Re: "HealthSouth Divests ASCs (April, page 14). In addition to being a significant business transaction, TPG Capital's nearly $1 billion purchase of HealthSouth's 139 ambulatory surgery centers is a defining event for the ambulatory surgery industry.

By returning the surgery centers to their roots - freestanding, independent, joint-venture models in each community - TPG, with the management team from HealthSouth's surgery center division, will have the opportunity to invigorate its centers and position them for a new period of growth. However, a major challenge exists. Many of the surgery center partnerships were formed in the late '80s and early '90s. The physician-partners are now reaching the senior stage of their careers. The surgery centers remain productive and profitable, and HealthSouth has already had success in bringing in new physician-investors at many centers. Still, TPG must find a way to effectively recapitalize the remaining surgery centers with new and younger physicians, while still recognizing the contribution and ownership of their more senior colleagues.

One hurdle will be valuation. The HealthSouth transaction was 1.3 times net revenue and about 10 times cash flow. Although reasonable adjustments could be made for liquidity and minority discounts, the challenge of recapitalizing surgery centers at these valuations will prove interesting. TPG will have to present a compelling vision for the future of its surgery centers in order to attract new physician-investors.

With the transaction, TPG will become the new leader in the ambulatory surgery center marketplace. It will be important to watch how TPG plans to grow the top line of its ASCs while maintaining their margins and to recapitalize the centers for a younger generation of surgeons.

Dick Cowart
Chairman, health law and public policy departments
Baker Donelson
Nashville, Tenn.
writeMail("[email protected]")

Fighting Fire
Re: "When Surgery Sends Sparks Flying" (April, page 73). Every surgeon and anesthesia specialist should read this article. The explanations make sense and provide lessons for all so that we don't make the same mistake.

Robert Kotler, MD, FACS
Cosmetic Facial Surgery
Beverly Hills, Calif.
writeMail("[email protected]")

This is an important article for all who operate on the face. The anesthesiologist is always in charge of the gases. He should not be able to deny this. Snoring indicates airway obstruction and it would probably have been wise to convert the procedure to general anesthesia with an ET tube at this point. I have had firsthand experience with this problem and will never allow oxygen to be delivered under sedation while operating on the face.

Name withheld upon request

This is the very reason that we insist our surgeons use a Bovie halter and that our anesthesia providers vent the drapes.

Name withheld upon request

IV Start Insurance
Re: "The Starting Line" (April, page 90). It never ceases to amaze me how many times patients remark that no one has ever bothered to numb their skin before IV insertion. My routine has evolved from using a 25g needle with plain lidocaine to using a 30g needle with lidocaine buffered with sodium bicarbonate to reduce the sting of the lidocaine. (Plain saline will also suffice.) We also now have the availability of EMLA cream and pressurized, needleless systems.

Barry L. Friedberg, MD
Cosmetic Surgery Anesthesia
Corona del Mar, Calif.
writeMail("[email protected]")