Bing Concert Series

Most students who went to Stanford University know the name Bing very well. Helen and Peter Bing are amazing benefactors to Stanford who have made extraordinarily generous contributions to many aspects of the university. As an undergraduate, I played in the orchestra in Bing Concert Hall, visited Ireland on a Bing Overseas Studies trip, and toured the Cantor Arts Museum, supported by the Bings. In any case, the hospital has a noon music performance twice a week in the atrium called the Bing Concert Series, and it is fantastic. Residency keeps us busy, but if I have a chance, I always stop for a moment to listen to the musicians - from jazz to classical to Irish to Latin. I am always so happy to see patients there, even if they come with their IV poles, TB masks, and surgical drains. Listening to live music in the hospital puts my day in perspective and makes me thankful that I work in such a pleasant harmonious environment.

Image of Jean-Gabriel Ferlan is in the public domain, from Wikipedia.

Fatigue

Some days, it is simply better to go to bed.

Image is in the public domain, from Wikipedia.

Face Off II

To secure the airway in the patient described in the last post, we did a retrograde wire intubation. This is one of the most complex intubation techniques, something that even an experienced practitioner may only do a dozen times in his career. It is often reserved for patients who have such distorted or traumatized facial anatomy that it is impossible to introduce even a small flexible camera into the nose or mouth. In our case, the patient's cancer made a standard intubation more complicated so the chief resident and attending decided to do the retrograde wire intubation.

In this technique, a needle is placed through the throat into the windpipe. A thin wire is fed through the needle toward the mouth until the wire comes out of the mouth. Then, a tube can be threaded over that wire back into the trachea. Though simple in description, it's not a small procedure. Luckily, our retrograde wire intubation went incredibly smoothly, and I got to see a rather rare method of accessing the trachea.

Face Off I

In 1997, there was a movie called Face Off which featured a face transplant. I recently provided anesthesia for a case that reminded me very much of the movie (it was not a real face transplant, though such surgeries have been performed). A gentleman who unfortunately had widespread invasive cancer of the jaw and throat needed a wide excision, lymph node dissection, tracheostomy, and reconstruction. For such a large surgery, the ear-nose-throat surgeons took off much of the skin of the face, a procedure that, for most, is as awful as it sounds. But for those few of us who chose to do medicine, who studied human anatomy, who dissected cadavers in the first month of medical school, this was an amazing experience. Watching the surgeons work, identify vessels, nerves, bones, and the cancer was quite remarkable. There is a certain beauty and art in the human body, and under the veneer of skin there is an intricacy and mechanic that I will not ever fully understand, at which I will continue to marvel. At the end of the eleven hour surgery, the patient's face was reconstructed and the only evidence of this intrusion was a thin necklace-ringed scar at the base of his neck.

Call

Overnight call is very different as an anesthesia resident compared to a medicine intern. Last year, I spent the night admitting patients to the hospital, ordering tests, making diagnoses, starting treatments. I also cross-covered the inpatients on other teams, addressing acute issues as they arose after their primary teams left. Now, as an anesthesia resident, I don't have either responsibility. At the VA, I instead hold the "airway" pager. I run to rapid response teams and code blues with a tacklebox and backpack holding the contents of an anesthesia cart. I carry everything I need to ventilate and intubate someone including drugs, masks, and multiple backup tools such as the fiberoptic laryngoscope. If there aren't any acute respiratory issues, I can help with obtaining IV or arterial access as needed. At the VA, emergency surgeries are uncommon since it is not a trauma center, but I am available to provide anesthesia for emergency operations. Lastly, I am the go-to person for patients who have epidural or nerve block catheters. I visit patients who are post-operative and see any preoperative inpatients who haven't been seen. Overall, it's not a big workload though its a lot of different small responsibilities. As a result, I get more sleep on call than I ever did last year.

Change in Plans

Occasionally, surgeries do not go as smoothly as planned, and as anesthesiologists, we have to adapt to changing circumstances. I had two cases that were converted from a minimally invasive strategy to an open one. In the first, the surgeons were attempting to do a distal pancreatectomy with a surgical robot. Despite the improved dexterity and manipulation offered by the robot, the patient's organs had too much adipose tissue to allow the surgeons to dissect effectively. After a few hours of struggling, the attending surgeon decided to open the patient. This is not an easy decision as it exposes the patient to a longer hospital stay, more post-op complications, and more pain. In an open fashion, they were able to resect the distal pancreas in just an additional hour. Since the amount of time under anesthesia and in surgery is also correlated with outcomes, it becomes a balancing act of risks and benefits in deciding when to change plans. Similarly, I was in a case where the surgeons initially tried to do a laparoscopic sigmoid colectomy, but eventually had to open.

In these cases, we have to anticipate the possibility of changes in the surgical approach. Some monitors and procedures are much easier to do at the start of the case, but only become necessary if the patient is having open surgery rather than minimally invasive surgery. Anesthesia is very much a specialty of anticipation and we learn to plan for the worst and hope for the best.

Saving Money on Trainees

With the recent economic crisis, there have been proposals to cut federal funding to residency programs. Obviously, I have a vested interest in this topic, and I think that without revamping the medical training system in the United States, this is a very dangerous idea. Medical residents are paid by the government as a result of the Medicare bill. Hospitals get reimbursed for the residents they train. Certainly, cutting this source of funding would save money on the government's part, but without funding, residency programs will collapse. We are not overpaid. For the hours we work, the years we train, and the responsibilities we carry, our salaries are hardly excessive. In fact, when an anesthesiology resident graduates and goes to private practice, he can make six times his prior salary. (Whether anesthesiologists are overpaid is a separate topic). Furthermore, residents have a heavy debt load after four years of undergrad and four years of medical school. It would simply be unsustainable for us not to make money. Few hospitals would be able to salary residents without federal support. As a result, trying to save money with training programs hamstrings those programs and would stop our supply of new physicians.

Now, there are proposals of bigger changes - perhaps revamping the entire system would be better - cut the costs of going to medical school, and in return, pull back on the salaries for residents. I don't know how such a big change would work. Certainly, medical schools do not depend on tuition for the bulk of their costs, but having gone to a state school, I know how tight finances are. And cutting income for residents later on puts pressure on them in a time of their life when they are looking to start a family, buy a house, etc. Only a well-tested and piloted program would be feasible, and in the end, I'm not sure that's where the biggest savings will be.

I understand the dilemma. The federal debt seems insurmountable without touching health care as an expenditure. No one wants to take away from the beneficiaries of Medicare, Medicaid, and other programs. But to take away from physicians-in-training is to take a large risk for little yield.

Spectrum

"Perhaps the classification as 'dying' is really more like height than it is like gender. Some people are clearly 'tall' or 'short' but many are 'in between.' Likewise, some people are clearly 'dying' or 'fully healthy,' but many are 'in between.' In fact, most of us will die without having a period when we could readily be recognized as 'dying' or 'terminally ill.' The new reality is that most of us will die from complications of a serious chronic illness that we will 'live with' for years. There will only occasionally be a transition from the 'living with' to a time of 'dying from.'"
-Joanne Lynn, Joan Harrold, Handbook for Mortals

Image is Still Life with a Skull, by Philippe de Champaigne, 17th century, in the public domain, from Wikipedia.

Stress, Anesthesia, and Fluffy Hats

The nice thing about being in the operating room is that you can hide hair loss under a scrub cap.

Back-Up Plan

This is a bougie, a thin plastic rod that is used as a back-up maneuver when we have difficulty intubating the trachea. Occasionally, after sedating a patient and paralyzing him, we take a look with a laryngoscope but can't see the vocal cords very well. If we can't get an endotracheal tube into the airway, we can occasionally try slipping this device in as it's thinner and more easily maneuvered. The bent tip allows us to guide it into the trachea and as it passes down, it clicks as it goes over the cartilage rings and stops when it hits the first split of the trachea into the right and left bronchi. When I felt this, I was amazed by the sensation. Once it's in, we slide a tube over it, and it acts as a stylet to guide the tube into the right place.

Image of bougie shown under Fair Use, from healthsystem.virginia.edu.

Pharmacokinetics and Pharmacodynamics

One of the interesting things about anesthesia is that it challenges us to use our knowledge from undergrad and the first two years of medical school. While many physicians lament that the pre-medical and pre-clinical curricula have little to do with practical medicine, this is not the case in anesthesia. We have to have some understanding of competitive antagonists from biochemistry, signal transduction pathways from cellular biology, and even Poiseuille's law from physics. Textbook diagrams include calculus. The graphs shown above demonstrate basic pharmacologic principles that we all learn in the first year of medical school and promptly forget, at least until we start anesthesia residency. It's really interesting because I'm using far more basic science principles, theories, and ideas than I did last year doing internal medicine. Even though a knowledge of physiology is central to almost any specialty, anesthesia is really applied physiology. We think through problems with a mathematical, biologic, or chemical framework on a daily basis. Thus, studying for me means returning to those things I've learned in the last ten years.

First image shown under GNU Free Documentation License. Second image is in the public domain. Both are from Wikipedia.

Pre-op clinic

I was in the VA pre-op clinic for a little bit in the past few weeks. Although the hours were much more benign, I did confirm that clinic is not the right setting for me. It was enjoyable to talk to the patients and their families, and helpful that I had done a few weeks of anesthesia, but the repetitive feel of it and the busy flow makes me happy to get back to the operating room. Seeing patients in the preoperative clinic helped me realize how important the pre-op visit is to smoothing the process for patients, educating families on what to expect, addressing relevant medical issues, and ensuring safe anesthesia.

Principles of Internal Medicine

Harrison's Principles of Internal Medicine is one of the defining textbooks of the field. Named after Tinsley Harrison who was the original editor-in-chief, the first ten editions of the book carried this amazing quote by Dr. Harrison:

"No greater opportunity or obligation can fall the lot of a human being than to be a physician. In the care of suffering he needs technical skill, scientific knowledge and human understanding. He who uses these with courage, humility, and wisdom will provide a unique service to his fellow man and will build an enduring edifice of character within himself. The physician should ask of his destiny no more than this and he should be content with no less."

Image shown under GNU Free Documentation License, from Wikipedia.

Position

Before I started working in an operating room, I never gave much thought to the positioning of the patient. It always seemed like one of those mundane things. But now that I am the one bringing a patient in, monitoring them through surgery, and then wheeling them out to recovery, I have gotten to know all our operating rooms well. In some, you have to go in head first; in others, feet first. There isn't a lot of room in the operating theater to do a complete turn. Most times, the head is close to anesthesia; that way, we can keep an eye on the airway. During the operation, the surgeons often ask us to move the bed up or down. While this may seem like a stupid task, I learned quickly that it was my responsibility as I raised the patient up and down that lines didn't get caught, tubes moved, catheters displaced, or things crushed.

The cases I've learned to dread have to do with complex positioning. Some patients are turned 180 degrees so that their feet face us while the ear-nose-throat surgeons or plastic surgeons work on the head. In these cases, we have to secure the breathing tube extremely well because we don't have ready access to the airway. In back surgeries or neck surgeries, we flip the patient over (from supine to prone). I've learned the toughest part of these cases is getting into the right position. When turning the bed 180 degrees, we have disconnect as much as we can (but some things - like the IV - can't come out), and turning the bed leads to all sorts of entanglement. When flipping a patient over, we have to support the head and face, maintain access to the breathing tube, and protect the eyes and nose - all difficult to do in an asleep obese patient. Positioning is a routine and mundane thing, but doing it right isn't simple.

Is Rationality Enough?

One thing that has fascinated me is how we form, modify, and reject beliefs. This, of course, is central to western philosophy; Rene Descartes in Meditations on First Philosophy asks us to doubt every single one of our beliefs until we can justify that they are on a solid rational foundation. And as purveyors of logic, philosophers inherently believe that argumentation based on scientific principles can sway opinion.

We know, of course, that this is not always the case. New data, studies, analyses, guidelines, and recommendations are coming out all the time, yet the practice of medicine is slow to change. Certainly, we are resistant to adopt new practices based on limited, unconvincing, or preliminary results, and many previous sagas such as hormone replacement therapy have taught us to move cautiously. But I think there is more than that. Part of our inertia is that emotions, anecdotes, fear, and irrationality weigh in on our decisions whether or not to change our practice. That is, science is all science, but medicine is not purely an application of logic, numbers, and rationality.

For example, say a new prevailing all-encompassing study demonstrated that mammograms before age 50 are not useful at all for the general population. Imagine that it were definitively proven that they don't catch enough cancers, they have too many false positives, and indeed, they create more pain, cost, and trouble than the cancers they do catch. How many physicians would change their practice? How quickly would such a change take hold?

Stephen Colbert made up the word "truthiness" during the pilot episode of his program to mean an appeal to emotion and "gut feeling" without regard to evidence, logic, or facts. "We're not talking about truth, we're talking about something that seems like truth - the truth we want to exist." When facing a patient who may have cancer, we want to be able to detect it and cure it and that gut drive may overwhelm any number of statistics and evidence pointing to the contrary.

This might be a problem. If we aren't listening to the dictates of research and remain entrenched in convention and hearsay, we aren't doing our patients any good. If we are unduly swayed by emotion and "truthiness," we aren't practicing optimal medicine. The time, effort, money, and minds contributing to research only pay off if they change the way physicians practice medicine. In the absence of open minds, medicine remains stagnant.

And yet, a counterargument is that medicine is the finessing of both science and art; we must weigh the strength of the research coming out, we must balance it against patient preference and subjective feel, we must interpret all these signals - both truth and truthiness - to come up with a coherent plan that makes sense. No matter how much my philosophy-trained self would like it, rationality is not everything; if it were, we could be replaced by automatons that fit people into boxes and guidelines and recommendations. No -- medicine is a tad more complicated than that. How do we change our beliefs and decision making schema? I don't know. I don't think discovering the evidence is enough; we must use it to persuade our colleagues, teachers, and students. We need to understand how new facts and data fit in pre-existing frameworks. But even more importantly, we need to understand the importance of emotion, convention, and "truthiness" so we neither discount nor give free reign to those influences.

Urology

Last week I had a couple days of urology cases which taught me quite a bit about the kidney. One was a percutaneous nephrolithotomy, a procedure in which a needle is passed from the back into the kidney to remove a stone. This is done under fluoroscopic guidance with X-rays. Although the stone can be visualized and one can aim a needle at the stone, the surgeon can't tell what he's passing through to get to the stone. As a result, the patient had a significant bleed when a renal artery was punctured. The kidneys get a lot of blood, and when the vessel bled, we knew it; not only did a pool of blood collect on the floor, but the patient's heart rate doubled and his blood pressure tanked. It was a good example of how anesthesiologists must respond rapidly to surgical problems. While the surgeons put pressure on the bleed with a balloon, we quickly opened fluids wide open, transfused a unit of blood, sent blood gases, and obtained more IV access (not easy since the patient was lying on his belly). The patient did well with our interventions and we tided him over to the ICU.

On another day, we had a laparoscopic radical nephrectomy - removal of a kidney - for cancer. Laparoscopy involves the use of surgery through small incisions by introducing tools and a camera into the body; these minimally invasive techniques prevent the morbidity associated with a large incision. However, the surgeons were having a lot of difficulty removing the kidney and the three hour scheduled case ended up taking nine hours. It is a surgical decision whether to convert a laparoscopic surgery to an open one, and it can be difficult to weigh the risks and benefits. However, it was an important lesson in adapting anesthetic plans to difficult surgeries and preparing for changes in the surgical technique if necessary.

A Curious Effect of Time

It's a strange feeling to find that my friends in medical school who started a little after me or took a year or two off to do research are now applying for residency or in the second month of their internship. It feels so long ago since I started internship, before I knew what a bowel regimen meant, before I could juggle a dozen patients at a time, while I was still adjusting to the title of doctor. It seems even longer since I embarked on my (well-blogged) journey to find a residency program, writing a personal statement, researching programs, and breezing through fourth year of medical school. Good luck to all my friends who are beginning that process or plunging into internship.

Reining in Costs

The recent economic woes of the U.S. government, the midnight hour in raising the debt ceiling, the downgrade of U.S. credit, and the political complexity of fiscal policy-making reminds us that along with social security, health-care expenditures will need to change. Raising taxes for the wealthy, increasing revenues, and cutting costs elsewhere simply won't be sufficient. As health care consumes more and more of the GDP, it becomes more and more unsustainable and harder to change. The recent events remind us strongly that we need to act now to change the system. What frightens us is the idea of shifting the burden of healthcare costs from the government to individual families. Health - good health - is so expensive that no one can afford it: individuals, companies, and now not even the government.

I don't have great solutions to this problem, and I know little of health care economics. But I think we might have to start proposing the ugly words no one wants to hear. Is it time for rationing? I've written about this in the past and I'm sympathetic to the concept that health care should not be rationed - that it would be ideal not to have a limit on how much a patient can get. Who's to say which medications or surgeries or visits should be covered and for which patients? But now that we are stuck between a rock and a hard place, these ideas are going to resurface. It's time to become practical.

For example, what if I raised a highly controversial idea: changing the gestational age of premature infants who we resuscitate. Depending on the hospital, preterm infants around 23 weeks are the youngest to be resuscitated. If a woman delivers a fetus prior to 23 weeks, then the fetus is not resuscitated; if the gestational age crosses the threshold, then resuscitation can be pursued. Here are the statistics:
From this graph, newborns resuscitated at 22-23 weeks had a 73.8% chance of mortality within 28 days. Those that do survive are likely to have a lot of morbidity from such an early birth. Overall, these patients have some amount of cost to a system's resources. What if as an overall standard, we decided that premature infants before 24 (or 26 or 28) weeks not be resuscitated. This decision would in essence say that the costs of resuscitating infants before that gestational age outweigh the benefits, especially since pre-existing morbidity and mortality is so high.

Now I want to be clear: I'm not proposing or advocating this. It is fraught with moral and ethical issues. It doesn't take into account changing technologies that may allow more effective resuscitation and care of premature infants. It would stimulate outcries from mothers whose premature babies are doing wonderfully, and perhaps mothers whose premature babies are not. I'm hardly an expert in this subject; I haven't done pediatrics for two years. But I only raise this point to show that if we are to control costs, one possible approach is to identify populations of patients, medications, or interventions whose health care costs outweigh the benefits they reap. I apologize to anyone who may be offended by my example.

Image of neonatal mortality by gestational age 1995-1997 is shown under Fair Use, from UpToDate, adapted from Alexander et. al, Pediatrics 2003.

The Airway II

Upon induction of anesthesia (a topic for a future blog), we insert the blade shown above into a patient's mouth and slip it down the throat. When inserted correctly, we lift the tongue and soft tissues up from the back of the throat, hoping to see the vocal cords. Carefully, we slide an endotracheal tube through the cords, which allows us control of a patient's breathing.

In theory, it's a fairly simple procedure, but the consequences can be dire; esophageal intubations (incorrect placement) used to be the most common cause of anesthetic death. And intubation gets harder with obesity, a history of neck surgery, a big tongue, loose or broken teeth, or a host of other factors. Anesthesia residency is about learning to troubleshoot suboptimal views and developing backup plans when a simple direct laryngoscopy fails.

One of the newer technologies is to use a blade with a camera at the end. This takes away the difficulty of looking through the mouth and trying to align anatomic axes to view the vocal cords. The GlideScope, shown below, is one of our backups in a difficult intubation, but even with this, navigating the endotracheal tube through a tight passage can be challenging.

Image of Macintosh blades shown under Creative Commons Attribution 3.0 License, is from Wikipedia. Image of GlideScope shown under Creative Commons Attribution Share-Alike License, is from Wikipedia.

The Airway I

The "A" in the anesthesia ABC's stands for airway, which is what most physicians think about when they think about anesthesia. (Some jokingly say B stands for book and C for chair). Anesthesiologists are the airway experts in the hospital, and we are often the ones to secure an airway during an emergency situation. For most surgeries, we need to intubate a patient - that is, place a breathing tube into the trachea (windpipe) to help a patient breathe. Our ability to do this under pressure in the most difficult patients makes our skill set different. While I am beginning to learn all the other things anesthesiologists do, the airway is a central focus.

Intubating a patient is a skill that has an incredibly steep learning curve but eventually plateaus once it clicks. It took me all of my first week of residency, trying different tricks, having different attendings, and learning the mechanical dexterity to be able to consistently see the vocal cords to place the breathing tube. At first, I was worried because it was so hard, but as I worked on it - studying the anatomy, practicing with models, and trying different suggestions, I finally got it - and now it's not that hard at all. I think this is the case for many hands-on interventions in medicine; unfortunately, we have to surmount the steep learning curve to reach the plateau where we can reliably and safely protect the patient.

Image from Gray's Anatomy is in the public domain, from Wikipedia

Two Weeks of Cases

In my last two weeks, I've had a wide variety of cases. One of the new things I have to do with anesthesia is log my operations and procedures as this eventually becomes important to satisfy the requirements of residency and as a record for future employers. Looking back at my case log, my last two weeks have been heavily focused on orthopedic surgeries, followed by general surgeries. I've done a lot of total knee replacements, a few hip replacements, and a smattering of finger fractures, toe amputations, etc. Doing a lot of one surgery helps, especially if it is with a single attending, because then I get to know the people, habits, steps in the operation, and preferences pretty well.

For general surgeries, I've provided anesthesia for procedures as simple as placement of a peritoneal dialysis catheter or rectal exam under anesthesia to those as complicated as a hiatal hernia repair or sleeve gastrectomy. At the VA, there are a fair share of lumps and bumps (biopsies of masses, removal of lipomas, debridement of wounds). There are a few combined cases between multiple surgical services such as urology to place ureteral stents and general surgery to do a laparoscopic sigmoid colectomy. Lastly, I've done a smattering of ENT cases like thyroidectomy and vascular cases like AV fistula creation.