀi>ÃiÊÌiÊviiÃÊV>À}i`ÊLÞÊ-ÊÌÊÃ«Ì>ÃÊvÀÊÌiÊ-Ê
ÃÕÌ>ÌÊ
Program, which provides comprehensive analysis of anesthesia
departments upon formal request of the administration and medical staff.
UÊ Proposed Statement on Standard Practice for Avoidance of Medication Errors
in Neuraxial Anesthesia, which defines medications drawn into syringes
and injected during spinal and epidural anesthesia as being “immediately
administered,” and thus not required to be labeled for compliance with
Joint Commission standards.
Spring 2010
31
ASA Director’s Report (cont’d)
UÊ Proposed Statement on Standard Practice for Infection Prevention and Control
Instruments for Tracheal Intubation, which calls for defined methods
of disinfection and decontamination, but NOT sterilization of such
equipment (another JC survey issue).
UÊ Ê Ê ÀiÃÕÌÊ vÀÊ iÜÊ iÝVÊ ìw}Ê VÀÌiÀ>Ê vÀÊ ÀiV}ÌÊ vÊ >Ê
individual as a “qualified anesthesia provider” was referred to committees
of the President’s choice. This is considered to be a matter of immediate
importance due to new CMS interpretive guidelines.
UÊ Ê >}iÃÊÌÊÌiÊÕìiÃÊvÀÊ>ÞÊVVi«Ì>LiÊ
ÌÕ}Êi`V>Ê
Education in Anesthesiology for compliance with the ABA Maintenance
of Certification program.
UÊ Ê >V>ÊÃÌ>ÌiiÌÃÊ>`Ê/Ài>ÃÕÀiÀ½ÃÊÀi«ÀÌÊ`V>ÌiÊÌ>ÌÊ-ÊVÌÕiÃÊ
to follow prudent fiscal management principles and is on sound financial
footing.
Have You Changed your E-mail Address Lately?
Please send CSA an e-mail with your new e-mail address or go
online at the CSA Web Site, www.csahq.org, to update your profile
if you wish to receive up-to-date information. The monthly Gasline
newsletter is now sent by e-mail only.
32
CSA Bulletin
$ATA %XCHANGE IN THE
)NFORMATION !GE
#REATION OF THE !NESTHESIA
1UALITY )NSTITUTE
By Richard P. Dutton, MD, MBA
Executive Director, Anesthesia Quality Institute
T
he Anesthesia Quality Institute (AQI), a
non-profit 501(c)3 corporation formed
with seed money from the American
Society of Anesthesiologists, was constituted to serve as a clearing house of
information for the specialty. The purpose is to leverage the tools and
connectivity of the Information Age to improve the safety and efficiency
of anesthesia practice. Unlike the Anesthesia Patient Safety Foundation
(APSF), the Foundation for Anesthesia Education and Research (FAER)
or the data projects of the subspecialty societies, the AQI is tasked with
collection and dissemination of data across the breadth of anesthesia practice
in the United States, including groups from the largest universities to the
smallest private practices. This will be accomplished by creation and
administration of the National Anesthesia Clinical Outcomes Registry (NACOR).
Unlike the National Surgical Quality Improvement Project (NSQIP) of the
American College of Surgeons, the NACOR will be broadly inclusive in pursuit
of anesthesia data. NSQIP conducts focused reviews and abstraction of randomly
selected cases from participating institutions, at considerable cost in time and
manpower. This has made it impractical for all but large centers to support.
While the data gathered is useful, it does not represent surgical practice at
the ground level. NACOR, in contrast, will be based on the continuous, passive
capture of digitized information from anesthesia billing systems, quality
management programs, hospital information technology platforms, and,
most important, Anesthesia Information Management Systems (AIMS), which
will represent true clinical data. Working through vendors of these
products, NACOR will build a database that begins with simple practice and
case demographic information and then works iteratively “upwards” towards
more sophisticated clinical outcome and risk adjustment information. In this
way it is intended to parallel—and to some degree influence—the “digitization”
of medicine.
Spring 2010
33
Data Exchange in the Information Age (cont’d)
At the level of the individual practitioner, the AQI will solve a number of pressing
problems. It will provide a common data collection and reporting format that
will meet the needs of MOCA recertification, the Surgical Care Improvement
Project, hospital quality management efforts (including survey by The Joint
Commission), participation in Federal data collections, and subspecialty registry
projects organized by the Society for Cardiovascular Anesthesia, the Society
for Pediatric Anesthesia, the Society for Obstetric Anesthesia and Perinatology,
SAMBA, and others. The data itself will provide important benchmarking for
both quality management and business applications, and participation in the AQI
will open an educational channel that will be used to foster adoption of best
practices across the specialty. For vendors of anesthesia information technology,
the AQI will help to standardize formats and definitions and will encourage the
dissemination of electronic platforms for collecting and reporting data.
At the national level, the AQI will provide demographic and “denominator” data
to inform ASA leadership efforts and provide context for the more focused
efforts of the APSF, FAER, and the Closed Claims project. Data in hand, it
will be possible to influence important discussions in the Center for Medicare and Medicaid Services on the most appropriate performance standards
for perioperative care. In an era of steadily increasing enthusiasm (and Federal
pressure) for comparative effectiveness research and adoption of electronic
healthcare records, the AQI and the NACOR will provide credibility to the ASA
in its efforts to guide the debate towards sensible standards with the greatest
chance of providing benefit to our patients. Linkage with the Surgical Quality
Alliance, a similar project just launched by a consortium of surgical societies,
and the data efforts of the Association of Operating Room Nurses will paint a
picture of the perioperative experience that includes both detailed process data
and long-term functional outcomes.
As a research tool, the NACOR will offer academic anesthesiologists a new
and different resource for understanding clinical practice. In much the way
that the National Trauma Data Bank and the Society for Thoracic Surgeons
database have fostered an increased understanding of outcomes in the surgical
specialties, the NACOR will provide a global look at anesthesia over time.
Indeed, it is a strategy of the AQI to seek financial support through grants
and contracts from federal agencies and private foundations anxious to build
information technology infrastructure nationwide. This will lead to a series of
hypothesis-driven studies leveraging the data capture mechanics of NACOR to
produce increased understanding of controversial areas of anesthesia practice.
Examples include the comparative effectiveness of pain procedures, the benefit
of monitoring standards in outpatient anesthesia and the appropriate threshold
for blood transfusion during trauma and emergency surgeries. As a resource for
34
CSA Bulletin
Data Exchange in the Information Age (cont’d)
contributing anesthesiologists and their practices, the NACOR will become the
largest and most important “data mine” in our specialty, with the potential to
contribute in part or whole to dozens of research projects in the next decade.
Although still in infancy, the AQI is growing rapidly. The technology for
collecting and warehousing data is in place, alpha test sites are being recruited,
data bridges are under construction from half a dozen IT vendors, and the
first case specific data began accumulating in January 2010. The first reports
of NACOR data will appear in July, and the first AQI Research Fellowship will
be offered in January 2011. Change comes quickly in the Information Age,
and knowledge is power. This is the vision of the AQI: Information. Knowledge.
Change. The power to improve the care of our patients.
More information about the AQI and NACOR, including a contact address, is
available through the ASA Web Site: http://www.asahq.org, then click on the
“Anesthesia Quality Institute” button on the left navigation banner.
CSA Needs Your Home Address and Your Zip+4!
If you have not given us your home address, please update your
information online at www.csahq.org under Members Only/Member
Profile Update, or call the CSA office at 800-345-3691. The new CSA
database offers CSA the ability to give members contact information
for their legislators. Since legislative districts are determined by home
address, your zip+4 is essential to provide you with this information.
Spring 2010
35
36
CSA Bulletin
California Society of Anesthesiologists Annual Meeting
and Clinical Anesthesia Update
May 14 – 16, 2010
Hilton Costa Mesa/Newport Beach
Costa Mesa, CA
This exciting and innovative program looks into the future of the specialty
of anesthesiology, from upcoming changes in clinical practice, to practice
management, to the impact of proposed government changes.
On Sunday, there will be a hands-on Ultrasound for Regional Anesthesia
Workshop. Separate registration is required. Saturday, corporate communications
coach Cheri Kerr will lead a two-hour interactive session, Effective Communication
Skills in the Perioperative Setting. Also on Saturday, Dr. Oswald Steward will
deliver a lunchtime speech on the future of stem cell research and therapy.
In addition to the scientific sessions, the meeting includes the annual political
and governance functions of the CSA. These include the CSA Issues Discussion
Forum and House of Delegates, the CSA Resident Research Awards, and the
Forrest E. Leffingwell Memorial Lecture.
You may register for the entire course, or opt for daily registration to select
the portions of the program of greatest interest to you. We hope that you will
enjoy this program and invite you to explore the many activities and attractions
offered by Orange County.
Zeev N. Kain, M.D., MBA
2010 Clinical Anesthesia Update Chair
Adrian W. Gelb, MBChB
Chair, CSA Educational Programs Division
Statement of Need
Anesthesiology is a dynamic specialty, with significant change over the next 20
years expected on a number of fronts, including new clinical technologies and
practices, regulatory changes, business process changes and more. In addition
to providing a comprehensive review of the latest clinical information, this
program seeks to prepare the practicing anesthesiologist for changes anticipated
in the next two decades.
Spring 2010
37
Lecture Topics Include:
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Anesthesiology
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38
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CSA Bulletin
Target Audience
This program is designed to educate and/or refresh the knowledge of practicing
anesthesiologists, nurse anesthetists, anesthesiology residents and students and
other health professionals in the practice of anesthesiology.
Educational Information
The California Society of Anesthesiologists is accredited by the Accreditation
Council for Continuing Medical Education to sponsor continuing medical
education for physicians.
The California Society of Anesthesiologists Educational Programs Division
designates this educational activity for a maximum of 19 AMA PRA Category 1
Credits™. Physicians should only claim credits commensurate with the extent of
their participation in the activity.
Hotel Information
The Hilton Orange County/Costa Mesa, Costa Mesa, CA
Take advantage of the special CSA rate of $129. Reservations for the Hilton
Orange County/Costa Mesa should be made by contacting the hotel at
1-800-HILTONS, or you can go to the online registration page online. You can
access this on the CSA Web Site at www.csahq.org on the 2010 CSA Annual
Meeting and Clinical Anesthesia Update page. The room reservation cutoff date
is April 22, 2010.
Orange County
The hotel is centrally located to all of Orange County and Southern California’s
most popular attractions, including nearby Newport Beach. The Hilton is a
perfect destination located within walking distance of famed South Coast Plaza
Shopping Center and near the Irvine business district.
Air Travel
The Hilton Orange County/Costa Mesa offers complimentary shuttle service to
and from the John Wayne/ Orange County Airport, a short five minutes away.
Learning Objectives
Faculty members have provided learning objectives for each lecture or
group of related lectures, and they are posted on the CSA Web Site at
www.csahq.org and will be included in the conference syllabus. You may also
call the CSA office at 800-345-3691 to have the objectives sent to you.
Spring 2010
39
Annual Meeting Highlights
Exhibits
Table top exhibits will be available for viewing on Friday and Saturday before
the lectures in the morning, and during coffee breaks and the lunch breaks.
House of Delegates Dinner
Friday, May 14, 6 – 8 p.m.
This dinner is for CSA delegates, alternate delegates, district directors, past
presidents and officers.
CSA House of Delegates – Saturday, May 15
8 – 8:45 a.m. First Session
Issues and reports to be considered and voted on in the afternoon session will
be explained.
9 – 11 a.m. Issues Discussion Forum
(Formerly the Friday night Reference Committee)
Issues introduced at the morning session of the House of Delegates will be
discussed. Any delegate or CSA member may speak to the issues during this time.
2 – 4 p.m. House of Delegates Second Session
The House of Delegates will reconvene after lunch to vote on recommendations
developed by the review committee following the morning session.
CSA Resident Research Awards Presentation
Saturday, May 15, 11 a.m.
Immediately precedes the Leffingwell Memorial Lecture. Winners of the CSA
Resident Research Competition are announced and prizes awarded.
Forrest E. Leffingwell Memorial Lecture
Saturday, May 15, immediately following the Resident
Research Awards presentation
This year’s Forrest E. Leffingwell Memorial Lecturer will be Mervyn Maze,
MBChB, Chair of Anesthesia and Perioperative Care, University of California,
San Francisco.
About the lecture: Forrest E. Leffingwell, M.D., was instrumental in the
formation of the California Society of Anesthesiologists. He was the second
president of CSA, serving from 1949 -1950. In 1962, he was elected President
of the American Society of Anesthesiologists and was honored posthumously
with the ASA Distinguished Service Award in 1969. Since 1973, we honor his
service and dedication with a memorial lecture at each annual meeting.
40
CSA Bulletin
FACULTY
CSA Clinical Anesthesia Update 2010
Zeev N. Kain, M.D., MBA, Program Chair
UC Irvine School of Medicine
Amr Abouleish, M.D., MBA
University of Texas Medical Branch
Edward R. Mariano, M.D., MAS
University of California, San Diego
Maxime Cannesson, M.D., Ph.D.
University of California Irvine
School of Medicine
Mervyn Maze , MBChB
1ÛiÀÃÌÞÊvÊ
>vÀ>]Ê->ÊÀ>VÃVÊ
Scott M. Fishman, M.D.
Chief, Division of Pain Medicine
University of California, Davis
David M. Gaba, M.D.
Stanford University School of
Medicine
David B. Hoyt, M.D., FACS
Girish P. Joshi, MBBS, M.D.
University of Texas Southwestern
Medical Center at Dallas, TX
Cheri Kerr
*ÀiÃìÌÊvÊÝiVÕ*ÀÛ
Alex Macario, M.D., MBA
Stanford University
School of Medicine
Spring 2010
Stanley W. Stead, M.D., MBA
"Ê>`ÊÕìÀ]Ê
Stead Health Group
Randolph H. Steadman, M.D.
Professor and Vice Chair
David Geffen School of Medicine
>ÌÊ1
Oswald Steward, Ph.D.
School of Medicine
Mark A. Warner, M.D.
Mayo Clinic
Shermeen B. Vakharia, M.D.
Medical Center
41
Workshop
Ultrasound for Regional Anesthesia Workshop
A hands-on workshop using live models
Sunday, May 16
7:30 – 10:30 AM
`Û>ViÊ,i}ÃÌÀ>ÌÊÃÊÀiµÕÀi`°ÊÌi`ÊÃi>ÌÃÊ>Û>>Li°
{{{{{{
Faculty
Ultrasound Regional Anesthesia Workshop
Jane Ahn, M.D., Workshop Co-Director
University of California Irvine School of Medicine
Steven Suydam, M.D., Workshop Co-Director
Kimberly M. Gimenez, M.D.
Gligor Gucev, M.D.
Keck School of Medicine at USC
Sharon Lin, M.D.
Edward R. Mariano, M.D., MAS
University of California, San Diego
James M. Moore, M.D.
>Û`ÊivviÊ-VÊvÊi`ViÊ>ÌÊ1
Joseph B. Rinehart, M.D.
{{{{{{
42
CSA Bulletin
Spring 2010
43
DO
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PA (Please circle one)
) __________________________________
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Or
Exp. Date ______________
T Visa
Disclosures
All faculty participating in continuing medical education activities sponsored by the California Society of Anesthesiologists are
UHTXLUHGWRGLVFORVHDQ\UHOHYDQW¿QDQFLDOLQWHUHVWRURWKHUUHODWLRQVKLSZLWKWKHPDQXIDFWXUHUVRIDQ\FRPPHUFLDOSURGXFWV
GLVFXVVHGLQDFRQWLQXLQJPHGLFDOHGXFDWLRQSUHVHQWDWLRQV'LVFORVXUHRIIDFXOW\DQGSURYLGHUUHODWLRQVKLSVZLWKFRPPHUFLDO
VXSSRUWHUVZLOODSSHDURQRXU:HEVLWHDQGLQWKHFRQIHUHQFHV\OODEXV
Signature: ________________________________________________
I authorize the California Society of Anesthesiologists to charge my account for the registration fee for this meeting.
Card# ____________________________________________________
Charge to my: ____________________________________________ T MasterCard
MAIL WITH CHECK PAYABLE TO: CSA
(For future CME reporting)
E-mail: ___________________________________________________ AANA # _____________ ABA # __________________
City/State/Zip ____________________________________________________________________________________________
Address __________________________________________________ Phone (
Name ____________________________________________________ MD
Registration: CSA Annual Meeting and Clinical Anesthesia Update,
May 14 - 16, 2010, Newport Beach/Costa Mesa, California
California Society of Anesthesiologists, 951 Mariner’s Island Blvd., Suite 270, San Mateo, CA 94404
650-345-3020 or 800-345-3691
FAX: 650-345-3269
csa@csahq.org
44
CSA Bulletin
$300
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$100
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$185
Friday
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$150
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$120
$210
$210
Friday
After 4/22
$175
$100
$100
$185
$185
Saturday
To 4/22
$150
$120
$120
$210
$210
$55
$55
$110
$110
Sunday
To 4/22
$90
T Saturday
Saturday
After 4/22
$175
T Friday
No refunds for cancellations after April 22, 2010
Register for this meeting online: www.csahq.org
$ ______________
'LVDEOHGSHUVRQVZLWKVSHFLDOUHTXLUHPHQWVVKRXOGFRQWDFWWKH&6$RI¿FHGD\VSULRUWRWKHPHHWLQJ
Total
$65
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Sunday
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$100
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*If paying for daily registration, please specify the day(s)
you will attend:
:RUNVKRSUHJLVWUDWLRQIHHVDUHLQDGGLWLRQWRFRQIHUHQFHUHJLVWUDWLRQIf you aren’t attending the conference, and wish to only
attend the workshop, please contact CSA at 650-345-3020 to be put on a wait list.7KH³:RUNVKRSRQO\ÍHHLV
&RQIHUHQFHDWWHQGHHVUHFHLYHSULRULW\IRUWKHZRUNVKRS7KLVZRUNVKRSLVIRUSK\VLFLDQVRQO\
$300
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Please circle the correct registration fee
and write in the total payment on the bottom line
$R 2EBECCA 0ATCHIN
/FFERS THE !-!lS
0ERSPECTIVES ON
(EALTH #ARE 2EFORM
By Rebecca J. Patchin, M.D., Board Chair,
American Medical Association
Please note that in her current capacity, Dr. Patchin
may speak for the AMA in this area, but she
cannot express her personal opinions. Given that
healthcare “reform” now has become the law of the
land, and that the AMA supported it (albeit certainly not in its entirety), and knowing
that a coalition of surgical specialties, including the ASA, did not, it might be of
interest that Dr. Patchin was gracious enough to respond to a series of four questions
posed to her approximately two weeks prior to the historic House of Representatives’
vote on March 21. Here were the questions:
UÊ 7
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previous attempts?
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bipartisan political effort, but on this occasion what has driven it, and what has
at least for now derailed it, has been brute partisan political maneuvering?
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essentially one voice, and that was the AMA, but on this occasion, there have
been many competing and contradictory opinions from various camps within
the House of Medicine, with a coalition of surgical specialties rejecting the final
Senate bill, while the AMA urged a “yes vote?”
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direction of its own HOD, but on this occasion, the AMA HOD passed a very
specific resolution detailing what is acceptable and what is not in a HCR bill,
and yet the AMA President would not commit during a HOD conference call to
honoring the explicit principles of that HOD resolution?
UÊ 7
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before, but on this occasion, there has been so much dissention within the ranks,
and so much vitriol, that it appears not unlikely that the AMA’s membership and
political power may be debased?
— Kenneth Y. Pauker, M.D., Chair,
Legislative and Practice Affairs Division; Associate Editor
Spring 2010
45
AMA’s Perspectives on Health Care Reform (cont’d)
I
f you were to review the actions of the American Medical Association House
of Delegates’ November 2009 meeting regarding Resolution 203, then you
would see that it is very long and has multiple parts, including that which
directs the AMA to continue to be involved in health care reform. Taking a
position on any legislation requires looking not only at each piece individually,
but also considering the sum of all the pieces, taken as a whole. Going forward,
as in the past, an AMA position will be determined after reviewing AMA policy,
and based upon an assessment of what is in the best interests of the AMA,
physicians, and our patients. That being said, here is the story of what the AMA
has done, and why.
Last June, the opening chapter of the nation’s health system reform debate was
written at the AMA’s HOD Annual Meeting. This was appropriate, as physicians
are the heart of our health care system and are passionate about how to
improve the system.
At that meeting, AMA delegates voted1 for the organization to “support health
system reform alternatives that are consistent with AMA principles of pluralism,
freedom of choice, freedom of practice, and universal access for patients.”
Physicians and medical students from every state and every qualifying medical
specialty debated and voted on behalf of their peers during discussions that
shape the AMA’s health policy agenda. The work is intense; the opinions and
debate are passionate. This democratic system makes the AMA, without question,
the umbrella organization of American medicine.
As President Obama spoke directly to AMA physicians at the meeting, the
twists and turns of the health system reform debate—the distortions and the
partisanship—were yet to come. Through it all, the AMA has worked to be
the voice of American medicine to achieve meaningful health reform for the
dedicated physicians who work within the confines of a broken system and
for patients.
The AMA carefully reviewed each piece of health system reform legislation
from both the U.S. House of Representatives and Senate. This process followed
established protocol of review and recommendation by the physician members
of the AMA’s Council on Legislation and then a vote by the elected Board
of Trustees. While we did not support every item in each bill, there were
significant provisions that comported with the policy passed by the HOD both
in June and in November.
At the November 2009 Interim Meeting, physicians passionately defended their
positions and then voted on a course forward for the AMA. At times there was
46
CSA Bulletin
fierce debate, but ultimately there was a clear final product2—a shared vision
on how to help physicians help patients.
Constructive engagement by the AMA improved the health system reform bills.
For example, AMA joined ASA in successfully opposing public option payment
rates being tied to Medicare—and in the final House bill the public option was
eliminated. On the Senate side, the AMA successfully opposed a proposal to
expand Medicare-eligibility to people age 55 through 64. Our work also led to
House passage of a stand-alone bill that permanently repeals the current Medicare physician payment formula that projects steep annual cuts. The AMA has
made clear to Congress that we will not support short-term action on Medicare
physician payment reform3 that increases the size of the cuts and the cost of
reform. The increasing cost of patient care cannot be shouldered by physicians
facing a 21 percent Medicare payment cut with more in years to come.
The AMA’s unique position at the center of American medicine has produced
policies that are integral to a health system overhaul and trusted by patients.
Polls show that Americans place their trust in physician groups like the AMA to
do the right thing on health system reform. We are working hard to honor that
trust, and the policies voted on by AMA delegates assure that we’ll continue to
be actively engaged in the health reform process.
Immediately prior to the health system reform summit at the White House, the
AMA wrote to President Obama and the bipartisan group of summit attendees
urging a focus on common ground principles of reform. The letter4 read in
part: “Our message to those attending the summit is: You know full well the
problems facing patients and the physicians who treat them. Focus on the
provisions that improve patient access to high-quality medical care, remove
barriers to care through common sense insurance reforms, reduce health system
costs, and sustain the vital patient-physician relationship.” The letter also
addressed the critical need for medical liability reform, saying “one sure-fire
way to significantly reduce health system costs is to expand and adopt medical
liability reforms. It has taken far too long for the greater good to prevail over
the interests of the trial bar in our nation’s capital.”
As the health system reform debate nears its final chapter, the AMA will
continue to stay engaged. We shall review each new iteration of the health
system reform proposals and bills on their merits—and through the lens of
AMA policy—to make decisions based on what is in the best interests of our
patients and their physicians.
Spring 2010
47
Postscript: As of the date of publication of this issue of your Bulletin, HR 3590 and a
reconciliation bill passed the House of Representatives, and a reconciliation methodology
is to be deployed to “improve” the Senate bill, pending the Senate’s agreement. A
coalition of surgical specialty organizations—including the ASA and representing
250,000 specialists—remain firmly opposed to several elements of the final bill. It
remains to be seen how the House of Medicine will digest its internal rifts, and whether
the AMA—which supported the bill, but not, again, its entirety—will suffer from a
potential loss of membership, or perhaps, even be transformed, in some manner, by
its own members who were dissatisfied with leadership decisions.
Endnotes
1
http://www.ama-assn.org/ama/pub/news/news/policy-hsr-alternatives.shtml
2
http://www.ama-assn.org/ama/pub/news/news/ama-continues-hsr-commitment.shtml
3
http://www.ama-assn.org/ama1/pub/upload/mm/399/sgr-letter-hr4691.pdf
4
http://www.ama-assn.org/ama1/pub/upload/mm/399/letter-to-health-care-summitattendees.pdf
ABA Numbers for Reporting CME credits!
-Ê ÜÊ Ài«ÀÌÊ Ê VÀi`ÌÃÊ i>Ài`Ê ÌÊ ÌiÊ iÀV>Ê
Board of Anesthesiology. These credits will be counted
>ÃÊvi}Êi>À}Ê>`Ê-ivÃÃiÃÃiÌÊ>VÌÛÌiÃÊÌÜ>À`Ê
your Maintenance of Certification in Anesthesiology
(MOCA) requirement. In order to report these credits,
doctors need to provide their ABA number. To obtain
an ABA number, visit www.theABA.org and create a
personal portal account.
48
CSA Bulletin
)N -EMORIAM
'ILBERT % +INYON -$
By John Hattox, M.D.
G
il Kinyon died February 18, 2010, of pulmonary embolus following
a cholecystectomy four days earlier. He also had amyloidosis. By any
measure, Gil lived a full and productive life.
He was born in Tipton, Iowa, and while an undergraduate student at the
University of Iowa, joined the U.S. Army. Gil was enormously proud of his
service in 94th Division, 302nd Infantry regiment, and he deserved to be. He
was awarded two Bronze Stars and had three Purple Hearts. He was part of
Patton’s Third Army and in the Battle of the Bulge. Some of the stories he related
to me about those days can only be described as hair-raising. Following his war
service, he became very active with the 302nd reunions.
After his release from the Army in 1945, he resumed his education at the
University of Iowa where he graduated from medical school in 1950. After an
internship in Indianapolis, he finished his residency in anesthesiology under
Dr. S. Cullen at the University of Iowa in 1953. He joined our Anesthesia Service
Medical Group in San Diego in 1953 and engaged in a very busy practice at
Scripps Hospital for 11 years. Toward the end of this time period, Gil experienced
an unbelievable tragedy—he lost his wife, Jesse, and two of his children in an
auto accident, and a later auto accident claimed the life of one of his remaining
three children. These events appeared to change his life profoundly. He saw a
need for service at the San Diego County General Hospital where there were
no anesthesiologists. He remained there for several years becoming the Chief of
the Anesthesia Division of Surgery briefly during the establishment of the new
medical school. While there he was responsible for altering the treatment of tetanus
and doing some of the pioneer work with the ventilating bronchoscope.
Gil then became associated with Mercy Hospital here in San Diego and
established a very successful residency program where he trained more than
40 residents. Many of these residents remained in the San Diego area in private
practice. While at Mercy, he was very influential in the establishment of a training
program for paramedics. He published a number of original papers and
presented work at international meetings including the World Federation of
Societies of Anaesthesiologists. And along the way, he married Mary who was a
great support for him and helped fill a huge void in his life.
Spring 2010
49
In Memoriam: Gilbert E. Kinyon, M.D. (cont’d)
Gil became interested in organizational medicine very early on. He became an
influential member of a large number of committees of the CSA including the
Guedel Library and was a good friend of Bill Neff. He served as president of
the California Society in 1972-73 and was awarded their Distinguished Service
Award in 1987. He was very committed to the CSA Bulletin and served as its
editor for 12 years.
Gil served on numerous committees of the ASA over a long period of time.
Perhaps his greatest interest was in the establishment of the preceptorship program
in the days when recruitment into the specialty was lagging. He served as a
delegate to the ASA House for 17 years and was elected Assistant Secretary of
the ASA from 1984-1987 and Secretary from 1988-1991. He was very proud of
his membership in the Academy of Anesthesiologists. He had looked forward
to attending their annual meeting which was being held in San Diego the week
following his death. Many of the members of the Academy attended his funeral
on February 27th. Gil funded a named professorship of Anesthesiology at the
University of Iowa last year as a reflection of his deep appreciation for the
education he had received there.
Gil was an activist. He believed in certain principles and did not hesitate to let
you know about them. He had a position on just about everything in life. He
and I were not of the same political persuasion which led to many interesting
and lively discussions. And he had the ability to make me think about his point
of view and to respect him for it. Gil was small in stature, but he had a heart of
gold which might not have been obvious to the casual observer. But he had it.
He was always a straight shooter. Bill Barnaby said it well when he heard about
Gil’s death—“Gil Kinyon always exuded the same upbeat, happy, optimistic
zest for life. Just being around him made one feel good. His contributions
during CSA’s early years were many. His wry smile and twinkle in the eye will
be long remembered.”
Gil lived a full, productive life and made his mark in this world. He crammed as
much into his 88 years as one could possibly imagine. It left me breathless. He
traveled extensively, visiting his many friends and colleagues overseas on multiple
occasions. Those of us who were lucky enough to be a part of his life and he
to be a part of our lives are indeed fortunate. Surviving are his wife, Mary,
his daughters Michele and Leslie and their families with two grandchildren,
Matthew and Alice Minor.
Donations may be made to University of Iowa Foundation, Anesthesia - Gilbert
E. Kinyon, M.D. Professorship, Box 4250, Iowa City, Iowa 52244, or Gilbert
Kinyon Men’s Scholarship Fund, La Jolla Presbyterian Church, 7715 Draper
Ave., La Jolla, CA 92037 or Kinyon Memorial Library, Scripps Hospital, 9888
Genesee Ave., La Jolla, CA 92037.
50
CSA Bulletin
'IL +INYON HAS PASSED AWAY a
By Peter L. McDermott, M.D., Ph.D.
Gilbert E. Kinyon, M.D.
1921 - 2010
Gil Kinyon has passed away and has left behind a host of friends and innumerable
fond memories. In his long, eventful life, he lived many different lives. One can
imagine a bucolic childhood growing up in the mythic splendor of a small Iowa
town—butter and bacon and corn. America before World War II may have had
its economic problems, but there was a simplicity to life, an inextinguishable
confidence in a better tomorrow, and the generally shared belief in personal
values, mutual respect, honesty, and decency.
Gil served his country in the war from 1942 to 1945. To say he served with
distinction is an understatement. Bronze Star with V and Oak Leaf Cluster,
Purple Heart with Oak Leaf Cluster, over 125 German soldiers captured singlehandedly—this is an Audie Murphy moment and more. He once told me that
they were looking for someone to surrender to and he just happened to come
along. Receiving his M.D. from the University of Iowa in 1950, he completed
a residency in anesthesiology there in 1953 and came to San Diego to begin
practice. Once seen, who would want to leave San Diego? Not Gil and not
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51
many others. His long successful practice at Mercy Hospital gained him the
respect of his colleagues and the affection of the nuns who sponsored the
hospital. He and I shared nuns, since the Sisters of Mercy ran both our hospitals
and got transferred back and forth. We also shared stints as editors of this CSA
Bulletin, though he did it better and longer.
Those of us blessed to be on Gil and Mary’s Christmas card list enjoyed the red or
green letters with the annual summary of trips taken, people and places visited,
adventures with old war buddies, and the countless friends he collected during
his many years. He never lacked energy, curiosity, optimism, and kindness.
He detected fools and knaves, but for the most part, he saw the goodness in
others. We shared a love of limericks. He sent me a collection of rather salty
rhymes. I seem to recall one of his favorites—“There was a young man from
Nantucket” … but I digress. We also shared a belief in the honor and value of
anesthesiology. He loved this specialty and being a physician. His contributions
to the development of the specialty and to the organizations that serve it
compose several pages in his curriculum vitae.
In the nearly 50 years I knew Gil, I, like so many others, benefited from the
relationship. That he will be missed is obvious. That he left the world a better
place for having been with us is also too true. We move on, satisfied in the
knowledge that we shared in his life and were privileged to have known this
wonderful man.
Plan Now to Attend!
2010 CSA Annual Meeting and
Clinical Anesthesia Update
May 14-16, 2010
Hilton Costa Mesa
Newport Beach,
Orange County, California
http://www.csahq.org/up-more.php?idx=37
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CSA Bulletin
0EERING /VER THE %THER 3CREEN
When is the best time for mistakes?
By Karen Sibert, M.D., Associate Editor
B
ack in the 1990s, my husband and I spent a year working at one of the
largest hospitals in West Virginia. The patients were the nicest people
in the world, and the hospital staff was terrific—kind, generous, and
hard working. Some of the surgeons were excellent, but others definitely were
not. My husband (a cardiac anesthesiologist) and I had to cope with surgical
complications the likes of which we had never seen before. Patients walked into
the hospital for elective aortic aneurysm repair and left in a hearse because the
surgeon could not get the aorta back into one piece. I particularly remember
watching the geyser of blood that erupted one day when a surgeon sliced
open the right ventricle during what was supposed to be a simple mediastinal
debridement. Steve and I thought we were capable anesthesiologists when we
arrived in West Virginia, but we were better by the time we left.
Maybe the best place to train anesthesia residents isn’t the one with the top surgeons
or the most dedicated teaching anesthesiologists. If surgeons are skillful
and supervise their residents closely, the anesthesiologist won’t face surgical
disaster often and may be unaccustomed to dealing with it. Likewise, if attending
anesthesiologists guide their residents’ hands at every opportunity, anesthetic
missteps will be rare. That may not be a blessing for the anesthesia resident
who should learn how to manage both surgical and anesthetic mayhem.
If you’re in private practice and don’t work with residents, you may not realize
just how much pressure there is today to watch the resident’s every move during
a case. We’re compelled to chart our presence at the preoperative assessment,
induction, line placement, emergence, and any “critical event.” Many of us
whip out the fiberoptic bronchoscope at the first whiff of a problem airway
rather than let the resident have another try. Attending surgeons rarely leave
their residents alone in the operating room except to close skin. To do otherwise
could be interpreted as poor quality care.
Certainly I don’t want a resident to make every mistake I’ve made; it’s better
to learn some things by hearing tales of horror than by living them. That is
the point of a good “morbidity and mortality” conference. But we had far less
supervision as residents years ago, and nothing focuses the mind better than
the need to fix a mess of one’s own making.
In retrospect, it might have been better if someone had stopped me, when I was
a resident, from injecting the full 100 mg of lidocaine for my patient’s spinal
anesthetic. I suppose we could call it a “subtotal” spinal in that the young man
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53
Peering Over the Ether Screen (cont’d)
could still speak, but let’s just say the level was higher (and the blood pressure
lower) than I wished. An attending might have come in handy during my first
cerebral aneurysm clipping when the surgeon asked to have the blood pressure
reduced to 60, and at first I thought he meant 60 systolic rather than mean.
Though the patients did fine, these moments are vivid in my memory more
than 20 years later. It may be that you’re more motivated to hit the books
when you realize that you have real responsibility and your ignorance could
kill someone.
Today’s arbitrary restriction of “duty hours” worries me too. In case you haven’t
heard, there is a limit of 80 hours a week for the residents of any specialty to
be in the hospital, and that may soon drop to 60 hours. This includes night call
hours when they may be asleep. Surgical residents now break scrub abruptly
in the middle of a case, like Cinderella when the clock strikes twelve, lest they
overstay their legal time limit. If they work up a patient at night in the ER, they
can’t scrub in on that patient’s surgery the next day. Anesthesia residents rarely
interview their inpatients the night before surgery. The concept of continuity of
care, or taking ownership of one’s patients, apparently has gone for good.
Of course senior staff needs to supervise trainees. However, if we hover too
closely, we’ll steer our residents around every submerged boulder in the stream
and they won’t learn to recognize for themselves where the boulders are lurking.
You need to learn how to work safely even when you’re tired—whether you’re
tired from being on call or from watching over a sick toddler at home.
It may come to pass that anesthesia residency will be extended, either formally
or informally, if residents don’t learn enough because of too much supervision
and too little time in the trenches. For the first time, we’re starting to see residents
graduate, go into practice, and then come back to do fellowships because
they realize how much they didn’t know. One private anesthesia practice near
Los Angeles no longer hires anyone directly out of residency because they have
found new graduates unable to function independently. The question I have
for the talking heads who make the residency rules is this: Is it better to make
decisions and face the consequences when you’re a resident, or to make all
your mistakes later when there may be no one around to help you?
54
CSA Bulletin
!RTHUR % 'UEDEL -EMORIAL
!NESTHESIA #ENTER
Impact of Published Manuscripts
By Merlin D. Larson, M.D.
T
he first issue of Current Researches in Anesthesia and Analgesia was
published in 1922, with Arthur Guedel as a member of the “Research
Committee” of the new journal. In the second volume of the same journal,
he had been promoted to second vice president and was in a prominent position
to influence editorial policy. The editor of the journal was Francis McMechan,
who at the time was not a practicing anesthetist. Guedel always had been in
private practice and had published several articles in the surgical journals.
Guedel also was on the editorial board when the first issue of Anesthesiology was
published in June of 1940. In that year, he wrote an article on cyclopropane
that was published in Anesthesiology, but he did not use that journal for any
further communications.
It may be a surprise to learn that none of Guedel’s publications would be found
acceptable for publication in any of today’s prominent anesthesia journals. Take
as an example his 1927 article on the reclassification of the surgical planes of
anesthesia (Current Researches in Anesthesia and Analgesia: August, 1927, pages
157-162). In that article there are very few numbers, no consents, no statistical
analysis, no standard deviations, no control group, and no institutional approval.
Similarly, in the 1927 journal of Current Researches in Anesthesia and Analgesia,
in which he and Ralph Waters described the cuffed endotracheal tube, the
absence of any measurements of any kind is noteworthy.
As we look back on the material that Guedel and Waters published, we can
recognize that the material was rudimentary science by our standards, but it also
was valid, highly relevant, and had a significant impact on the direction of the
specialty. It also is apparent that their keen insights might have been totally lost if
more rigorous editorial policies had been in place. The authors’ instructions for
the 1922 issue of Current Researches in Anesthesia and Analgesia consisted of one
sentence: “Manuscripts should be typewritten double spaced and accompanied
with photos or drawings to illustrate them.”
Spring 2010
55
Guedel Center (cont’d)
Today the authors’ instructions for Anesthesia and Analgesia consist of 15 pages.
If we take the word count for authors’ instructions for 1922, 1977, 1990, and
2009, a rough chart can be constructed to show the exponential rise in the
requirements that must be met prior to having an article reviewed (Figure
1). If we extrapolate this chart for another 50 years (to 2060, Figure 2)), the
authors’ instructions would produce a small book that would be required reading
before submitting a manuscript.
Figure 1. Ê7À`ÃÊÊÕÌÀ½ÃÊÃÌÀÕVÌÃÊvÀÊAnesthesia and
Analgesia for 1922, 1974, 1992, and 2009 show an exponential
rise over this period of time.
These comments are simply an observation, not a criticism. All of the scientific
journals have strengthened their requirements that must be met prior to the
review of a manuscript. This is partly due to submission of material that is
marginally unethical and also because some individuals have learned to “work
the system” by publishing false data. But these stringent requirements make it
almost impossible for the busy private practitioner (who usually has no
secretarial help and no office) to publish ideas about how anesthesia should be
delivered, or who might have encountered interesting cases that have
instructional merit.
56
CSA Bulletin
Figure 2.Ê/iÊwÀÃÌÊvÕÀÊ`>Ì>Ê«ÌÃÊÊ}ÕÀiÊ£ÊÜiÀiÊÕÃi`ÊÌÊV>VÕ>ÌiÊ
a formula (shown on the graph) and then projected to the year 2060
xäÊÞi>ÀÃÊvÀÊÜ®°ÊvÊÌiÊ>ÕÌÀ½ÃÊÃÌÀÕVÌÃÊVÌÕiÊÌÊÀÃiÊ>ÌÊ
these historical levels, then the entire written journal would be filled
ÜÌÊ>ÕÌÀ½ÃÊÃÌÀÕVÌÃ°
If one looks back on the origins of the scientific journal, then it is apparent
that the journals were never intended to be limited to members of “academia.”
Furthermore, the actual written article was never taken as the final word on any
subject. Instead, these early scientists took pains to actually demonstrate their
findings to an interested audience.
The scientific journal wherein written communications could be disseminated
to a wider community began in the 17th century. The first English journal was
the Philosophical Transactions of the Royal Society of London and the publication
was edited by Henry Oldenburg, the Secretary of the Society. He accepted letters
and manuscripts from diverse sources (there was no “Guide to Authors,” so
this would be the zero in the graph), but he was careful to not publish all
communications that were sent to him. Oldenburg spoke several languages,
had traveled widely in Europe, and was acquainted with a large number of
scientific friends—and he used these friends to evaluate his manuscripts. Peer
review thus started with Henry Oldenburg.
Spring 2010
57
Figure 3. Henry Oldenburg, circa 1665. Portrait attributed to
John Van Cleef. Public Domain Document. Oldenburg was the first
editor of Philosophical Transactions of the Royal Society of London,
the longest surviving scientific journal that still is published today.
Through Oldenburg’s guidance, the Transactions published a wealth of valid
scientific ideas and observations. For example, Isaac Newton, Rene Descartes,
Benedict de Spinoza, Gottfried Leibniz, Marcello Malpighi, Christopher Wren,
and Robert Boyle are among the list of correspondents. However, many of the
papers that were published at that time have been shown to be mere speculation
and fantasy. There are many communications that describe observations of
mermaids, perpetual clocks, and the transformation of metals into gold.
In addition to the Transactions, the Royal Society held regular meetings, but these
events were not at all similar to our Annual Meetings. Their meetings were often
filled with demonstrations given by authors to support their written claims.
58
CSA Bulletin
The correspondence of Robert Hooke is of special interest to anesthesiologists.
In 1665 Hooke wrote to Oldenburg about experiments proving that the lungs
did not require intermittent inflation and deflation in order to sustain life. The
prevailing thought at the time was that ventilation was necessary to propel
the blood through the pulmonary circulation. Hooke performed an interesting
experiment to prove that by simply delivering a constant flow of fresh air into
the trachea he could sustain the life of a dog. Hooke made small incisions in the
parietal pleural and through the thoracic wall to provide an escape for a constant
(not intermittent) source of fresh air that was provided through a bellows
into the dog’s trachea. This dog survived until the constant source of air was
interrupted, showing that the movement of the lungs was not a necessary
requirement for life, but life did depend upon the flow of pure air through the
lungs. In addition to describing this experiment in the Transactions, he also
demonstrated it at the Royal Society meeting on October 24, 1667.
Even after communications were published in these early Transactions, the
Royal Society was skeptical of some of the letters that were published. The
communication by Antonie van Leeuwenhoek in which he described single
cell organisms was a case in point. Leeuwenhoek was a draper by profession,
but he had a unique interest in making lenses that revealed tiny creatures in
rainwater. The idea of animals with only one cell was completely at odds with
the prevailing understanding at the time. The Royal Society was so skeptical of
this letter from van Leeuwenhoek that they sent a delegation to Delft, Holland,
to review his data. This committee returned to England convinced that these
“animalcules” did, in fact, exist.
Arthur Guedel apparently realized early in his career that a scientific publication
has very little influence unless the idea that it represents is valid enough to be
demonstrated and promoted. He promoted his ideas by traveling to meetings
and showing how an anesthetized dog could be submerged in a water tank
and could survive intact through the use of a cuffed endotracheal tube. In only
a few decades, cuffed endotracheal tubes, endotracheal intubation, positive
pressure ventilation and muscle relaxation had become the standard of care.
Cuffed endotracheal tubes had been described before, but Guedel was not an
“academic” and had not searched the literature to know that the idea of cuffed
tubes had “fallen off the cliff” when it was first introduced by Dorrance in 1910,
17 years prior to Guedel’s publication.
Our entire specialty might benefit from reading the thoughts of those who,
like Guedel and Waters, administer anesthetics every day. These individuals
develop unique skills that are nearly impossible to disseminate. Perhaps
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59
there should be a new journal entitled: “Journal of the California Anesthesia
Practitioner.” It could be either a printed journal or an “e-journal” and would
be edited and reviewed entirely by anesthesiologists who deliver anesthesia
on a daily basis. The requirements would be: Manuscripts should be typewritten
double spaced and accompanied with photos or drawings to illustrate them. Human
research would require institutional approval. Some good and some bad material
would be published. But, as we are all friends and live in close proximity, we
could say to one another: “I don’t believe you; show me. I will come visit you!”
The beauty of science is that it makes little difference what any one person
publishes about how nature works. If it cannot be repeated, if it is mostly
true but irrelevant, if it is outright false, or if it cannot be promoted by actual
demonstration, then it will languish forever in the dusty corridors of the library
basement … or somewhere in cyberspace as a dormant electronic file.
Plan Now to Attend!
2010
Fall CSA Hawaiian Seminar
November 1-5, 2010
Mauna Lani Bay
Hotel & Bungalows
Kona, Hawaii
http://www.csahq.org/
up-more.php?idx=38
60
CSA Bulletin
$ISTRICT $IRECTOR 2EPORTS
-ARCH The district director reports that appear below contain personal views expressed by each
director, rather than statements made by or on behalf of CSA.
Edward R. Mariano, M.D.—District 1
(San Diego & Imperial Counties)
After the devastating earthquake in Haiti, Scripps deployed an 11-person
medical-surgical team, led by the CEO of Scripps Health, Chris Van Gorder, to
aid local healthcare workers at Hospital Saint Francois de Sales in Port-au-Prince.
Healthcare staff from UCSD, Sharp Grossmont, and Alvarado Hospital also
took part in various relief efforts.
In hospital news, the recently renovated Sharp Memorial Hospital was recognized
by California Construction Magazine with a Best of 2009 Award for the healthcare
division. The 334 private patient rooms include accommodations for an overnight
guest, wireless Internet, and other amenities to encourage family-centered care.
A new operating suite at Sharp Mary Birch Hospital for Women and Newborns,
unveiled in fall 2009, features the latest in robotic surgical technology. Minimally
invasive robotic surgery is also available at UCSD, Sharp Memorial, Scripps,
and Palomar Medical Center. At UCSD, Thomas Jackiewicz was named the
new Chief Executive Officer. UCSD Medical Center, Hillcrest, also opened
state-of-the-art labor and delivery suites at the end of 2009.
With its draw as a popular tourist destination, San Diego is a common site
for anesthesiology conferences. San Diego recently hosted the Society for
Cardiovascular Anesthesia’s Annual Comprehensive Review and Update of
Perioperative Echocardiography, and it will be the site for the Cleveland Clinic’s
12th Annual Pain Management Symposium on Coronado Island this March.
This fall, San Diego will host the American Society of Anesthesiologists Annual
Meeting, and several District 1 members will be participating on the Local
Arrangements Committee, which is chaired by Edgar D. Canada, M.D., District
1 member and CSA Past President. Encouraging new membership and filling
our open CSA delegate positions continue to be my highest priorities.
Stanley D. Brauer, M.D.—District 2
(Mono, Inyo, Riverside & San Bernardino Counties)
In light of the controversy with the opt-out issues in California, hospital
administrators and CRNAs have used the need for coverage at rural hospitals as
reasons they support the Medicare opt-out. Our district ranges from urban to rural
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61
District Director Reports (cont’d)
areas with very low population, including cities such as Bishop and Mammoth
Lakes. Anesthesiologists traditionally have staffed the small hospitals in both of
these locations. According to recent contacts with administrators and nurses at
these two hospitals, coverage appears more than adequate. When I asked what
the job prospects were for any finishing residents, it was clear there were no
shortages, and they would need to get in line after others to obtain a position.
On the other hand, reports exist that St. Mary’s in Apple Valley has terminated
their contract with their anesthesiology group and have brought in a CRNAbased group. Looking at the hospital’s Web site, the only anesthesiologist listed
on the medical staff is Mersedeh Karimian, D.O. They perform many surgeries,
including CABG procedures in six operating rooms. This is certainly not an
isolated rural area, but it is moderately urbanized, with a nearby competing
hospital in Victorville. St. Mary Medical Center’s parent organization is
St. Joseph Health System, with many hospitals throughout California. Draw
your own conclusions.
Prime Healthcare, owned by cardiologist Dr. Prem Reddy, is back in the news in
our district. Valley Health System, which consists of Hemet Valley Medical Center
and Menifee Valley Medical Center, is in bankruptcy court. A Hemet-based
physician group, led by Dr. Kali Chaudhuri, had been approved to purchase
the remaining assets under a debt organization plan, as well as a plan to keep
the hospitals open. Prime Healthcare claims that the Chaudhuri agreement
was an insider deal. Valley Health Care lawyers allegedly denied any of these
allegations. Prime Healthcare lawyer Marc Rappel plans to offer the court “a
better, higher offer.” In December, the company purchased a portion of Parkview
Hospital’s debt, which consists of a $30 million bond with a payment due
creditors the last part of February.
The reaction to the way Prime Healthcare has run its hospitals is interesting.
According to an article in the Press Enterprise, Jim Lott, Executive Vice President
of the Hospital Association of Southern California, made the following
comments. He stated, “A lot of people don’t like his business model, but no
one can take issue with the effectiveness of his business model. I’m glad to see
him in the game. It’s results that matter.” A spokesman for the Physicians for
Healthy Hospitals offered a different viewpoint. “Prime Healthcare’s business
model may fatten its corporate purse, but it comes at a toll to patients and local
communities.” Because Prime Healthcare currently owns 13 hospitals, many
anesthesiologists in California are being affected.
Reports from many practices relate difficulties in contracting with Blue Cross.
Pomona Valley Hospital reportedly no longer contracts with Blue Cross, and
San Antonio Hospital is contemplating the same approach. Sources at several
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CSA Bulletin
surgery centers state they no longer contract with Blue Cross because of the
low payment rates and its selling of their contracts to other companies, making
dealing with Blue Cross very difficult.
Wayne Kaufman, M.D.—District 3
(Northeast Los Angeles County)
On the East side of the district, the City of Hope has been waging an advertising
blitz. Their very effective commercials have been playing both on traditional
formats such as radio (KCRW, KPCC) as well as untraditional ones on the
Internet (Hulu). I have found their Internet commercials to be very slick. Clearly,
these ads are helping to fuel a growing surgical volume, as Michael Lew, M.D.,
Chief of Anesthesiology at the City of Hope, informs us of plans to open a new
ambulatory surgery center to help take care of the increased volume.
“Expansion” is the keyword for the ongoing activity at USC’s Keck School of
Medicine. Over the past eight months, the Department of Anesthesiology has
added 16 new faculty. These physicians will help to run multiple new sites at
both USC University Hospital and Los Angeles County-USC Medical Center,
including the takeover of H. Claude Hudson Outpatient Center. It is also
expected that they all will join the CSA.
Currently, plans are underway to move surgery and critical care operations
from the USC-Norris Cancer Hospital to USC University Hospital so that the
Norris building can undergo its earthquake retrofitting. USC’s Department
of Anesthesiology will be instrumental in helping provide critical care and
emergency coverage to aid in the transition.
I would like to apologize for not having a district meeting for this last quarter
as well as this abbreviated district report. As some of you already know, my
father, Leonard B. Kaufman, M.D., passed away suddenly over the Labor Day
weekend. It is my hope to have a district meeting sometime this May or June,
and I will send out invitations as soon as I arrange a date and location.
Dr. Leonard Kaufman was one of the first graduates of the University of
California at Irvine Medical School. He did his anesthesiology residency at Los
Angeles County-USC Medical Center and then proceeded to work at many of
the hospitals in both District 3 and District 11, including White Memorial,
St. Vincent, and Good Samaritan Hospital. He specialized in cardiac
anesthesiology and loved his work. He trained many of the residents who
rotated from either USC or Martin Luther King-Drew. He was politically active,
serving as both a delegate for District 3 for the CSA as well as an officer for
the Los Angeles County Medical Association. Near the end of his career, he
returned to where he started at the LAC-USC Medical Center to help train
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63
anesthesiology residents. In addition to his support of the Salerni Collegium
(a fundraising organization raising funds to support USC medical students),
Dr. Kaufman also created a scholarship fund to help deserving medical
students. Despite the many changes occurring in medicine over the time of his
career, he never lost the enthusiasm for his profession—a love which he has
obviously passed on.
John G. Brock-Utne, M.D.—District 4
(Southern San Mateo, Santa Clara, Santa Cruz,
San Benito & Monterey Counties)
We had a very well attended dinner meeting in Redwood City on November
9, 2009. Over 50 people attended. The speaker was Ted Eger, who did an
outstanding job talking about inhalation anesthetics. After the talk, Bill Feaster
gave us an insight into the latest developments in anesthesia/medicine at both
the state level and the federal level. It was very interesting and informative, and
all he said has come to fruition. The dinner meeting was supported by Baxter;
we are grateful to Terilyn Hanko of Baxter who made this happen.
Another dinner meeting has been scheduled in Palo Alto on April 15.
Dr. Jerrold H. Levy, Professor of Anesthesiology and Deputy Chair of Research
at Emory University School of Medicine, will be speaking on Hereditary Antithrombin Deficiency and the use of Thrombate lll.
It is with concern that I note that some members of our district have elected
not to renew their CSA membership. I have attempted to contact them all
personally, but I only have been successful in regaining two. While most of the
people on the list are still active in our area, 15 percent have left for Southern
California or another state.
At Stanford University Medical Center, the H1N1 flu vaccine has been given to
all staff members. If they do not take it, they may lose their privileges. Has this
been the case for all hospitals in California?
A new crop of residents are entering the workforce, and by all accounts there
are plenty of job openings. It would seem that the demand for clinical anesthesiologists is gaining momentum. However, the economic conditions, payment
for services and health demographics will be the primary determinants for the
future demand for anesthesia services. Let’s hope it all works out. To attract
the next generation of physicians into anesthesia, they must see the existing
workforce in anesthesia as being happy and that there is no shortage of work
for them.
64
CSA Bulletin
Paul B. Coleman, D.O.—District 5
(Kern, Tulare, Kings, Fresno, Madera,
Merced, Mariposa, Stanislaus & Tuolumne Counties)
Stanislaus County’s residency program in existence for 35 years recently lost
its accreditation. The county was concerned that it would lose permanently
the program that serves 80,000 poor patients. The Centers for Medicare and
Medicaid Services (CMS) stated that the program did not meet the requirements
of the federal Balanced Budget Act when it moved from the defunct county
hospital to Doctors Medical Center (DMC) back in 1997.
Even though an administrative contractor had approved years of funding
for the program after the move, DMC and the county had to repay over $19
million that federal officials had paid to the program between 2001 and 2008.
For the residency program to continue, CMS stated originally that the County
would need to create a new program with a new curriculum, new faculty, and
a new director and that training would have to be halted for 12 months. The
county feared such stipulations would have brought the entire County’s health
delivery system to a halt. With help from local congressmen—Rep. Dennis
Cardoza, D-Merced, and Rep. George Radanovich, R-Mariposa—the Department
of Health and Human Services relaxed their demands. The county created a
consortium with DMC and Memorial Medical Center (MMC) to oversee the
new residency, increased training slots from 27 to 30, and worked toward the
continued requirement of creating a new curriculum.
Originally a family practice residency, there is now discussion of broadening
the scope to include training in internal medicine, pediatrics, surgery, and
emergency medicine with further subspecialty training at the local Kaiser
hospital. Federal funding makes up 65 percent of the program’s costs. The
County, with DMC and MMC, will cover the remaining costs. Though graduating
medical students often shy away from residencies with accreditation issues, the
County has been upfront with all applicants regarding the program’s status.
The new program, which starts in July 2010, has received 583 applicants vs.
530 the previous year. Of the 583 applicants, 50 percent are medical students
who graduated in the United States and 30 percent are Americans students
who attended Caribbean medical schools.
What was originally known for years as Modesto City Hospital, and later as
Kindred Hospital Modesto, has closed. Kindred Healthcare, based in Kentucky,
made an unsuccessful attempt to sell the hospital last year after a series of
regulatory investigations led to administrative penalties. The hospital lost
Medicare reimbursement in 2008 and was converted to a rehabilitative center
in 1993.
Spring 2010
65
Modesto hospitals received strong overall patient scores in a recent issue of
Consumer Reports—which compiled information from a number of sources
including patient satisfaction surveys sent to patients of all ages by Medicare.
Out of a possible score of 100 points, Stanislaus Surgical Hospital rated 91,
Memorial Medical Center 78, and Doctors Medical Center 71. No rating was
available for Kaiser Modesto Medical Center, which is in its second year of
operation.
Neighboring Oak Valley Hospital in Oakdale and Emanuel Medical Centre of
Turlock scored 67 and 57 respectively. Merced’s Mercy Medical Center scored
49 points. Doctors Medical Center received a below-average score for noise. As
a response, the hospital made a number of modifications, including placement
of glass barriers around nurses’ stations. Stanislaus Surgical Hospital, a shortstay surgical facility, received top marks in areas such as doctor communication,
cleanliness, attentiveness of staff, pain control and quietness.
Uday Jain, M.D.—District 7
(Alameda & Contra Costa Counties)
CSA District 7 consists of the East San Francisco Bay counties of Alameda and
Contra Costa in northern California. The city of Oakland is included in this
district. Several industrial and inner city areas are also included.
The Kaiser Permanente anesthesiologists constitute a large proportion of
District 7 anesthesiologists. District 7 has a high proportion of CSA members.
District 7 has held eight meetings during the past couple of years. The programs,
usually held on weekday evenings, have included a sponsored dinner and
academic lecture. The most recent one, on January 23, 2010, was held on a
Saturday morning and included a symposium on perioperative pain management
and ultrasound-guided regional anesthesia. In order to be inclusive, we have
always invited all the anesthesia providers from the Bay Area. The next
symposium will be held on Saturday morning, April 10, 2010. Tong Gan,
M.D., will speak on nausea and vomiting, and on fluid management. Adrian
Gelb, MBChB, will speak on monitoring of awareness. A full hot breakfast will
be served. All CSA members are invited.
Hospitals in District 7 employ more CRNAs than those in most other districts.
Alameda County Medical Center and Kaiser Foundation Hospitals employ a
significant number of CRNAs. The relationship between M.D.s and CRNAs
appears to be positive. Governor Arnold Schwarzenegger’s opting out of
the Medicare requirement that CRNAs be supervised by physicians, may in
the future lead to changes in our district. Hence our district enthusiastically
supports the legal challenge being mounted by CSA.
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CSA Bulletin
There are no anesthesiologist training programs in this area. Samuel Merritt
College, Oakland, has a CRNA training program, and its students receive
clinical training at various District 7 hospitals. Residents in other specialties do
anesthesia rotations at various District 7 hospitals.
A new Kaiser Foundation Hospital opened in Antioch, which is in the northeast
part of the district.
One of the problems facing District 7 hospitals is the difficulty in recruiting
qualified personnel for perioperative care. There are frequent shortages in the
operating room and the post-anesthesia care unit. However, recruitment of
qualified anesthesia personnel has not been a problem.
Medi-Cal and other cuts in the new California budget are going to have a
significant effect on our district. The recession has reduced the revenues at
virtually all the hospitals. San Leandro Hospital is trying to avoid closure.
Although Kaiser has suffered a reduction in enrollment, we are providing
excellent care with fewer resources.
Jeffrey Uppington, MBBS—District 8
(Alpine, Calaveras, Amador, Sacramento, San Joaquin, Placer, Yuba,
El Dorado, Yolo, Sutter, Nevada, Sierra and East Solano Counties)
The recession has affected many, if not all, hospitals and practices. Many of the
effects are local and unique, but some are universal. Sacramento and nearby
counties are but one example of the challenges hospitals and physicians face.
All hospitals pay for free care and have bad debt. I reported on last year’s
figures in my previous report. Since then the figure has risen for all hospitals,
particularly UC Davis Medical Center, which bears the brunt of charity care in
the city. The reason for this is complex and is partly related to history. When UC
Davis decided to found a medical school in 1966, it was decided that the University would purchase the Sacramento County Hospital and over 120 acres of
land on Stockton Boulevard. The new UCDMC contracted with the County to
take care of all the county patients. The County paid the hospital a lump sum
annually and the hospital looked after all the Sacramento County patients that
came to it. In that sense, it remained the “County Hospital.”
Gradually patients from other nearby counties without hospitals also came to
visit UC Davis Medical Center and were not turned away from the Emergency
Room. Having been the “Hospital of Last Resort” before the Medical School
started, it remained such thereafter.
Spring 2010
67
At the beginning of the Hospital’s fiscal year in 2009, Sacramento County
unilaterally decided that they would no longer pay an annual negotiated rate
for County patient care, but would instead use an intermediary to pay a fee for
pre-approved services and procedures. They also went from the UCDMC being
the sole contracted hospital, to contracting with other major hospital systems
in the county, Sutter and Mercy. This they did, despite the warnings of the
UCDMC that it would likely increase the County’s cost of care. The County’s
rationale was that they would save money, which was important to them as they,
like many counties, were approaching bankruptcy. Unfortunately, UCDMC was
proved right and the County went into an increased negative balance.
The county then decided that it would no longer contract with UCDMC, but
would keep contracts with the other provider hospital systems. The contract
was thus terminated, with the county owing UCDMC about $100 M, though
this has been contested by the county. Rather reluctantly, UCDMC has now
sued Sacramento County for the money.
The physicians have been affected differently from the hospitals. UC Davis
physicians have been well used to dealing with and treating County patients.
They have been used to doing this for low payments because the amount of
money with the previous County contract was never enough to cover all the
costs. UCDMC had a system of distribution of the County monies to the various
physician groups and the hospital. When the County changed its contract to
Sutter and Mercy, the contract was with the hospitals. Perhaps because with
UC Davis, the hospital and the physicians contracted together, the County may
have assumed that their new contract with the other hospitals included the
physicians, but of course it did not. UC Davis physicians are employed by the
Medical School; Sutter and Mercy have private groups who contract separately.
It is not clear that physicians now seeing County patients will get paid for their
labors.
The other part of this rather sad story is that many patients have been uprooted
from their usual hospital and physicians, and have been moved to new ones.
This may not be that uncommon, given the fluidity of contracts these days, but
it has affected poor and disadvantaged patients particularly.
Yolo County had previously altered its contract with Sutter Davis, despite
warnings from Sutter Davis that it would be fiscally disadvantageous to the
county to do so. Yolo County also is in a difficult fiscal situation. I wonder if
this sort of scenario has played out in other counties that do not have their own
hospital, and rely on contracts with hospitals in that county to maintain services?
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CSA Bulletin
Meanwhile life goes on. Kaiser South has opened its new Level 2 Trauma Center.
Sutter and Mercy continue to build. UC Davis Medical Center is scheduled to
open its new Pavilion in September this year. Plans were made many years ago, of
course, but there has been a softening of hospital censuses over the last year. I have
not heard of changes in CRNA/anesthesiologist relationships since the opt-out.
Samuel H. Wald, M.D.—District 11
(West Los Angeles County [western portion])
Children’s Hospital Los Angeles recently held the 48th Annual Clinical
Conference in Pediatric Anesthesiology in cooperation with the Pediatric
Anesthesiology Foundation, a southern California tradition. The conference
drew over 300 attendees from across the country and, in addition to local
speakers from CHLA and UCLA, Drs. Lynne Maxwell, David Steward and
Jerrold Lerman travelled to Disneyland as faculty speakers. The conference was
directed toward both the full-time and the occasional pediatric anesthesiologist
with multidisciplinary topics. Over three days there were practical and
theoretical talks, workshops, and ample time to allow the attendees to interact
with the speakers.
As of the writing of this report, several members of the UCLA faculty have gone
or will join the relief efforts in Haiti. The first faculty member, Dr. Dorothea
Hall, participated with a land-based group from Miami at the start of the
medical missions. Since that time, a UCLA multi-disciplinary team has joined
the USHS Comfort, and CSA members, Drs. Bita Zadeh, Barbara Van de Wiele
and Neesa Patel each have committed to separate time slots aboard the ship.
We wish them the best with their efforts and appreciate the time and energy
they are devoting to this important endeavor.
John S. McDonald, M.D.—District 12
(Southeastern Los Angeles County)
Los Angeles County has instituted California’s first network of stroke-specialty
hospitals. In District 12 Torrance Memorial Medical Center and Little Company
of Mary San Pedro have been designated as two of nine stroke-specialty
hospitals in Los Angeles County.
Little Company of Mary Torrance intends to begin its expansion tower this fall,
breaking ground for its new West Pavilion. This endeavor will add 96 private
rooms, a comprehensive women’s center, and a new pharmacy and laboratory.
Harbor-UCLA Medical Center has begun construction of its long anticipated
16-room OR/Intensive Care Unit and Emergency/Trauma facility. The new
facility will replace its current 10 operating rooms, increase its emergent capacity,
Spring 2010
69
and better integrate its trauma facility with its operating suites. The facility
has also begun construction of a new three-level parking facility alongside the
hospital, intending to alleviate the current parking difficulties.
Torrance Memorial Medical Center is also breaking ground this fall, and plans
to complete its tower by 2015. Demolition of the site began in February. The
new tower will provide 256 patient rooms (25 percent more than its current
occupancy) and a new 18-room surgical suite with a 12-bed burn center. The
facility is planned to be occupied by 2015.
It has been a difficult year for so many. We have had our ups and downs, with
all sorts of problems from our governor and his “opt-out” decision to the recent
threat regarding future fiscal stability regarding our patients.
At least for now, things seem to be stabilizing a little, and we look onward and
upward. Speaking of that, I wonder how many of you know what advantages and
protection you accrue with a membership in the ASA and the CSA? Late last year
I put together a brief talk on the benefits of belonging to the ASA and the CSA.
This was for both my faculty and residents. If you are interested in it, please let me
know and I shall send you a “copy of the slide summary of the talk.”
The slate for District Delegates and Alternate Delegates is in the process of
being finalized.
I hope this finds all of you healthy and happy.
Paul B. Yost, M.D.—District 13
(Orange County)
On September 8, the CSA in “the OC” held a very well attended dinner talk
at Mastro’s Steak House. The speaker was one of our CSA members: Dr. John
MacCarthy who spoke about Electronic Medical Records and ways the EMR can
improve patient care, efficiency, and timely billing. The dinner was sponsored
by Anesthesia Business Consultants. On November 18, CSA in the OC held
another dinner meeting at Morton’s Steak House. Dr. Greggory Sorensen spoke
about “The Benefits of Point of Care Testing.” The talk was well attended and
generously sponsored by Abbott Point of Care testing.
In general, surgical volumes throughout Orange County are slightly down
to steady. The decrease in volume seems related to the economy with many
surgeons reporting that patients are cancelling or delaying surgery because of
loss of employment, loss of insurance coverage, or inability to pay deductibles
and out-of-pocket expenses for procedures. Elective plastic surgery cases are
down throughout the county. There also are trends in the payer mix at many
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CSA Bulletin
facilities. Some hospitals are seeing an increase in Medicare patients, and other
facilities are seeing a higher percentage of Medi-Cal cases.
In spite of the generally decreased volumes throughout the county, and the
feeling amongst most groups that they are slightly overstaffed, there are a couple
of facilities and groups that are looking to expand modestly. This is a positive
change over my last informal survey of the county.
Around the County:
IHHI, the owner of four Orange County Hospitals (West Med Anaheim, West
Med Santa Ana, Coastal Communities, and Chapman) was placed in receivership late last year and its assets are up for sale in March of 2010. One of the
bidders is Prime Healthcare, which was blocked from purchasing Anaheim
Memorial in 2007 by the State of California. The California Attorney General’s
office in 2007 declared that it was unable to conclude that “the sale is fair to
Anaheim, reflects fair market value ... and is consistent with the public interest.”
Although surgical volumes at the four hospitals have stayed steady, the
uncertainty has had an effect on the physicians working at the hospitals.
Children’s Hospital of Orange County broke ground on its new patient care
tower which will feature its own state-of-the-art Operating Rooms, including
a hybrid OR. The new building is expected to open in the spring of 2013.
Volumes at CHOC and St. Joseph’s of Orange have been steady.
St. Jude will be opening a new surgery center with seven ORs in April of 2010.
Their surgical volumes are steady, and they are seeing an increase in cardiovascular cases.
Fountain Valley Regional Medical Center has seen a slight decrease in surgical
volume.
Mission Hospital opened a new tower in November of 2009, with a state-ofthe-art interventional radiology suite, new SICU and post-stroke unit. They are
now a regional stroke center and are performing emergent cerebral angiograms,
thrombolysis, and coiling.
Saddleback has seen steady volumes with minimal changes.
University of California Irvine recently opened its new state-of-the-art
University Medical Center tower and simulation center, and its new chronic
pain center. UCI has been very successful in earning an increased level of NIH
grant funding for research. And, in July, UCI will be increasing the size of its
anesthesiology residency class.
Spring 2010
71
Rima Matevosian, M.D.—District 14
(Northwestern Los Angeles County)
We have been advocating for greater participation in our district. With the
recent CSA district elections, our CSA delegation is full, with Drs. Rusheen and
Stead elected as delegates, and Dr. Ovsepian elected as an alternate delegate.
Additionally, we are in the final planning stage of a district meeting. We will
encourage each hospital in our district to participate. We already have welcomed
several new members to our district and encourage each anesthesia group to
have their members join the CSA.
Our hospital, as well as many others in the District, has received requests
to approve policies allowing the greater use of propofol sedation by nonanesthesiologists. We always have considered the use of propofol for sedation
to be the realm of the anesthesiologist. Fospropofol is now a FDA Schedule
IV controlled substance. Consideration is being given to reclassify propofol,
adding further backing to our belief.
Because of anesthesia drug shortages, many hospitals have had to conserve
their remaining stock of affected medications.
L.A. County continues to wrestle with a severe budget shortfall. The L.A.
County Department of Health Services Hospitals has taken significant steps
to reduce costs. This includes close scrutiny of scheduling and the ordering of
supplies.
The number of patients hospitalized with H1N1 (swine flu) in our district
has decreased, which mirrors the national decline. A very active informational
campaign, as well as vaccinating thousands of community members has helped.
Jacques Neelankavil, M.D.—District 15
(Residents)
There have been some changes in the academic programs in District 15. UC
Davis is expanding and opening new facilities to house their ORs and ICUs. In
addition, they have a new program director. The UCLA anesthesia program has
started sending residents to Long Beach Memorial Hospital for OB anesthesia
experience in a private practice setting. The Ronald Reagan Hospital at UCLA
continues to flourish.
There has not been significant activity of district members on committees in
their hospitals, nor in other societies to report.
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CSA Bulletin
District 15 members continue to be concerned with CRNA practice in
California and the overall job market, which continues to be competitive
in most areas. Most residents describe their experiences with CRNAs in
their program as positive. Residents are interested in learning more about
Anesthesiologist Assistants and how they may play a role in the future
Anesthesia Team model. Most important, district members are interested in
seeing how the lawsuit brought against the governor will affect our future
practice. Health care policy and health care reform are also on the minds of our
district members.
Contribute to the CSA
Legal Defense Fund
*i>ÃiÊVÌÀLÕÌiÊÌÊÌiÊ
-Êi}>ÊiviÃiÊÕ`°Ê
CSA currently has ongoing litigation to protect
the quality of care for senior citizens. The annual
dues statements will be mailed on June 1, and
a suggested contribution to this fund will be
included. It is easy to contribute when you pay
your dues.
9ÕÊ>ÞÊ>ÃÊVÌÀLÕÌiÊÌÊÌiÊvÕ`ÊÊÌiÊ
-Ê
Web Site at www.csahq.org/donation_pay.php.
Spring 2010
73
74
CSA Bulletin
#ALIFORNIA AND .ATIONAL .EWS
Olympic Athletes Who Became Physicians: The
California Connection: California has been part of the
life story of several Olympic athletes who have become
physicians. Perhaps the most famous is Debi Thomas,
whose hometown is San Jose. She won the bronze
medal in figure skating in Calgary in 1988 after winning
the United States National and World Championships.
She attended Northwestern University Medical School,
and currently is an orthopedic surgeon in Indiana.
Whereas figure skating is a “pretty individual sport,” she reflects that she now
enjoys being part of a team of healthcare practitioners. Eric Heiden hails from
Madison, Wisconsin. The year following his failure to win a medal at the1976
Olympics in Innsbruck, Austria, he became the first American to win the World
Speedskating Championship. At the 1980 Olympics at Lake Placid, he won
five gold medals, while breaking five Olympic records and one world record.
Returning to Stanford as an undergraduate, he then became a professional
cyclist and even won the United States Cycling Championship in 1985, and
captained the first American team to be invited to the Tour de France in 1986.
He graduated from Stanford Medical School in 1991, and then became an
orthopedic surgeon, currently practicing in Salt Lake City, and specializing in
arthroscopic procedures and anterior cruciate ligament repair. He currently also
serves as the medical director for the United States Speedskating and Cycling
Teams. (Extracted from the Wall Street Journal article written by Dennis Nishi,
February 16, 2010.)
Michael Jackson’s Death Declared a Homicide: A Los Angeles coroner’s
report concluded that Michael Jackson died from “acute propofol intoxication,”
and thereafter the District Attorney charged Dr. Conrad Murray, a cardiologist, with
homicide. Specifically, Dr. Murray was charged with involuntary manslaughter,
alleging that he acted “without due caution and circumspection,” but “without
malice.” Dr. Murray had indicated that he prescribed propofol as a sleep
medication, allegedly supplemented by lorazepam. However, anesthesiologist
Dr. Selma Calmes, hired as a consultant to the coroner, stated that to her
knowledge, “There are no reports of its use for insomnia relief … [and that]
… the only reports of its use in homes are cases of fatal abuse, suicide, murder
and accident … [and further that] … the standard of care for administering
propofol was not met” [and that] “propofol was administered without the
recommended equipment being present, including a continuous pulse oximeter,
EKG and blood pressure cuff.” Moreover, she declared that propofol
administration requires “full monitoring by a person trained in anesthesia.”
Dr. Calmes also stated that “Multiple open bottles of propofol were found,”
Spring 2010
75
California and National News (cont’d)
apparently in violation of the boxed warning to discard open ampoules within
six hours of their opening. Moreover, she indicated that “the levels of propofol
found on toxicology are similar to those found during general anesthesia for
major surgery.” (Extracted from the CNN Justice article written by Alan Duke,
February 10, 2010.)
Hospice Use Continues to Grow, But Late Referral Causes Concern:
In 2008, two of every five deaths in the United States occurred under the care of
a hospice program. However, one-third of those patients died within a week of
enrollment, a 4.6 percent increase in what is considered to be a “short hospice
experience.” Nonetheless, an average length of service increased to 69.5 days
from 67.4 days in 2007, the median length of stay being 21.3 days. Sixtynine percent of hospice patients died at home or in a residential facility, while
21 percent died in a hospice inpatient facility. Service provided to those of
Latino origin (5.6 percent) or of mixed race (9.5 percent) increased in 2008,
while services to African American decreased from 9 percent to 7.2 percent.
Sixty-eight percent of patients enrolled in hospice constituted non-cancer
malignancies, a continuing trend that has been found since 2003. These
include heart disease (11.7 percent), lung disease (7.9 percent), stroke or coma
(4 percent), kidney disease (2.8 percent) and dementia (11.1 percent).
(National Hospice and Palliative Care Organization, November 2009.)
Surgical Deserts in the United States: The supply of surgeons in the
United States is unevenly distributed and even presents potential problems
with access to surgical services. Yes, there are places without surgeons in the
United States! With greater than 130,000 surgeons in active practice in 2006 in
the U.S., the national surgeon-to-population ratio is 45/100,000 persons. The
minimum acceptable ratio has been determined to be between 4-6/100,000.
However, reflective of a maldistribution of all physicians, 30 percent
of the 3,107 counties in the U.S. (comprising 9.5 million citizens) lacked a
single surgeon! Most of these counties are located in rural America with older
populations, lower than national per capita incomes, higher proportions of
their populations living below the Federal Poverty Level, and populations
averaging only 10,000. Regional maldistribution also exists, as most of these
surgical deserts are located in the Midwest, South and West, and these same
counties are underserved for primary care as well. Interestingly, although counties
without hospitals are unlikely to have general surgeons, half of those counties
without surgeons do have hospitals, the majority of which are titled Critical
Access Hospitals. These small rural hospitals provide 24/7 inpatient and
emergency services, incentivized to do so by enhanced payments from Medicare
and Medicaid. (Summarized from D Belsky, T Ricketts, S Poley, K Gaul, E Fraher,
G Sheldon. Surgical Deserts in the U.S.: Places Without Surgeons. American
College of Surgeons Health Policy Research Institute, July 2009.)
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CSA Bulletin
California and National News (cont’d)
General and Family Practice Physicians Offered Less Salary Than
CRNAs: The shortage of general and family practice physicians across the
nation will only be exacerbated by the fact that medical centers offered CRNAs
an average base salary of $189,000, greater than the $173,000 offered to
primary care physicians, according to the data released by Meritt Hawkins and
Associates, a physician recruiting and consulting firm. This obtuse situation has
held sway for the past four years, even though many primary care physicians
already are on shaky financial grounds with their costs continuing to increase
while private as well as public insurers continue to ratchet down their payment.
The United States currently has a shortage of about 60,000 primary care
physicians, but this figure is almost certainly going to increase dramatically
should healthcare reform materialize and extend health care insurance to
millions of previously uninsured Americans. These stark economic facts
assuredly do not encourage medical students to choose primary care,
especially in light of the approximately $100,000 of debt facing the average
medical school graduate. (Parija Kavilanz, Yahoo! Finance, March 12, 2010.)
Critical Care Module 8
ICU Sedation
CORRECTION
À°Ê >Ê >ViÊ >`ÛÃi`Ê ÕÃÊ Ì>ÌÊ >Ê iÀÀÀÊ Ê ÌiÊ `ÕiÊ Ì>ÌÊ
appeared in the Winter 2010 issue of the Bulletin identified
dexmedetomidine as an alpha-2-adrenoreceptor antagonist.
The correct information is that dexmedetomidine is an alpha2-adrenergic agonist.
Spring 2010
77
.EW #3! -EMBERS
A list of new CSA members is set forth below by membership category.
Active Members
Mohamad Abdalla
Raana Anwaruddin
Jay A. Avila
Mari K. Baldwin
Thomas A. Burns
Deborah D. Castine
Jaiyong Choi
Lynna P. Choy
Manorama S. Chowdhry
Catherine B. Chung
Lewis S. Coleman
Giovanni Cucchiaro
Mason X. Dang
Damon M. Dertina
Clara Espi
Matthew F. Giudice
Peter D. Gougov
Matthew J. Haight
Kenneth D. Hale
Jan Hirsch
Barry K. Johnson
Inderjeet S. Julka
Randhir Kaboo
Bryan S. King
Anne Marie Koch
Gerardo P. Labasan
Kurt Letson
Jeffrey A. Lewis
Elaine C. Liew
Gregory S. MacDonell
Terrin E. Martin
Timothy M. Maus
Mervyn Maze
Julian D. Medina
Robert H. Meints
Mauricio Michaels
Anne Elise Nooney
Sumera Panhwar
Jonathan H. Payawal
David C. Richards
Owais Saifee
Rachel A. Scheuring
Andrew E. Solomon
Naiyi Sun
Fadi T. Tahrawi
Jeremy D. Thom
John T. Waring
Tina B. Wong
Yiping Wu
Barry Young
Resident to Active Members
Jennifer C. Chang
Allison K. Duffy
Mathew R. Malkin
Einar Ottestad
Sepideh Sohrabi
Suzanne L. Strom
Van K. Tran
Roman J. Trochanowski
Glenn A. Valenzuela
Affiliate Members
Stephen M. Eskaros
Resident Members
Omar S. Chowdhry
Bahar A. Mjos
Samuel C. Seiden
Troy Tada
Geneva B. Young
Retired Members
Camilla R. Kochenderfer
2010 CSA Forrest E. Leffingwell Memorial Lecturer
Mervyn Maze, MBChB
CSA Annual Meeting and Clinical Anesthesia Update
Saturday, May 15, 2010
Hilton Orange County/Costa Mesa
78
CSA Bulletin
-ARK 9OUR #ALENDAR
2010
Apr 26-28
ASA Legislative Conference, Washington, D.C.
Apr 30May 2
Western Anesthesia Residents’ Conference, Disneyland Resort
Hotel. www.warc2010.com
May 14-16
CSA Annual Meeting and Clinical Anesthesia Update,
Newport Beach/Costa Mesa Hilton Orange County
Jun 12-15
Euroanesthesia 2010; Helsinki Fair Centre, Helsinki.
Sponsor: The European Anaesthesiology Congress;
Contact +32 (0)2 743 32 90; Fax +32 (0)2 743 32 98;
secretariat@euroanesthesia.org; http://www.euroanesthesia.org/
Oct 16-20
ASA Annual Meeting, San Diego, California
Nov 1-5
2010 CSA Fall Hawaiian Seminar, Mauna Lani Bay
Hotel and Bungalows, Kona, Hawaii
Dec 10-14
64th Postgraduate Assembly in Anesthesiology; Marriott
Marquis Hotel, New York, New York. Contact NYSSA at
212-867-7140; www.nyssa-pga.org
2011
Jan 24-28
2011 CSA Winter Hawaiian Seminar, Hyatt Regency
Maui Resort & Spa, Poipu Beach, Maui
May 13-15
CSA Annual Meeting & Clinical Anesthesia Update;
Fairmont San Jose, San Jose, California
IN MEMORIAM
Gilbert E. Kinyon, M.D.
James B. Sullivan, M.D.
La Jolla, CA
Arcadia, CA
Upon notice that a CSA member is deceased, a donation is sent
to the Arthur E. Guedel Memorial Anesthesia Center in their memory.
Spring 2010
79
Calendar (cont’d)
ASA Delegates and Alternates to the
American Society of Anesthesiologists
Terms begin at the close of the annual CSA meeting at which they were elected.
Delegates
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
Alternate Delegates
Virgil M. Airola, M.D. (11)
Stanley D. Brauer, M.D. (10)
Michael W. Champeau, M.D. (12)
Neal H. Cohen, M.D. (10)
Patricia A. Dailey, M.D. (12)
Christine A. Doyle, M.D. (12)
James W. Futrell, Jr., M.D. (12)
J. Kent Garman, M.D., M.S. (10)
Steven D. Goldfien, M.D. (12)
Linda B. Hertzberg, M.D. (11)
Stephen H. Jackson, M.D. (10)
Patricia A. Kapur, M.D. (11)
Thelma Z. Korpman, M.D. (10)
Norman Levin, M.D. (11)
Jack L. Moore, M.D. (10)
James M. Moore, M.D. (10)
Rebecca J. Patchin, M.D. (10)
Kenneth Y. Pauker, M.D. (10)
Johnathan L. Pregler, M.D. (10)
Michele E. Raney, M.D. (12)
Mark A. Singleton, M.D. (11)
Stanley W. Stead, M.D. (10)
Earl Strum, M.D. (10)
Peter E. Sybert, M.D. (11)
Narendra Trivedi, M.D. (12)
Paul B. Yost, M.D. (12)
Mark I. Zakowski, M.D. (11)
Eugene Bak, M.D. (10)
Edgar D. Canada, M.D. (10)
William W. Feaster, M.D. (10)
Jonathan S. Jahr, M.D. (10)
Zeev Kain, M.D. (10)
Kevin Luu, M.D. (10)
Edward R. Mariano, M.D. (10)
Rima Matevosian, M.D. (10)
Marco Navetta, M.D. (10)
Dennis M. O’Connor, M.D. (10)
Manuel C. Pardo, Jr., M.D. (10)
Nitin K. Shah, M.D. (10)
Karen Sibert, M.D. (10)
R. Lawrence Sullivan, Jr., M.D. (10)
Sydney I. Thomson, M.D. (10)
Judi A. Turner, M.D. (10)
Jeffrey Uppington, MBBS (10)
Samuel H. Wald, M.D. (10)
Robert D. Martin, M.D. (10)
Vacant
Vacant
Vacant
Vacant
Vacant
Vacant
Vacant
Vacant
Save the Date!
2011 Winter CSA Hawaiian Seminar
January 24-28, 2011
Hyatt Regency Maui Resort & Spa
Ka’anapali Beach, Maui
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CSA Bulletin
CSA District Directors and Delegates
District Director
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
Delegates
Delegates
Edward R. Mariano, M.D. (12) (ermariano@hotmail.com)
Vanessa J. Loland, M.D. (12)
[vacant]
(10)
Adam F. Dorin, M.D., MBA (13)
[vacant]
(10)
Lise R. Wiltse, M.D. (13)
[vacant]
(10)
John J. Peckham, M.D. (11)
[vacant]
(10)
Dalia A. Banks, M.D. (13)
Stanley D. Brauer, M.D. (12) (sbrauer@llu.edu)
Thelma Z. Korpman, M.D. (12)
Lawrence M. Robinson, M.D. (13)
Michele E. Raney, M.D. (13)
John Lenart, M.D. (11)
C. Perry Chu, M.D. (13)
Ihab R. Dorotta, M.D. (11)
Wayne A. Kaufman, M.D. (12) (Waynekaufman@hotmail.com)
John Hsu, M.D. (12)
Steven M. Haddy, M.D. (11)
Michael W. Lew, M.D. (12)
Jeffrey D. Parks, M.D. (11)
Tawfik L. Ayoub, M.D. (13)
Eugene L. Bak, M.D. (13)
James H. Daniel, M.D. (13)
John G. Brock-Utne, MBChB (12) (brockutn@leland.stanford.edu)
Jonathan Chow, M.D. (12)
Frank A. Takacs, M.D. (13)
Anthony Debs, M.D. (12)
Sydney I. Thomson, M.D. (13)
Michael J. Laflin, M.D. (13)
Vivekanand Kulkarni, M.D. (13)
Mark L. Rigler, M.D. (10)
Richard J. Novak, M.D. (11)
Harrison S. Chow, M.D. (13)
Vanila M. Singh, M.D. (11)
[Vacant]
(13)
Paul B. Coleman, D.O. (13)
Tamim Wafa, M.D. (11)
Barry P. Kassels, M.D. (13)
Amitabh Goswami, D.O. (13)
Kevin Luu, M.D. (13)
Steven J. Younger, M.D. (10) (steven@stevenyounger.com)
Vince A. Campitelli, M.D. (10)
Matthew Bertram, M.D. (11)
J. Steven Edwards, M.D. (11)
Manuel C. Pardo, Jr., M.D. (13)
Heidi Witherell, M.D. (11)
Jenson K. Wong, M.D. (13)
Tin-Na Kan, M.D. (12)
Uday Jain, M.D. (10) (uday_jain@yahoo.com)
Jason B. Lichtenstein, M.D. (12)
Michael S. Klemm, M.D. (11)
David Brewster, M.D. (13)
Johannes G. Peters, M.D. (11)
James H. Gill, M.D. (13)
Jeffrey A. Poage, M.D. (11)
Janey L. Kunkle, M.D. (13)
Jeffrey Uppington, MBBS (10) (juppington@ucdavis.edu)
Gail P. Pirie, M.D. (12)
Brian L. Pitts, M.D. (13)
Joseph F. Antognini, M.D. (12)
Leinani Aiono-Le Tagaloa, M.D. (13)
Brian L. Wagner, M.D. (11)
Todd D. Lasher, M.D. (13)
Amrik Singh, M.D. (13)
Michael R. Leeman, M.D. (10)
Hong Liu, M.D. (13)
Jonathan F. Barrow, M.D. (11) (jfbarrowmd@gmail.com)
Patricia L. Decker, M.D. (13)
Joseph J. Andris, D.O. (11)
Keith J. Chamberlin, M.D. (13)
Susan S. Yamanishi, M.D. (12)
Theodore McKean, M.D. (13)
[Vacant]
(11)
Marco S. Navetta, M.D. (12)
David J. Vierra, M.D. (11)
Howard D. Spang, M.D. (13)
James Justice III, M.D. (11)
Samuel H. Wald, M.D. (11) (swald@mednet.ucla.edu)
Philip R. Levin, M.D. (12)
Calvin Johnson, M.D. (11)
Joseph Rosa III, M.D. (12)
Swati N. Patel, M.D. (13)
Karen S. Sibert, M.D. (13)
Keren Ziv, M.D. (11)
Judi A. Turner, M.D. (13)
Antonio H. Conte, M.D. (13)
Bita H. Zadeh, M.D. (13)
John S. McDonald, M.D. (11) (jsm5525@ucla.edu)
Ronald J. Rothstein, M.D. (13)
John A. Lundberg, M.D. (12)
Mike Ho, M.D. (13)
Noel L. Chun, M.D. (13)
William A. Bode, M.D. (11)
Paul B. Yost, M.D. (11) (pby123@aol.com)
Ian Chait, M.D. (13)
Brian L. Cross, M.D. (11)
T.J. Hsieh, M.D. (13)
Arthur Levine, M.D. (11)
Dennis M. O’Connor, M.D. (13)
Steve Yun, M.D. (12)
Michael S. Schneider, M.D. (13)
Nitin K. Shah, M.D. (13)
Rima Matevosian, M.D. (11) (matevos@ucla.edu)
Jeffrey M. Rusheen, M.D. (13)
Aram K. Messerlian, M.D. (11)
Stanley W. Stead, M.D. (13)
Jacques Neelankavil, M.D. (10) (JNeelankavil@mednet.ucla.edu)
Babak Abedi, M.D. (10)
Panda Prutaseranee, M.D. (10)
Brian Ash, M.D. (10)
Naileshni Singh, M.D. (10)
Dena Janigian, M.D. (10)
Adam Tibble, M.D. (10)
Jessica Kentish, M.D. (10)
Brendan Tribble, M.D. (10)
Jichang Li, M.D. (10)
TBA (10)
CSA Future Meetings
Free CME Program for CSA Members
CSA CME Critical Care Program, Modules 1-8
CSA CME Obstetric Anesthesia Program, Modules 1-4
CSA CME Pain Management and End-of-Life Care, Modules 1-12
CSA Bulletin and CSA Web Site (www.csahq.org)
May 14-16, 2010
CSA Annual Meeting &
Clinical Anesthesia Update
Newport Beach/Costa Mesa Hilton
Orange County, California
November 1-5, 2010
CSA Fall Hawaiian Seminar
Mauna Lani Bay Hotel & Bungalows
Kona, Hawaii
January 24-28, 2011
CSA Winter Hawaiian Seminar
Hyatt Regency Maui Resort & Spa
Ka’anapali Beach, Maui

CSA Bulletin - California Society of Anesthesiologists

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