Thursday, September 29, 2011

Patients on the Pain Service

I saw a lot of fascinating cases on pain service. One woman who had never taken a pain medication in her life was admitted with a fracture. Her primary doctor put her on escalating doses of morphine but she didn't get any relief. She continued to report severe pain, and finally we were consulted. We suggested patient-controlled analgesia with hydromorphone, a related opiate. She controlled how much she could get; this would allow us to calculate her needs. With one push, she fell asleep and her pain was completely eliminated. For some reason, this woman responded to one opiate but not another. Yet when we tapered her off of her morphine, she showed signs of withdrawal. Although she got no pain relief from morphine, she got all the side effects.

Another patient was a woman who had her arm amputated in a work accident. It was awful; she underwent plastic surgery, but afterwards, had the sensation of phantom limb pain. Even though she had no hand, she could feel her fingers, intertwined, knotted up, highly uncomfortable. Her brain was still sending signals assuming her hand was there. We approached this aggressively; she normally takes no medications, and we immediately put her on six. Yet that strange sensation never left; I realized how elusive certain forms of pain can be.

Lastly, I took care of a patient who had anaphylaxis, a life-threatening allergy, to fifteen different medicines, most of which were pain medications. She could not tolerate codeine, hydrocodone, oxycodone, morphine, hydromorphone. Her chronic pain was controlled with methadone. But she was getting a shoulder surgery, and afterwards we had to tackle her pain despite her allergies. Interestingly, the other medication she tolerated well is meperidine which has a similar chemical structure to methadone. Although negotiating her pain was a challenge, it was also a highly educational experience.

Tuesday, September 27, 2011


Although interrelated, pain medicine and addiction medicine are separate fields. However, on my acute pain rotation, I was introduced to some of the issues regarding opiate addiction. Addiction is an awful disease. We saw several patients, all young, all of whom became tolerant to and then dependent on pain medications. These are the patients who all the attendings know; they spend more time in the hospital than out of it and each time they are here, pain management gets consulted. Some patients have real pathology; one had an extensive surgery and has real pain, but over a prolonged hospital stay of several months, has required more and more pain medication. Even though now she is actively trying to decrease her use, it is a long road because she's been on opiates for so long. On the other hand, we have another patient who is on sky-high doses of IV pushes, probably because she likes the feeling she gets from it. Converting her to equivalent doses of long-acting medication or even to a patient-controlled machine don't achieve the same effect. She has no intention of changing her regimen and is incorrigible in her demands.

Sometimes physicians find these patients frustrating. Addiction makes patients belligerent, hostile, demanding. It decreases our threshold of safety for medications. It makes doctors wary and we undertreat pain and underprescribe medications on discharge because we don't want things to be abused. But it is also a very real disease. Patients with addiction have no free will at all. They are mentally, psychologically, and physically dependent. They have no choice in the matter, and it is not simply a question of willpower or strength of character. While patients can resolve to fight cancer or do physical therapy through pain, it is behavioral changes like overcoming addiction, exercising regularly, eating well that still proves to be the most challenging.

Image of opium poppy is in the public domain, from Wikipedia.

Monday, September 26, 2011

Home Call

Home call is an odd concept. On the pain rotation, four of us took turns taking call. When on call, we'd stay late to tuck patients in but go home, available by pager. It's an odd feeling, having that loom over us. We carry our pagers around like a leash. We sleep in our beds, but never soundly. And the following day is a full work day like any other. It makes me respect what fellows and attendings do, because they often have pagers with them all the time. True, they get paged less often, but since the buck stops with them, I imagine the pager still gets checked impulsively.

On pain, most of the time, we are able to address pages remotely. We can troubleshoot certain issues and enter orders at home. But occasionally, especially if it is a problem related to an epidural, we have to come in, and that can be a little painful in the middle of the night between two full days.

Sunday, September 25, 2011

Shades of Pain

Many people think of pain as one sensation, one thing. But as I've learned on the pain service, pain comes in many forms and colors; each distresses a patient in a different way and each requires a separate treatment modality. For most of us, we think of pain as nociceptive pain, the type of pain we experience if we cut ourselves or burn ourselves or touch something acidic. It is the pain we expect someone to have after surgery. And indeed, a majority of our patients are post-operative, and this kind of pain responds well to opiates. But other types of pain include neuropathic pain, the type of discomfort long-standing diabetics feel in the absence of injury. Phantom limb pain occurs when a patient has an amputation but still feels his hand and fingers. I saw a patient with this that was extraordinarily difficult to control. Headaches have many characters but most of them are not related to the pain we feel if we slam a car door on our fingers. Whether a common tension headache, a low pressure headache worse when standing, an electrocuting trigeminal neuralgia, or debilitating migraine, pain takes on many different masks.

The worst pain I saw on this service was cancer pain. Unremitting, relentless, and unabating, cancer is really an awful perpetrator. These are the patients where we pull out all the stops. When metastatic disease invades muscle, nerves, adjacent organs, the spine, we have to tackle the discomfort with everything we have. The most extensive pain regimens I've seen involve patients with end-stage widely invasive cancer; they are on multiple fentanyl patches, suck on fentanyl lollipops, use hydromorphone PCAs with settings that would immediately overdose anyone else. We even use medications that double as street drugs like ketamine. What makes this difficult for me is that cancer pain does not get better. While pain improves after a surgery or a cut or a burn and even occasionally with nerve damage, cancer pain is dogged and challenges our ability to palliate until the end of life.

Saturday, September 24, 2011

The 5pm Consult

Hospital etiquette is to call consults early in the morning so that subspecialty services can see the patient and staff them by the afternoon. Sometimes we get exasperated by the consult that gets called at 5pm, especially if it is not urgent. But after being an intern in that situation of calling and a resident receiving that call, I've learned the far most important thing is to be polite, see the patient, and help the primary team. There's no place for laziness or unprofessional comments. It happens, of course; no one can deny how tiring, difficult, and stressful residency can be. But we always remember that we are here to take care of patients and staying an extra hour or two is hardly a big sacrifice.

Wednesday, September 21, 2011

Pain Management

Pain, especially in the hospital, is such a prevalent problem. All physicians (except perhaps radiologists and pathologists) have some facility in treating pain. One of the first things we learn in residency is opiate management, quickly followed by learning the bowel regimen (since opiates commonly cause constipation). For the most part, doctors do just fine. So when do you need a consultation from a pain management specialist?

The pain subspecialty is made up of multiple specialties: anesthesiology, neurology, psychiatry, and physical medicine and rehabilitation. Thus, it is a highly interdisciplinary field that draws tools, skills, and strengths from many different areas. We approach pain in a multimodal manner; from a nonpharmacologic standpoint, we address psychological issues, psychiatric comorbidities, addiction, expectations, physical and occupational therapy, biofeedback, acupuncture and acupressure, meditation, massage. With medications, we use not only opiates, but opiates in many delivery systems: patient controlled analgesia, intrathecal administration, epidurals, transdermal delivery. We use the opiates other physicians fear: meperidine, suboxone, methadone, and sky-high doses of mainstream medications. And along with our multimodal approach, we use nonopiate adjuncts: acetaminophen (both orally and IV), NSAIDs, neuropathic agents, tricyclic antidepressants, selective norepinephrine re-uptake inhibitors, local anesthetics (both locally and intravenously), NMDA antagonists like ketamine.

Lastly, the pain service can do invasive procedures for pain. We block nerves under fluoroscopy in the operating room or ultrasound guidance at the bedside. We do trigger point injections with botox. We place continuous pump infusions into the spinal space. We do pulsed radiofrequency treatments, ablation of nerves, and implantation of spinal cord stimulators. I've done a few nerve blocks and it's incredibly satisfying to see the relief patients get. It's really a fascinating specialty.

Tuesday, September 20, 2011

Why Everyone Needs an Intern

Hospitals run on interns. With the new work hour changes, the hospital has started creating specialty services without house staff (residents). This is not necessarily new; for a long time, we've had a dedicated cystic fibrosis team made up of an attending and nurse practitioners which worked seamlessly. However, as resident hours are more restricted but the overall patient load has remained the same, house staff are covering fewer patients. In fact, the liver transplant team I was on in June no longer has interns and residents; it is run by physician assistants and nurse practitioners. Other services, such as lung transplant or even our chronic pain service, are run by fellows.

Like all system changes, this has its issues. Interns and residents are good at the day-to-day busy work. We know how to order the CT scan on a weekend, how to use the computer system, how to look up who's on call. These details - which have little to do with clinical medicine - have everything to do with how a hospital runs. Services with nurse practitioners and physician assistants often get up to speed pretty quickly; the NPs and PAs learn the nuts and bolts. However, clinical fellows have a harder time because they often switch; the rotation for our fellow is 2 weeks long (done twice a year) and this doesn't allow much time to learn the basics.

The last thing that worries me is that patients on housestaff teams always have a covering intern, someone on call and in house who has information about the patient. If an issue comes up or a code is called, the covering physician always comes to the bedside. If the patient is on a team run by nurse practitioners, physician assistants, or fellows, those practitioners don't stay in house. While many problems can be addressed from home and fellows will come in if needed, in an emergency situation, the people who know the patient the best may not be available.

I don't think there's a perfect system, and I think what we have works fairly reasonably. However, I wanted to point out the complexities of covering every patient in the hospital.

Monday, September 19, 2011


"Did you ever say yes to a pleasure?
Oh my friends, then you also said yes to all pain
All things are linked, entwined, in love with one another."

One of the most fascinating aspects of pain is that it is so pervasive and central to art, literature, theatre, media, philosophy, and all forms of expression. Ever since we could communicate, we have talked about pain. Our greatest thinkers dwell on what it means and why it exists. Our greatest painters, sculptors, dancers, and artists try to depict it. Our greatest storytellers create myths, recount tales, and personify it. The experience of pain is, to some extent, the experience of being human.

Image of tragic mask on the facade of the Royal Dramatic Theater, Stockholm is shown under Creative Commons Attribution Share-Alike License, from Wikipedia.

Saturday, September 17, 2011

The Slow Code

All patient identifiers in this story have been changed. One afternoon, I was scuttling about the hospital checking off my to-do list when I get an urgent page from my attending: "We are in the OR. Please see rapid response team called for room D303, it is one of our chronic pain patients." I dropped everything and ran over where I met the patient for the first time. I had heard of her on rounds and recognized her as a young woman with chronic neuropathic pain that had failed treatment with opioids, anti-inflammatories, anti-neuropathic agents, anti-depressants, and a host of other medications. She was getting an infusion of a newer drug that only a few attendings had intimate knowledge of. The rapid response team had been called because of altered mental status. A few minutes after the infusion had started, she became unresponsive, but 30 seconds later, regained consciousness. Her vital signs remained stable. I quickly evaluated her, and she appeared to be close to her baseline except for a mild headache and some myalgias. The ICU fellow showed up and we conferred. We obtained an EKG, some basic labs, and stopped the infusion. The attending arrived in scrubs from the operating room (he's the kind of attending that on the floor always wears a suit and tie), and we all felt comfortable with keeping the new medication off and observing.

Over the next few hours, I continued to do my floor work, but I overheard the fellow talking to the nurses because the patient was slowly getting worse. Her headache became more and more severe to the "worst headache of her life" (her chronic pain was in her extremities), and she began having nausea and vomiting. I started worrying about increased intracranial pressure so I went to go see her. The first thing I noted was that she had the strangest arrhythmia. Her heart rate would flip back and forth from bradycardia at 40 (regular) to tachycardia to the 120s (also regular). Her oxygen saturation was pretty poor; she was already on a 6L facemask and I bumped her first to a Venturi mask, then a non-rebreather. Something was going on, and I did not know what.

Part of the problem with this situation was that there was no leadership. The fellow was constantly pulled away for other matters, and I didn't know this patient very well. We flip-flopped on a medicine consult versus a cardiology consult, but finally I called the ICU fellow. With increasing oxygen requirements and an unclear arrhythmia, I felt she needed a higher level of care. Eventually, an ABG came back with hypercarbia and the patient was intubated in the ICU. She was extubated the following day with a stable heart rhythm and discharged the day after that. It was felt that her headache, oxygen requirement, and arrhythmia were all associated with this new medication infusion. Only one case report had been published in the literature of a similar circumstance.

The truth is, recounting the story makes it sound easier than it was. All last year as an intern, I had backup, but in this case, I felt that I was running the show - the fellow didn't provide the support I needed. I could feel myself walking through the differential diagnosis in my head, deciding on the labs to order, figuring out which consultants to call, and coordinating the care. The whole incident played out over hours, and it was stressful being in that situation as I didn't know the patient or the medication well. Afterwards, I debriefed with the medical student and we discussed all the things that didn't seem to work. It was a very good lesson on crisis management for me.

Friday, September 16, 2011


A study in the August 2011 issue of the New England Journal of Medicine looked at lifetime risk for malpractice lawsuits. Researchers used a national insurer's records from 1991 to 2005 and found a surprisingly high rate of lawsuits. Neurosurgeons and cardiovascular surgeons had the highest annual risk for lawsuit, almost 20%, whereas psychiatrists and pediatricians had the lowest annual risk, less than 5%. By age 45, 36% of doctors in low-risk specialties and 88% in high risk specialties had faced their first claims; by age 65, low-risk doctors had a 75% risk and high-risk doctors had a 99% risk of lawsuit. Of these, only 22% of lawsuits resulted in payments to claimants.

This explains why "defensive medicine" is so pervasive. Being sued for malpractice is an inevitability, and so the practice of medicine is pressured by forces other than what is right for the patient. It also points to the widespread belief among doctors that legal action against doctors needs to be curtailed. Only a fifth of lawsuits result in a payout, suggesting that most lawsuits do not involve malpractice and may unnecessarily drive up the cost of medicine. Whether through caps on maximum payouts or through expert court panels or through other methods, reining in the number or impact of lawsuits may benefit society overall in the long run.

Thursday, September 15, 2011

The Chronic Pain Service

Stanford has a fairly unique inpatient pain management program for patients with severe, debilitating diseases who are admitted directly to the pain service for very specialized protocols. For example, we start ziconotide, a unique analgesic derived from the toxin of a snail, delivering it into the spinal space for some chronic nerve pain syndromes. We have a special dihydroergotamine protocol for patients with refractory migraines. We also detox patients who have addiction issues. It's interesting to see these specific therapies for a very small population of patients. Although the pain management fellow is mostly in charge of this service, hearing about it and learning about these new cutting edge interventions is educational and interesting.

Wednesday, September 14, 2011

Too Many Cooks in the Kitchen

One of the wonderful things about an academic institution like Stanford or UCSF is that you have specialists of all kinds. It's pretty common to get a smattering of consultations for patients with complex problems, whether medical, surgical, psychiatric, or something else. We have cutting edge tests, tools, and therapies. However, having "too many cooks in the kitchen," so to speak, can be frustrating at times. I remember as an intern last year, my consultants would occasionally contradict each other or keep the patient in the hospital for tests that were really outpatient issues. The primary team is always aware of how long a patient has been in the hospital. Consultants, on the other hand, often take advantage of the convenience of a patient being admitted and keep them there longer than necessary. Even right now, on the pain consultation service, we are seeing several patients whose main or only issue is pain management. One patient is having multiple procedures to try to control his pain, but the scheduling of these procedures and technical problems with them have kept him in the hospital longer than necessary. It's good to have access to lots of consultants, but it also creates confusion of who is in charge and drives up the costs of medicine.

Sunday, September 11, 2011

September 11, 2011

All stories start with some sacred truth, and this story started ten years ago. It is like seeing lightning again. Storms come in and scatter leaves askance. Suddenly we look up and a flash of brightness casts into relief the heaviness of the skies. For some, it is shock, reverberation, awakening; for others it is unremitting malevolence; for others it is the illumination of grief; for others it is the reclamation of hope; and for others it is justification for the decade. Lightning flashes again. What do you see?

For the last ten years, much of what we do, what we value, what we spend our money on, what we worry about, what we think, how we dwell, what we tolerate, and what we love has been tinted by four planes on a fateful morning. You can trace out the shockwaves as they echoed around the world, as if the event held reins that carefully orchestrated a global marionette dance. No one could have predicted how much the world would change over the last ten years. It is as if the boulder of Sisyphus got away and has been rampaging down the hill, taking us all with it. We now take for granted these changes, that we're gridlocked in several global wars, that we no longer press our faces against the glass to wave airplanes goodbye, that we mop the floors of security checkpoints with our socks, that we have all incorporated some sense of prejudice that we would never admit.

The world has changed; that is certain. But we have also started a process of rebuilding. We have grown saplings in memory whose canopy now shields us. We have carved memorial into stone, imbuing our grief into art. We have begun to design towers again. We have perhaps surmounted the crux of this global war and started to look beyond vengeance and dismantling. We have resumed our jobs. We spend 364 days of the year more or less on our own.

But today, we are joined by memories: memories of those we love and those we never met but who we love all the same. We find by bond of tragedy some quiet equanimity with those around us, and perhaps this will be the last time. Every single year in the last decade, I sat down on September 10th and wrote. There is an evolution of emotion over those ten years; when I first picked up the pen, I was seventeen. I tried to persuade words, caress images to express what I felt. But how hard it is to describe the impact of a thing like nine-eleven. We write and write and write, and all that comes out is a phantom of what we mean, and it has taken ten years for me to accumulate some measure of composure about this topic.

In the first two years after 9/11, I wrote in anger, imploring people not to forget the gravity of what happened. "I cannot stand relegating that memory to some distant and aloof history," I wrote, "So many will pay tribute by rote - pinching out candles as soon as they are kindled...How much meaning is there in a day of fasting when every other day is a feast, a day of remembrance when every other day is oblivion?" It was hard to see at that time that we needed to move towards healing, toward achieving some semblance of normality. Indeed, in 2004 and 2005, I nearly forgot to write about September 11 as it had faded in its impact. As a midnight gravedigger, I began to unearth those reflections. I wondered why memory was important and wrote, a little petulantly, "Another disaster, another tragedy, a pinch of nutmeg, a sprig of parsley. Fields of vices spring up! What have we to battle them? A soliloquy? A treatise? Words, words, words." And yet I continued to write, stubborn to find "some semblance of meaning, some coherence of moral."

Five years after the event, I realized "a new generation emerges that will learn our shock and grief through history books." Isn't that something? That we would be so defined by an event that others would only acquire second-hand? How do we protect their innocence, and should we? In 2007, I asked whether we could move on; "Are we stricken with inertia, bound like Greek Gods to orbit a fiery luminescence of the past?" I challenged those who paused in silence on September 11 to justify why they did it, why it was important. "Tell me. Because if we've lost cause, then it is time to come back inside, put piety on the hat stand, hang the cloak of duty for another day's resolve because I hate to admit it, but you will tap that well again and it best not be siphoned for an empty gourd." The following year, half-way through medical school, I pondered the randomness that you and I were not on the destined planes, not having breakfast in those towers of memory; "by stochastigarchy," I wrote, "we were drawn elsewhere, away from the epicenter." Finally, two years ago, I wrote about where I was on that day "when plumes like hands sent skyward a misery unfettered, a poison mistaken for a draught."

Last year, I wrote this:

"She is nine today, and in the fourth grade. She likes ice cream and plays four square and never washes her hands before meals. Imagine how big she is; she looks upon the world with wide eyes. She breaks rules sometimes; maybe she stays up past her bedtime drawing under the covers. What does she draw? For reasons unknown to her but stark to us, she draws misery and memory, sketches of fire and loss. They are not sad drawings, only serious ones, ones that outstrip her age, a light that casts generations upon her face. This is the juxtaposition of innocence and reality; she is only beginning to know what she means, how like Helen, she turns fleets. And we turn to her. She is a marking, a pivot point, a child whose grace we cannot take for granted. Give me a lever, said Archimedes, and she will be the fulcrum. She will move planets; they will take flight and hurl out into space, satellites that echo into orbit a refrain she has taught. With crayons, she maps out connections, a gravity that tugs on your heart when you hear of strangers in distress. Oh, it's all propaganda, you say, and it is; what could be more persuasive than a nine year old who teaches us to relinquish selfishness, to volunteer, to donate, to pray, to wish. She is nine this year, but think of what she has endured, and imagine how fast she has had to grow. Listen; don't ignore her because she whispers. No whisper is left unheard. 09.11.10."

I only recount this saga because I find myself at its epilogue. It is time to close the book. Writing on this eclipse year after year has taught me much about myself, about rationing emotional bandwidth, about excavating meaning in something that appears devoid of such, about writing the hard and fast-running feelings. We write to discover, and the sacred truth I find here is simply this. I cannot say whether September 11, 2001 and the impact it has had on this world was an inevitability. We cannot choose where we are born, which religion our parents take, what political system we struggle with. Perhaps the world had no choice and we were sent careening down this uncertain and unavoidable path. The world has changed for the better and it has changed for the worse, and we are here ten years later.

But whether illusion or not, we do have the sense of free will, and despite all those things we cannot control, we feel that we can choose good or evil, right or wrong, to move forward or to stall. After ten years of this funeral wake, it is time for us to take hands and rebuild. There will be more tragedies, more sorrow, more evil. We must take from these ten years what we can and set aside those emotions and values - fear, anger, vengeance, hatred, intolerance - that have no place in a post-9/11 world. Stagnant dwelling does no good. Ignoring the past does no good. But recognizing things for what they are, honoring those who took part, and incorporating the right values and morals into our everyday lives, that is what I take away. We are in a world that is hardly perfect but eminently liveable, in a society whose values are tarnished but not irreparable, in a story that has slowly rebuilt crumbling edifices into beautiful memorial. No whisper is left unheard. I write to turn this whisper into a song. 09.11.11.

Image of firefighter at Ground Zero in the public domain, from Wikipedia.

Saturday, September 10, 2011


Atropos of Greek mythology was the eldest of the Three Fates, known as the "inflexible" or "inevitable." She determined the mechanism of death and ended the life of each mortal. Indeed, of the Fates, Clotho spun the thread of life, Lachesis measured the length of life, and Atropos ended it. Interestingly, Atropos lends her name to atropine, an anticholinergic medication which is used to speed up the heart. Indeed, we keep atropine in our crash carts for hemodynamic emergencies. But then, such a name might be fitting as atropine may indeed decide whether someone survives or dies.

Image of Bas relief of Atropos cutting the thread of life is shown under Creative Commons Attribution Share-Alike License, from Wikipedia.

Thursday, September 08, 2011

Consultants as Educators

I believe that consultants should play a role in teaching. When I ask for the help of specialists, I am not trying to "dump" work on them, but rather seek elucidation of a problem I can't solve. When I read specialist notes, I really scour them - did they ask any questions on history that I didn't think of asking (like pets or travel in an infectious disease note)? Did they pick up something in the exam which I didn't notice? What goes into their thinking process? If I see the consultants, I ask them. Occasionally I learn enough that next time I run into the same problem, I know how to start the troubleshooting. Furthermore, it is part of the professional drive to continue to learn, and consultants and referrals allow us to do so. So when I write my pain management notes, I try to outline what we are thinking, how medications act synergistically, and what side effects to expect. I don't know if the primary team really reads all of it, but I try to include some sort of discussion for them if I've learned anything interesting regarding the case.

Wednesday, September 07, 2011


My attending on pain service right now focuses a lot on the pharmacology of pain medications, and I learned the most about cytochromes yesterday than I have in the last 3 years. We all learn about cytochromes as medical students; they are the enzymatic systems in the liver that aid breakdown of drugs. And for Step I of the Board exams, we dutifully memorize those agents that speed up or slow down each specific cytochrome. But that is usually the end of cytochromes for most physicians.

Anesthesiologists, however, have to be very familiar with the cytochromes that metabolize our drugs. For example, we are consulting on a woman who had a transplant and also has chronic pain treated with methadone. Her methadone requirements are much higher than expected, and I learned that steroids speed up the cytochrome p450 3a4 which breaks down methadone (as well as fentanyl and benzodiazepines). If eventually her immunosuppression is tapered down, her methadone should be changed in the same manner. Likewise, cytochrome p450 2d6 is responsible for metabolizing tricyclic antidepressants, a class of medications that also treat neuropathic pain, and for converting the hydrocodone in vicodin to the active metabolite hydromorphone. We have a few consults for patients on antidepressants which inhibit the action of cytochrome p450 2d6. Hence, we have to start tricyclics at a very low dose but also avoid vicodin which may never be converted to an active form.

Indeed, this week is a lot about learning the pharmacokinetics and pharmacodynamics of pain medications. We spend time discussing mechanisms of action for medications, context-sensitive half-lifes, and similar basic science applications to clinical medicine. It's fun to see these principles at work because for many of us, we feel that they are so far removed for practical medicine that we shouldn't learn them.

Monday, September 05, 2011

Da Vinci

I've written in the past about robots, including the Da Vinci Surgical System (shown above). They're amazing technological advances that allow complex surgeries to be done in a non-invasive fashion. At the VA, I provided anesthesia for a few robot surgeries and got to see them in action and from the anesthetic perspective. Unfortunately, they are less favorable from an anesthesia standpoint. Robot surgeries are much longer than their open counterparts, so patients are exposed to more anesthesia. In surgeries such as a robotic prostatectomy, the patient can be positioned in an extreme angle like "steep Trendelenberg," tipped back on their head for hours. And for anesthesia in particular, the robotic arms often get in the way of the patient's head and airway. So from our standpoint, it's not our favorite type of surgery.

Image is in the public domain, from

Sunday, September 04, 2011

Weekend of Call

Unfortunately, I am the on call resident for the pain service this long weekend. From Friday until Tuesday, I round on our patients and am available by pager day and night. I've been working hard to whittle down the service but it's still been pretty tough. Although I don't have to stay in house, I have to keep my pager with me and come in for new consults or a concerning patient. It's a lot more tiring than I expected because of the constant stress of always being available. I've had to make a couple trips to the hospital each day. I suppose at some point, I'll get used to it.

Saturday, September 03, 2011

Acute Pain

I'm currently on the acute pain service at Stanford. It's a tough rotation. Pain management is not the right thing for most residents, but for those who like it, it can be very rewarding. Our service has several aspects. For the most part, we provide consultation to surgical services post-operatively and manage patients with regional nerve catheters, epidural catheters, and single shot spinal anesthetics. Although the primary operating room anesthesiologist chooses what anesthetic technique to use and implements it, if it is a "neuraxial approach" like an epidural or spinal anesthetic or a regional nerve block, we pick up the patient postoperatively. That makes up the bulk of our service as we get 5-15 patients a day (which means the service hovers around 25 and the turnover is huge). The rest of the service is made up of hospital-wide consultations. Indeed, I consulted pain last year for some of my medicine patients. Any service - psychiatry, medicine, obstetrics, surgery, even emergency medicine - can ask us for advice in managing pain. Sometimes these patients have chronic pain issues and are on high doses of narcotics. Other times, they've exhausted all the common medications and need help with some of the more exotic drugs. We also have a very small primary service of chronic pain patients who are admitted for pain procedures. Overall, it's a really busy rotation, and I feel a lot like I'm an intern again.

Thursday, September 01, 2011

Done with the VA

I only have two months at the VA this year and I just finished my general OR time there. I really enjoyed it. It works at a slower pace (which can be frustrating at times, but is so nice early in the year), the attendings are outstanding, the experience was diverse but not too complex. I got to do ENT, urology, plastic surgery, ophthalmology, general surgery, orthopedic, and other cases. We had simulations, morbidity & mortality rounds, and spontaneous bedside teaching. I love the patient population at the VA; the veterans are patient, understanding, and kind to trainees. Their medical histories were not unusual; there weren't any extraordinarily rare diseases or surgeries. It's a great place to start. I got to know the surgeons and operating room staff; the anesthesia techs, in particular, were awesome. Overall, it was a really good experience and got me started pretty smoothly.