Not dead, just on vacation

The joy of locum tenens work is that I can, actually, take a vacation. I have been working a lot, and so now I am going to be away from anything that begets blogs about medical care for most of a month. I will be singing polyphonic music in the Republic of Georgia and canoeing, briefly, in the Skagit River. I will miss the doctoring, but only a little bit. I will then return and jump right back in, with both feet.

I might write another blog while I am in foreign lands, but probably not, so I'm guessing I'll be checking in again sometime in early October.

Should physicians treat friends and family?

It is a very odd thing that most doctors, especially ones who really love what they do, provide advice and sometimes treatment to family members and good friends. It is also held to be true that this is a bad practice. How do we reconcile this?

In 1847 the AMA published its first "code of medical ethics" which covered many subjects and, though short, is dense and diatribe-like. It seemed to me, when I read through it, that it was mainly concerned with discouraging various forms of quackery, which was rampant in the relatively unregulated environment of the early 19th century in the United States. We physicians were enjoined to "unite tenderness with firmness and condescension with authority" and our patients were reminded that they needed to do what we told them and not fuss and argue with us. Physicians were required to be always available to sick patients, to get consultation when necessary, to treat those who could not afford to pay. In turn, patients were told to avoid seeing more than one doctor because we might disagree and then there would be dissension within the profession. Physicians were to be of superior moral character, not advertise, not have patents on surgical instruments, be cheerful and treat each other and each others' family members for free. It was noted that if we were to treat our own family members, we would be apt to be timid and irresolute.

The American College of Physicians published its 6th ethics manual last year and said this about treating family and friends:

Physicians should usually not enter into the dual relationship of physician–family member or physician-friend for a variety of reasons. The patient may be at risk of receiving inferior care from the physician. Problems may include effects on clinical objectivity, inadequate history-taking or physical examination, overtesting, inappropriate prescribing, incomplete counseling on sensitive issues, or failure to keep appropriate medical records. The needs of the patient may not fall within the physician's area of expertise . The physician's emotional proximity may result in difficulties for the patient and/or the physician. On the other hand, the patient may experience substantial benefit from having a physician-friend or physician–family member provide medical care, as may the physician. Access to the physician, the physician's attention to detail, and physician diligence to excellence in care might be superior."

Which leaves me ethically stranded about where I was before. It is wonderful to be able to provide medical care to friends and family. When I look at what a patient has to go through when they have any one of a number of very common symptoms, a rash, vaginal itching, urinary discomfort, an upset stomach, a productive cough, and the eventual outcome, often an unnecessary antibiotic after a wait of several hours, with almost no history taken and precious little planned followup, I cringe. Can I do better than that for someone I know well and love? Yes. I can. 

And yet.

It is not uncommon that the easy problem that I can take care of in no time leads to another problem and then I may not be available. Then I have treated the patient but left no easily accessible record to help the next care provider figure out what's going on. And sometimes I give really good advice, but the patient doesn't believe me because I'm not really their doctor. Then they do some wrong thing and come back to me for advice when  that doesn't work and I am annoyed because they didn't listen to me in the first place and I'm now doing something else important and for annoyance of this magnitude I really should be paid. And sometimes my familiarity really does cloud my judgement. I don't insist on actually seeing them and miss a very important piece of information that I would never have ignored in a patient in my office.

I have provided hospice care for close friends and family. I think that worked out very well, and I can't imagine standing by watching communication snafus worsen the pain of dying. And yet it was pretty tricky. My heart strings were pulled and decisions really were more difficult than they would have been had I not been so intimately involved. My children have not had much experience with being doctored in the way that has become standard in our culture. But much of what is now done in doctors' offices has traditionally been the job of a mother, including managing the countless colds and tummy troubles that plague children and the inevitable bumps, bruises and lacerations. When I meet the children of physicians, they speak proudly of how their physician parents hydrated them, placated them, benignly neglected them. It is what is most often done, at least with really healthy children. I have traded uncomplicated medical care of close friends for jars of honey or gratitude or just the satisfaction of knowing that the right thing was done, all so far with no ill effects. 

I have also refused to treat people close to me for issues that were complex or required prescriptions for controlled substances, or when my relationship with them was one which made the blurring of roles a bad idea.

I salute the American College of physicians for the final two sentences in the paragraph about treating those with whom one has a prior relationship. They didn't have to recognize that care of family and friends can be "substantially benefi(cial)" to both the patient and the physician. I can just imagine the arguments that may have accompanied this as the document was written. It is as  deeply ambiguous as the subject it addresses.

On the RAC--the recovery audit contractor informational letter and me

In 2003 the Medicare Modernization Act established the Recovery Audit Contractor (the RAC) program to evaluate Medicare overpayment. It was extended to involve all 50 states in 2006 and will eventually involve Medicaid payments as well. The government hired 4 companies to audit payments to hospitals, durable medical equipment suppliers, physicians and other providers throughout the country. Health Data Insights is responsible for the largest geographical area, including my state, Idaho.

Since 2006 we have expected visits and inquiries from various individuals involved in the audits, and eventually we expect that we will all be presented with requests for repayment of money to Medicare in settlement of what the auditors believe are overpayments. This is definitely happening but, other than various highly publicized cases of fraud, I haven't heard that this process has been particularly odious or destabilizing. Nevertheless, in Medicare's report to Congress last year (http://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Recovery-Audit-Program/Downloads/FY2010ReportCongress.pdf) 92.3 million dollars in "corrections" were reported for 2010. 18% of these were actually underpayments and the rest overpayments. The auditing companies were paid based on recovery, and were allowed to keep 9-12.5% of the money they recovered.

In July a letter came to me at the hospital (where I only pick up mail sporadically) which reported what the auditors felt was an overpayment. Apparently their automated system noticed that both I and another physician had billed for discharge services for a patient on the same date, and they intended to reopen the claim and send me an adjustment letter. The letter they sent me was informational only, and began a "discussion period" during which I could send information that might affect the claim. I was given a website (www.racinfo.com) at which I could find a discussion period submission form. It wasn't obvious where to find that, but it was available under the provider information tab.

I reviewed the medical records and found out that I had, in fact, taken care of the patient and discharged her on the date in question, and I printed out a screen shot of the medical records which was blurry enough that I knew it wouldn't fax. So I called the provider relations number (866) 376-2319 and actually talked to a real person. I asked her what happened, why they couldn't read just as well as I that the claim was valid, and she explained that there had, in fact, been two claims by different doctors (me and one of my partners who had taken care of the patient earlier) for the same service and that they hadn't looked at any medical records, just the automated billing. I'm a bit annoyed, but I guess it makes some sense that the burden of proof would be on the doctors who got the disputed payments. I will send them the records tomorrow. If all else fails, I will pay the disputed amount which is only a bit over $73.

Mostly doctors don't bill for hospital services, but communicate what was done to a billing office. We have pretty much no clue what happens after that, other than, in some general way, we get paid. If we work for a small group, we see a spreadsheet which shows that we made so much money from hospital work and then we eventually get money based on overhead and the various things that were paid to us for the myriad of services we provide. It's actually pretty amazing that huge orders of magnitude mistakes don't happen all the time, and so perhaps they do. I suspect that the fact that this patient's discharge was billed twice was an error of foggy wits, not of evil intention, but it is likely that such mistakes are very common and ongoing.

The most common error mentioned in the report to congress, which resulted in the greatest amount of claims adjustment was billing for medical equipment that a patient used while hospitalized. Hospitalization costs are bundled for medicare and the hospital receives the same amount of money for a certain diagnosis and level of service intensity regardless of the resources they use. If Medicare is also billed for medical equipment used during the hospitalization, this is clearly a mistake. If it is a mistake that has resulted in millions of dollars in recovered payments, my guess is that this is because of a colossal misunderstanding resulting from a ridiculously complex payment structure.

The details of medical billing are so complex that people in billing offices need to go to classes to learn how to do it and the people who provide the services (doctors etc.) are usually not aware of what is being billed. When we do see the details, it is hard to make sense of them and so most of us go no further than shaking our heads. I am completely willing to believe that a significant amount of the billing for my services could be inaccurate. It is very likely that a non-negligible portion of the work I have done in the last 25 years was never even billed, since it requires some effort on my part to report what I have done to the billing department, and on a busy day that is the least of my concerns. Even if I do report my work, there is a good chance the communications could be lost in transit or could be misunderstood or wrongly transcribed. It makes perfect sense that Medicare would hire auditors to look for mistakes. For Medicare, the RAC is a clear win, since they pay only commissions on the recovered money. For us as physicians it is scary and annoying, and if it is financially painful will probably make us more careful.

A physician I know from Canada told me that she does have to bill the government for her services, but it is incredibly easy. She just does it on the computer at the end of each week. Errors and fraud are nearly unavoidable with the system we now have, and the remedy we have chosen (RAC) is painful and time consuming. It will make overworked and disillusioned physicians approach their jobs with even less energy and enthusiasm, which is far from a desired outcome. Reform of the fee for service system is in the works, and it truly can't come soon enough.

Getting the DNR--ethics and end of life decisions

During an internal medicine residency, newly hatched doctors are responsible for some of the sickest patients in their teaching hospitals. This is because those patients often don't have private doctors to attend them and are poor and sometimes self abusive, with the complex problems that go with smoking, drug and alcohol abuse and lack of regular medical care. These patients often present with their diseases late in game, when much must be done quickly. There is little or no time to discuss end of life issues and so the assumption is made that these folks want "everything done" which includes machines and potions to support organs and bodily functions as they cease to work right. A scenario might look like this: 48 year old heroin abuser comes in with fever of 104 and symptoms of a stroke. He is admitted to the intensive care unit with low blood pressure, becomes gradually delirious and his heart rate increases, he is sedated for trying to crawl out of bed and run off, he becomes lethargic and is unable to breathe for himself, a central line is inserted and he is intubated and put on a ventilator, his blood pressure is supported with pressors and fluids, his oxygen level cannot be supported despite high ventilator settings. His kidneys cease to work and his heart goes into a rhythm that produces no blood pressure at all, he receives CPR with chest compressions, he is resuscitated, but barely alive, unable to communicate, obviously brain damaged beyond repair, placed on dialysis, eventually succumbs to overwhelming infection. We call this a "flail."  It is horrifying and time consuming and ultimately a colossal waste of human and monetary resources. Repeated experiences of this type sour most of us on the idea of being resuscitated, so many doctors consider themselves "DNR (do not resuscitate)." We don't want to be resuscitated ever, no matter what. There are some things that are worse than death.

Some resuscitations go well, though. A patient arrives in the emergency department with chest pain, develops an arrhythmia, has chest compressions briefly and electrical cardioversion and is conscious within minutes or hours. Some people briefly can't support their own needs for respiration and require a few days of ventilation before being able to breathe adequately. Although they are weak and puny for awhile, they go home and live to tell the story, go back to work, raise families, climb mountains. These successes usually happen to people who were vital before they became really sick, the younger folks, without multiple or terminal illnesses to begin with.

When someone is admitted to the hospital, the physician responsible for their care (which is more and more often the hospitalist) determines, if possible what their wishes would be regarding life support should their breathing or heart stop. These discussions are very difficult if the patient has not thought about resuscitation and has not talked with a physician who knows them about options. Often patients have reasonable hesitance to make potentially life determining decisions with a doctor who they don't know and who doesn't have time to talk with them about the implications of these decisions. In our heads we have a pretty good idea of which patients would do well should they require cardiopulmonary resuscitation, and we really want people whose chances of recovery are lousy to tell us that they are DNR. A DNR decision means that will not flail them. We will not get into a situation in which failure is likely. Should this patient become so sick that medicines, hydration and appropriate surgical procedures cannot save them, we will transition to a strategy that makes death peaceful and painless. 

We rarely succeed in communicating this to patients and many who will not benefit from cardiopulmonary resuscitation say "Oh yes, doctor, I want everything done." Some say this because their experiences are different from ours, they have seen doctor shows in which resuscitation was successful, they think that withholding resuscitation means getting substandard care, and sometimes they think that we just want to spare ourselves the trouble of saving them. And some of these concerns are valid. A patient who is "DNR" may not be watched as closely or treated as quickly if they decompensate. Some people with horrible prognoses do get better after being resuscitated, though this is pretty uncommon and usually involves a pretty significant decrement in quality of life.

Even though it is hard to establish trust with patients or their families in the context of being a hospitalist, I think it is one of the most important discussions to do right. It is everso tricky, though. Even asking the question can make a patient frightened or hostile. They wonder if we are asking this question because we secretly think they are going to die soon. They feel that the subject is too private to broach with a near stranger. They have never thought about it and don't want to start now. They think that if they make a decision not to be resuscitated that their family members will think that they don't love them. But sometimes patients have been waiting, oh so patiently, for someone to bring up the subject and be willing to take enough time to answer the questions that they have been afraid to ask. I find that a discussion of resuscitation is best started after I learn about who a patient is and what they have done for a living and what they spend their time doing at home. What were they good at when they worked? Do they have kids or grandkids? Where do they live, do they travel, do art, take care of other people, have pets? It is hard or impossible to help a person navigate the end of life if I don't know them. 

Even though I am a bit biased against intensive and technological medical care, I love actually doing it. The tools of this trade are really clever and the immediacy of the practice is inspiring and brings people together. I have seen beautiful and compassionate intensive care, which makes patients and families feel valued. Nevertheless, there are always the unintentional and casual cruelties of disturbed sleep, needles, boredom, prickly heat, bowel indignities, physical pain and nausea. Death following chest compressions and electrical cardioversion is not peaceful. When I sit with a person and hear that, no, they don't want intensive care or cardiopulmonary resuscitation should their heart or lungs cease to work, and it is clear that resuscitation is not in their best interest, my heart feels lighter. I can focus more on what the patient values rather than what procedures are most likely to keep them alive for the longest time. 

More on Atul Gawande's Cheesecake Factory metaphor--how to not eat there all the time, but still improve medical care

Atul Gawande, a surgeon who writes for the New Yorker magazine, recently wrote an article about how the medical profession might learn from a large restaurant chain how to provide really good service inexpensively. I was intrigued, because I would very much like to see medical care get better and cheaper, and find it very frustrating that progress is so slow. But I was also a little horrified by the vision of my profession becoming another mindnumbingly reproducible chain restaurant.

One of the reasons that medical care has been expensive and not successfully focused on customer satisfaction is that physicians, at least good ones, are kind of scarce and have been trained in a culture that makes us consultants rather than service personnel. (Also, of course, the fact that we are usually paid by a deep pocketed third party without much consciousness of what the consumer really wants is a major issue.) If we, as physicians, are available to help solve a person's medical problems we need not concern ourselves with details like making the process easy or pleasant. We regard our individuality as an asset and dislike being told what to do.

Still. It would be really nice if we could learn to utilize the hard won data about which practices work to make people healthier and which do not, and adopt practice patterns accordingly.

One of the ways to make us doctors practice medicine in a certain way is to pay us well only when we toe the line. Another is to make the practice settings where we work encourage such behavior and make other behaviors very difficult. Both of these things happen. The first is called "pay for performance" and doesn't necessarily work that way, and irritates us. The second can be done via computer systems that make standard pathways fall easily from diagnoses, and non-standard ones be technically more difficult. This is also irritating, especially when the right approach falls somewhere outside of the box.

And yet many of us do medicine that is outdated and ineffective, out of habit, laziness or inattention, and our patients suffer and pay money for it.

Recently physician's organizations have worked on helping us to focus on the most stupid things we do in order to pick the low hanging fruit of waste. (See my post on the Choosing Wisely campaign http://choosingwisely.org/?page_id=13) Besides not doing stupid useless things, there is also research about how to take care of patients in ways that actually make them better. So someone, but not everyone, knows what generally works and what generally does not. We theoretically could know which tests help answer what question in the least time and resource consuming ways, which medications or treatments are most likely to work, and which ones to try when they don't. Some medical practices have refined the art of communication, with doctors, specialists and patients and are happy to share their processes with other groups.

Physicians behaviors are best changed by teaching them new ways of doing things that really work. We are lifelong students. We complete a minimum of 24 years of schooling by the time we go to work and have to document ongoing education throughout our careers. Mostly we do way more education than we ever document, following new developments by computer or print journals and by talking to our colleagues. What we see and hear, though, is spotty, not necessarily exposing us to the most important new information.

I would propose that we create a curriculum for physicians that teaches us stuff about delivering high quality care upon which there is good consensus. I'm sure we could cover the big items in a few days a year. There are already "update" courses in nearly every specialty, taught by all sorts of organizations, but they hit on whatever the individual teachers think is valuable with varying teaching success. The big item curriculum would be like the menu of a successful restaurant chain, giving us excellent but standard fare. We would also keep learning, like we do now, interesting and non-standard information. It would feed my soul if, at the big item update course, we had a final speaker point out ways in which what we had just heard was not actually the gods' own truth and would probably look significantly different the next year, and required some level of customization to serve our own patient populations.

Innovations in medicine happen when somebody tries something that is different and it works. These wonderful and game changing shifts in practice can only happen when we can all feel free to give medical care that is outside of the box, paying attention to how our individual patients look, feel, sound, and what they say they need from us.

Why a person might or might not want their health care to resemble a meal at The Cheesecake Factory--a response to Atul Gawande

When I drive down a street and see only national chain restaurants and retail stores, I am sad. Can we do no better than this, to make everything the same, supporting certain foods, certain products at the expense of the tremendous variety of such things that exist?

Atul Gawande just wrote a very compelling article in which he explored the chain restaurant The Cheesecake Factory as a model or metaphor for good health care.  He not only ate there, but toured the facility and observed the processes that allow this huge place to provide food that is interesting, delicious and affordable. His main thesis is that an industry that standardizes excellent practices can provide high quality care, and that it is not unthinkable that medicine could be substantially improved by adopting such a model. He also looked at some excellent hospitals that have begun to standardize such things as patient care in the ICU and total knee replacements.

There are many things that, through scientific inquiry, are known to be VERY GOOD IDEAS. Things like preventing blood clots in the legs with certain medications, elevating the head of the bed of patients on ventilators to prevent pneumonia, handling central venous catheters in such a way as to avoid catheter infections can save lives and should be done routinely. There are certain practices that are agreed to be "best practices" by either evidence or expert opinion, such things as maintaining quiet in patient care areas, numbing up arterial puncture sites, preserving normal sleep wake cycles, which significantly improve quality of care for patients. Both inpatient and outpatient medicine are positively crawling with "best practices."

Surgery is a field that is absolutely ripe for protocol driven procedures, because so many things can go wrong when a person is anesthetized and cut open, and so many things must be remembered and performed perfectly and quickly. Atul Gawande is a surgeon. His checklists (see his book, The Checklist Manifesto) seek to make the multiple complexities of practicing medicine and surgery easier to navigate.

The Cheesecake Factory is a fully realized real world example of well performed standardized processes, and therefore more delicious even than checklists. I am often frustrated as I watch, via medical charts, the variety of inattentive and thoughtless medicine that passes for OK in hospitals and clinics. It would be really nice if everybody knew and could practice in a way that actually made sense when there is really believable evidence to support these processes. In addition, I often find myself functioning at the very edge of my abilities due to the complex coordination of what seems to be nearly infinite data in the setting of real patients actually getting super sick and flirting with death. In these situations I long for processes that make it easy for me to be smart or impossible for me to be very stupid. I look for computers to help me focus on the important information and remind me when I forget something that needs to be done. I look for nurses to pay attention to things that were, at some point in the past, the private realm of doctors, such as tests and medication interactions and recommended prevention strategies.

But I don't want medical care to resemble a meal at the Cheesecake factory, though I hear the salmon is delicious.

Much of medicine is practiced on people who are as different from each other and as individual as snowflakes. My patients are never the same as one another, and the problems and stories they bring me require of me a different responses based on so very many things. A patient might come in with a numb toe, having recently split from her husband, with a lump in her throat. Or he might come in with "heartburn" and Asperger's syndrome and a notable suspicion of the medical profession. Not only are the possible diagnoses for each of these people myriad, so are the ways I might start to investigate them and the ways I might treat them while waiting for more data. These are the real patients who are difficult to treat with "evidence based medicine" since nobody ever did a study on them looking at what worked and what did not, because each one is unique.

When a physician is encouraged to use protocols and pathways in treating patients, he or she is tempted to force patients into artificial categories which lead to these protocols. Patients know when this is happening and they feel like herd animals, and they experience not being listened to. And yet I am not against pathways and protocols in general since they can help us avoid some egregious mistakes and obscene waste. The trick, I think, is to avoid being too impressed with The Cheesecake Factory, to use protocols in situations where they really are indicated and to preserve a sense of creativity and curiosity when faced with real people with really interesting problems.

The Stanford Advanced Airway Management and Fiberoptics Course--learning to put tubes down peoples' throats to help them breathe

The actual secret to long life is continuing to breathe. The body has many amazing processes that go on all the time, little tiny molecular ones and microscopic cellular ones, organs that digest, produce hormones, pump blood, big juicy custard-like organs that think thoughts, stringy nerves and muscles that propel us, reproductive organs that beget poetry and children. It would be hard to judge any of them as being the most necessary, but the process of breathing would be a top contender.

People stop breathing for all kinds of reasons, most commonly because they have lived out their span of years and are done. When everything else ceases to work and the brain no longer gives adequate signal to the muscles of respiration to defy the elastic recoil of the diaphragm, chest wall and lungs, breathing stops. But sometimes breathing ceases or becomes ineffective because of a drug overdose, a lung inflammation or infection, morbid obesity, fluid overload, tumors, trauma, a reversible cardiac problem, a hot dog gone down the wrong way. In such situations it can be life saving to place a tube through the mouth or nose to provide oxygen and get rid of carbon dioxide. 

I suspect that was an excessively long explanation of the obvious for just about everyone who has watched any of the doctor shows on TV or had anything to do with health care. So I shall be done now with explaining. Except a few more things since it won't take long and not everybody knows all the terms. When  tube is placed anywhere in a person, the process would be accurately described as "intubating" the person, but practically we only use that term to mean putting a tube into the airway to provide support for breathing. A ventilator is the machine that hooks up to the tube to do the breathing, though a person with a bag who did the same job would also be a ventilator. But that would sound really funny. 

All that to say that I just attended Stanford University's class in managing the difficult airway (actually the person with a difficult airway, to be picky.) It was taught almost entirely by anesthesiologists, the doctors whose job it is to maintain a person alive and ideally pain free during surgical procedures and operations. They intubate patients many times daily to support their breathing while they are so deeply anesthetized that they can't breathe for themselves. Because they are so good at it, they often help us intubate patients who are reversibly dying for other reasons. They are not always available, though. 

Most of the students were anesthesiologists, too, and the tricks taught in the course were really clever. A tube does not just naturally want to go down the trachea and into the lungs. If I stuck one down my own throat, past my gag reflex, chances are pretty good it would go into my esophagus, and if that tube were hooked up to a ventilator, my stomach would blow up with air, which wouldn't be very helpful. A metal laryngoscope with a light can help the tube go in the right place, but sometimes there is no straight shot to see to the trachea, guarded by the vocal cords, and more toys are needed. There are fiberoptic scopes that can be introduced into the right place, and the tube advanced over them. There are video laryngoscopes and introducers of various sorts. There are balloon type devices called laryngeal mask airways that can fit over the airway to provide a soft seal and be hooked up to a ventilator. There are ways to convert these to endotracheal tubes under direct vision using exchange catheters. And, if all else fails, a tube can be placed through a membrane above the thyroid cartilage after a hole is made with a scalpel. This is gory but life saving if we decide to do it soon enough. There are many different companies that produce the clever and expensive tools that make all of this possible, and because we are the US and money is pretty much no object when it comes to the things that save lives, these tools are INCREDIBLY COOL. There is even a video laryngoscope that makes introducing a tube really easy that, despite its great optics and excellent functionality, is entirely disposable and costs the hospital $80 per unit. It probably gets billed out at 5-10 times that, but that $80 number is still pretty impressive. It's also kind of horrible that we can't wash it and reuse it.

Beyond the cool toys (which included both mannikins, new and old tubing technology and actual pig tracheas on which to practice cricothyrodotomy skills) the major message of the course was that in something as important and time sensitive as supporting breathing the physician must always make a well thought out plan, taking into consideration everything that is known about the patient. One way to get a very uncomfortable plastic tube into someone's trachea is to give them adequate sedation and then use a medication to completely paralyze all of their muscles. Once this is done there will be no breathing unless it is done for the patient by the health care provider. In tricky situations it is sometimes possible to leave the patient awake and thus able to breathe albeit poorly or temporarily for themselves, and simply numb the airway passages. This doesn't always work. When the patient is sedated and paralyzed or unconscious and near death, a breathing device must go in, and the choice of which one depends on what we know about which one goes in most quickly, most successfully and with the least harm to the particular patient. When stakes are high and everyone is a bit twitchy, the operator must have rock solid backup plans should the initial procedure not be successful, must know the equipment and have excellent communication skills that include calling for help.

I now feel entirely comfortable intubating plastic torsos in all of the most dire situations they might find themselves, especially when I am at Stanford where I can easily lay my hands on the most advanced technology. It will be interesting going back to my own hospital and scoping out what is available when real people are counting on being intubated. It will, of course, be different, but the hands on experience from 15 hours of being around airway gods and placing tubes in fake tracheas will probably serve me well.

Stanford's faculty did an excellent job of teaching. The course was co-lead by Drs. Vladimir Nekhendzy and Jeremy Collins, whose knowledge and background in management of the sickest patients was vast. They were experienced, passionate about what they did, collegial and respectful of our different backgrounds. There was a perfect mix of lectures and hands on demonstrations and practice. The food was superb and the weather was ideal.