Wednesday, February 10, 2016

Laryngoscopes and the Environment

There exists an odd debate regarding laryngoscopes. The Joint Commission which regulates hospitals regulates the sterility of laryngoscopes. The traditional scopes and blades have to be sent down for processing, which apparently involves multiple chemical baths. In response, some companies have designed single use disposable laryngoscopes which circumvents the regulations on sterile processing. They claim that throwing away these laryngoscopes - which have a light source, batteries, and a good amount of plastic - is better for the environment than multiple chemical baths. Maybe this is true, but I am shocked that this is considered a "good" solution. We go through so much equipment in the hospital; there must be some way we can avoid massive amounts of chemicals or tossing every instrument as if it were single use. This is not a sustainable solution, and the Joint Commission needs to recognize the harms it causes with its regulations.

Saturday, February 06, 2016

Zika


The outbreak of Zika virus, along with all the other recent global outbreaks - Ebola, Avian flu, swine flu, Chikungunya, Middle Eastern respiratory syndrome coronavirus, etc. - remind me of the global nature of infectious disease and public health. Each individual disease will come and go, but the problem will not go away. The globalization of the world, the ease of travel, the disparities in living conditions and health care, and environmental changes with global warming will make global infectious disease a recurring threat. I recently reread Margaret Atwood's Oryx and Crake, and it really strikes home. If we do not work on improving global health conditions and reducing health disparities, if we do not start studying and focusing on what global warming means, if we do not create the resources to tackle emerging diseases, one of these microbes will get out of hand.

Zika Virus electron micrograph is in the public domain, from phil.cdc.gov.

Thursday, February 04, 2016

Super Bowl 50

Apparently, with Super Bowl weekend coming up, the area expects an influx of over a million visitors. That really surprised me! All the local hospitals (including the one I am at) have put into place plans for increasing capacity, triaging patients, and responding to a mass emergency. It makes me think of the system strains that occur with large events like the Olympics, presidential debates, and big conferences.I suppose preparation and planning are key. Hopefully I won't need to rush in this weekend.

Monday, February 01, 2016

Sleep and Dreams

Sometimes, when I am feverish or sick, I have bizarre dreams with flights of ideas. My mind fixates on the strangest things (including work things) and no matter how much I try, no matter what meditation techniques I employ, I can't get these strange thoughts and images out of my head. I wonder whether that is what patients with delirium experience. Delirium is a really common hospital problem where a patient waxes and wanes in their attention and orientation. If you take a perfectly normal high functioning executive and give her an infection, treat her with antibiotics, stick her in the intensive care unit where she is awoken every hour, exchange her clothes for a gown, place tubes and lines that tangle her up, she will get confused. It's easy to imagine how she might not remember where she is, how she might become paranoid, how she might even have hallucinations or delusions.

We underestimate how tough it is to be an inpatient, especially in the intensive care unit. These days, I am at most in the hospital for a twenty-four hour stretch, and even that is enough to drive me crazy. I cannot begin to fathom being elderly or sick or alone for days or weeks in the hospital. I know there are a lot of initiatives to improve hospital life, and I make a big point of it by identifying patients that don't need to be woken up through the night, but it's still not pleasant.

Families also underestimate this problem. In the intensive care unit, I see patients at the end of life. Families recognize this but also want us to "just keep doing what we're doing" whether for more time or for a miracle or because they cannot stand to stop. Even though I can treat pain and anxiety and constipation and nausea and a dozen other symptoms, I cannot eliminate all suffering. The hospital is not a dignified place. It is not a comfortable place. It is a necessary place that comes with risks, benefits, and alternatives, just like everything else.

Saturday, January 30, 2016

Self

The care of the self is the foremost task for the healer. We cannot take care of others if we ourselves are in trouble. We are stricken by the same things all others are. We get physically injured, we get chronic diseases, we get emotionally distraught, we get psychologically troubled. We get tired, we get depressed, we get stressed. These are normal things that happen to people, but unlike many others, doctors often do not take time off to nurture themselves. This is deeply ingrained in our training; missing work is considered a weakness, a burden on others. Only recently has physician well-being become a catch-phrase. But it is such an important thing. We want our doctors to be healthy, sound of mind, clear of judgment. In order to have that, we need to build a system that gives our physicians time, space, and support to care for the self.

Thursday, January 28, 2016

Gratitude

I got a holiday card from a patient thanking me for a good surgical/anesthesia experience. I was even more surprised when I opened it up and realized she had written a lot - it was like a five paragraph essay. It's not terribly common to get thank-you letters or cards, but it does make a big difference for someone like me. Thank you.

Sunday, January 24, 2016

Sugar

A man with no known history of diabetes comes in for a resection of a brain mass. He hasn't been on any steroids, but on arrival to the pre-operative area, his blood sugar is 450. How do you proceed? Questions like this (I think) are pretty good boards questions because there is not necessarily a black-and-white answer. On boards, you pick a side and justify it as best you can. You don't waffle, but you know that if you have sufficient reasoning, you'll do okay. In real life, though, what do you do?

On the one side, there's a patient who has a brain tumor expecting to have it taken out. Delaying or canceling the case can have serious neurologic consequences. How long will it take for the patient's internist to get his sugars under control? How quickly might this tumor progress? Where is its location and what symptoms has it already caused? Is it really fair to go to a patient who has been planning on this for weeks, who has been fasting for a day and say that you have to cancel for something that is not his fault? What if you cancel this case and the exact same thing happens two weeks later? And there are systems issues too, though they are less important. What happens to your relationship with a surgeon if you cancel too many cases? What's the effect on OR efficiency? Is this really necessary?

On the other hand, 450 is a very high glucose. Someone with undiagnosed severe diabetes has an increased risk for surgery. He may also have undiagnosed coronary, vascular, or kidney disease. How many other things haven't been figured out? Could this be diabetic ketoacidosis? A patient who is going into DKA has a significant risk of dying; he may have hypovolemia, acidemia, and metabolic disturbances. Even if this is just pure hyperglycemia, it leads to increased infections, poor wound healing, and higher mortality. Furthermore, the stress of surgery itself leads to an inflammatory stress response which increases sugars. Even if he is not in DKA right now, surgery can tip that over. How can you justify taking him to surgery?

Of course, real life plays out a lot less dramatically. I consult several of my colleagues and talk to the surgeon about the risks and benefits. Then I spend a lot of time chatting to the patient about my thoughts. Ultimately, we decide that the best course of action is to delay the case several hours to get the glucose under better control. I check labs so that I know I'm not missing any other diagnoses. I administer intravenous insulin until the glucose is better. In the operating room, I place an arterial line and check frequent glucoses to keep the sugars under control. I consult a medicine hospitalist so that he has someone managing his sugars postoperatively. It takes a lot of extra work, but it's the right thing for the patient.

Friday, January 22, 2016

Blood

The unanticipated bleeding airway is quite rare. Most times, when we encounter blood, we expect it - a trauma victim with a smashed face, a bleeding tonsil, a patient with a tongue mass. So unexpectedly encountering blood on intubation can be a little alarming. A patient having a routine gallbladder surgery goes off to sleep. When I look with a laryngoscope to intubate her, I notice a frondy pedunculated mass in the back of her throat. It's bleeding. It can't get my laryngoscope around it without touching it, and the slightest pressure causes it to bleed. I react instinctively: I don't think I can intubate her easily so I go back to mask ventilating her and call for help. Another anesthesiologist comes in with a video laryngoscope and we take a look at the mass together. The surgeon also peers at the screen and notes that it looks very much like a lesion from HPV (human papillomavirus). With the video laryngoscope, I manage to intubate the patient, but the experience is a little stressful. Even as I suction blood from the back of the mouth, touching the mass inadvertently causes more bleeding. The blood pools continuously so it is challenging to do anything for more than a few seconds. Time feels strange; even though just a few minutes go by, it feels like so much longer. I also have to multitask; I remain cognizant of the patient's vital signs and depth of anesthesia. I draw up and give additional medications as needed. There is a conscious effort to suppress panic, but also an awareness to assess risk. On the one hand, I can wake the patient up, cancel the surgery, and have her assessed by our ear-nose-throat surgeons. On the other hand, I can "just intubate her" through the blood, risking failure and getting blood into the lungs. Fortunately, well-trained instincts lead me to the best option: to call for help, reassess the situation, formulate a plan, and proceed cautiously. After intubation, we checked her coagulation panel and platelets to make sure we weren't missing anything. In the end, the patient did fine. After the surgery, we gave our ENT consultants a quick phone call, rechecked the airway before extubation, and watched her in recovery a bit longer than usual. When I talked to her in the recovery room, I was not surprised to hear that she actually does have some bleeding when she brushes her teeth, and was planning to see her dentist. We managed to set her up with an appointment with an ENT surgeon as well.

Tuesday, January 19, 2016

Splinting


When a patient has multiple rib fractures, the dreaded complication is actually pneumonia. Rib fractures are surprisingly painful, so much so that patients splint when taking a deep breath or coughing. Splinting is the sudden arrest of a breath, often quite involuntary. Instead of taking slow, deep breaths, these patients take shallow rapid breaths. We often have to coach them to take fuller breaths with a device called an incentive spirometer.

The issue is that coughing is the body's natural way of getting secretions up from deep within the lungs. If a patient can't cough, they can't clear these secretions, and that provides a perfect medium for an infection. While rib fractures and lung contusions are rarely life threatening, a bad pneumonia in a patient who can't take deep breaths or cough is quite serious. This is such a problem that we often place epidural catheters in trauma patients with multiple rib fractures or lung surgery patients in order to help the patient breathe deeply and cough.

On a hike over the weekend, I slipped and fell on a log, and probably had some sort of rib contusion as a result. Compared to multiple rib fractures, this is really nothing, but for the first time, I experienced splinting. When I take deep breaths or try to cough, I can feel my muscles tense up, resisting me because my body knows its going to hurt. I was surprised how involuntary this felt. I takes so much willpower just to do the simplest motions. Now I know have a little more empathy for my patients who have much bigger injuries.

Image showing rib fractures shown under Creative Commons Attribution Share-Alike License, from Wikipedia.

Monday, January 11, 2016

Off This Week

This week I have a "staycation," a word I've been hesitant to use, but now that an emoji is "word of the year," I suppose I can incorporate some portmanteaus. I have some projects I am trying to motivate myself to work on. Although I love blogging and it has a therapeutic quality for me, I am trying to work on other writing like formal essays, creative nonfiction, poetry, and short stories. It's so easy for me to defer on those bigger projects and just write a blog, but I hope this week to push myself to setting ink to paper and pursuing something different.