Sometimes you need a refresher on measurements of the mitral valve via TEE. Here’s a great 2D TEE walk through for mitral stenosis.
Here it is. I didn’t want to opine, but it’s here and I can’t get away from the topic. I see it at work. I watch it at home. It comes up in discussions… so in order to make it stop, I’m going to give you an idea of what I see and what I think about Obamacare and whatever else is out there.
What I see:
When Obamacare was initiated, I recall seeing a patient who had broken her foot while hiking locally. She had a surgeon who was covered under Obamacare, as well as an anesthesiologist. However, the hospital chose not to accept Obamacare and she had to pay out of pocket for her overnight stay.
It seems that we’re seeing more and more insurance companies pulling out of the system because it doesn’t seem to be profitable for them. Insurance companies are a business; they’re not looking after the wellbeing of the patient. Physicians, nurses, caretakers, the care team look after the wellbeing of the patient.
How many people do you know are satisfied with their insurance coverage?
I’m covered by Anthem on a PPO plan with about 240 physicians. My insurance rate is lousy for the coverage I receive — a high deductible plan. I’m young and healthy and take responsibility for my health — why am I paying $620/mo for barely there medical coverage as a physician? Well, the answer is that our company makeup is a majority of older partners who skew the coverage toward a higher premium — basically a mini-Obamacare environment. I’m subsidizing their health coverage… and someday, hopefully I will still be healthy bc I’m responsible for my health (keypoint right there folks) and doing everything I can now to give my body the best fighting chance to survive into “old” age.
Anyone think to make insurance companies accountable with transparency re: ACA? Start there. Does anyone else think it’s odd that the people who are helping shape the bill don’t actually participate in the care/exchanges like the public? All the while, government and insurance companies dictate coverage and force physicians into tougher situations to deliver care. Is this what you (the public) want? When was the last time you saw the fine print of the bills being passed? Don’t just follow the masses, look for the details and truth for yourself.
A couple of weeks ago, I took care of a patient who desperately needed to get better from acute CHF. At that time, we placed the patient on an impella… but the next day, it was deemed that he needed ECMO to reperfuse his organs. After a week on ECMO with continued impella support, ECMO was titrated down and off while maintaining 3.9L/min flow from the impella. During the wean off ECMO, the patient had been extubated and was mentating clearly and interacting appropriately.
Fast forward a couple days after getting extubated, the patient was ripe for an LVAD. But which one? (We ended up placing the patient on HeartWare LVAD).
- Cost-effectiveness: HeartWare > HeartMate II (UK NHS study, April 2014)
- LV Geometry: HeartWare = HeartMate II (J CT Surg, 2013)
- Stroke & GI bleed risk: HeartWare > HeartMate II (J Card Surg 2013)
- Risk of device failure: HeartWare < HeartMate II
- ENDURANCE trial: Randomized patients eligible for DT 2:1 to the HeartWare centrifugal flow LVAD versus the HeartMate II axial flow LVAD. The trial did reach its primary noninferiority endpoint of stroke free survival at 2 years (55.0% in the HeartWare patients versus 57.4% in the HeartMate II patients). Of note, a change in the design of the HeartWare device during the trial (sintering of the inflow cannula) appeared to decrease the incidence of pump thrombosis. Overall, the stroke rate was higher in the HeartWare arm whereas device malfunctions requiring exchange or urgent transplantation were more common in the HeartMate II arm. Data analysis suggested that better blood pressure control in the HeartWare arm may decrease the stroke rate and a second cohort of patients is being enrolled with more attention being paid to blood pressures management.
- ROADMAP study: (Risk Assessment and Comparative Effectiveness of Left Ventricular Assist Device and Medical Management in Heart Failure Patients) was an observational study of the Thoratec HeartMate II LVAD compared to optimal medical management in patients with advanced heart failure. Thirty day mortality was the same in both groups (1%) while one year survival was 80% in the LVAD group compared to 64% in the medical group (on an as treated basis). Functional status and quality of life improved significantly more in the LVAD group (analyzed by 6 minute walk, health related quality of life, and NYHA class). Unfortunately, adverse events in the LVAD group remained similar to what was previously reported in the DT trial, with bleeding being the most frequent adverse event.
- Bridge to Transplant: HeartWare = HeartMate II (Ann Thor Surg, Feb 2014)
- ADVANCE trial (bridge to transplant): 94% survival at 180 days with HeartWare
- PPT: LVAD Update 2015
- Anesthesia for LVAD
“There’s an emergent case coming for impella placement.”
Impella? I’ve read about these devices and I’m familiar with managing patients on LVADs as well as providing anesthesia for LVAD placement. But, I’ve never done an Impella on a critically unstable patient.
- U/S guidance: probe position similar to infraclavicular block. Find 3rd, 4th rib.
- Pt position: Head away from side of block. Ipsilateral arm abducted.
- PEC 2: Inject 20 ml 0.25% bupi between pec minor and serratus.
- PEC 1: Inject 10 ml 0.25% bupi between pec major and pec minor.
- Serratus: 5th rib, mid-axillary line. Inject 30 ml 0.125% bupi along top (superficial) and bottom (deep) of serratus muscle (which is just deep to the latissmus dorsi).
Subject: I’m strongly “Opposed” to AB 72 (Bonta).
As a physician anesthesiologist, I routinely treat patients during life’s most difficult and uncertain moments, often in life-sustaining surgeries. I agree that patients should not be surprised by out-of-network charges that can arise during these difficult times.
However, AB 72 (Bonta) shifts the onus of arranging for patient care from health plans and insurers onto physicians like me who might not be able to reach contract agreements with health care services plans and insurers.
As such, I’m concerned the net effect of this bill will be to disincentivize health plans and insurers from negotiating fair payment arrangements with physicians and building adequate provider networks.
Moreover, AB 72 (Bonta) requires physicians to be responsible for appealing, then arbitrating compensation disputes…a losing battle and a time consuming process that takes time way from our practice…time better spent caring for our patients.
Most troubling of all, this bill undermines my right to negotiate a fair contract with health plans and insurers by statutorily imposing on me payments that another physician has accepted as the value of their services. Contracted rates of payment already represent substantial discounts to usual and customary market rates. AB 72 (Bonta) will rapidly force a spiral of even lower rates (driven by health plan and insurers) leading to even more restricted provider networks and further reduce access to quality health care for all Californians.
Suggested amendments by the California Medical Association that would have removed our opposition have been summarily rejected by the author and sponsor. Therefore, I strongly urge your “NO” vote on AB 72 (Bonta).