Happy Halloween

You may have to enlarge the picture. I have a thing for clever Halloween costumes. I hope you have many happy trick-or-treaters and a wickedly wonderful evening.

Image shown under Creative Commons Attribution Share-Alike License, from www.flickr.com.

Prior to Incision II

This is a continuation of the case described yesterday. My attending and I scrambled to resuscitate this anesthetized patient, staving off a code and trying to figure out what was going on. I ended up pushing several sticks of phenylephrine and ephedrine, and finally we resorted to epinephrine. With just a touch of epinephrine, the patient's blood pressures and oxygen saturation shot back to normal. We ended up proceeding with the surgery, and although she required some mild vasopressors during the case, her vitals remained reasonable. After extubation, she did fine.

In the end, our hypothesis was that this patient had red (wo)man syndrome from vancomycin administration. Although she had tolerated vancomycin in the past, perhaps the rate we were administering it led to a transient vasodilation. On the floor, vancomycin is given quite slowly, but in the operating room, we administer it quicker to make sure we have systemic levels of antibiotics prior to incision (especially in a patient who has a history of prosthetic infections). Furthermore, co-administration of opiates and smooth muscle relaxants increases likelihood of red man syndrome. Mast cell degranulation and histamine release leads to transient hypotension and erythema; indeed under the drapes we noted a macular rash. Luckily, despite hemodynamic instability, this syndrome is rarely life-threatening.

Prior to Incision I

A middle aged woman is getting a revision hip replacement. She has a significant cardiac history, mild congestive heart failure, gastroesophageal reflux disease, asthma, and severe arthritis. She underwent a primary total hip replacement six months ago, but unfortunately, the prosthesis was infected. It was subsequently removed and an antibiotic spacer was placed. Cultures grew methicillin resistant Staphylococcus aureus (MRSA) and she finished a course of vancomycin. After being cleared by the infectious disease specialists, she was scheduled for a revision hip arthroplasty.

After a smooth IV induction of anesthesia and an uneventful intubation, we placed a radial arterial line to follow blood pressures and blood gases, a second IV, and then positioned her in the lateral decubitus position. Her anesthesia was maintained through volatile anesthetics (sevoflurane), and vancomycin was started. The surgeons went out to scrub, and during that time, the patient's blood pressure and oxygen saturation dropped like a stone. Within thirty seconds, she went from 100% O2 saturation to 85%, and her blood pressures went from a mean arterial pressure of 70 to 30. I immediately started bagging with 100% oxygen, turned off the inhaled anesthetic, and pushed phenylephrine. Despite my best efforts, I could only modestly raise her oxygen and blood pressures. It was pretty terrifying. The orthopedic surgeons came back to find me in a flurry, drawing up medications while squeezing the bag, listening to breath sounds, inspecting the circuit, running my IVs wide open. There did not appear to be any problems with the ventilator or circuit, the airway pressures felt reasonable, I was delivering adequate tidal volumes, and yet on 100% inspired oxygen, the patient was at a meager 90% oxygen saturation. The patient had bilateral breath sounds, a mild tachycardia, but pulses were barely palpable. I went through sticks and sticks of phenylephrine trying to stave off a code. The exciting conclusion to this case will come tomorrow.

Endoscopy

I was assigned to provide anesthesia in the endoscopy suite one day. Initially, I was relieved; after all, how bad could endoscopy be? Upper endoscopy, colonoscopy, and ERCPs shouldn't take too long and they weren't high risk procedures. Little did I know. In 95% of cases, endoscopies are done under conscious sedation supervised by the gastroenterologist; the anesthesiologist doesn't hear about them at all. They only call us if things are really tough. One of my endoscopies was for a woman with metastatic pancreatic cancer, congestive heart failure, oxygen-dependent chronic obstructive pulmonary disease, and renal failure. Managing her airway, fluids, and medications was definitely a challenge. Two of my patients had neurologic defects so they could not follow commands; we treated one like a pediatric patient, doing an inhaled induction and mask-ventilating until we could get an IV in place, then finishing the induction with IV anesthetics. One patient had a congenital defect and did not have forearms; of course, the anesthesiologist is given the responsibility of obtaining venous access. Lastly, I did not recognize how difficult "out-of-OR" anesthetics are; our equipment isn't the same, we are far away from additional help, and even our anesthesia techs who get our supplies are a ways away. It felt pretty isolated, and subsequently, a little scary providing general anesthetics in the basement of the hospital.

Image of an endoscopist is in the public domain, from Wikipedia.

On a Lighter Note

I don't actually have the citation for this, but one of my friends sent it to me and I found it quite amusing. It is shown under Fair Use.

More Preoperative Clinic

With the ebb and flow of the rotation lottery, I got assigned to yet another week of preoperative clinic, this time at Stanford. This was the clinic I worked in last year as an intern, and so I knew all the faculty and nurse practitioners really well. It was fun being back in a familiar environment, though compared to the VA, Stanford's preoperative clinic was much, much busier. With time and experience, the process becomes easier, more efficient, smoother, and now that I had been in the Stanford operating rooms, I had a keener sense of what patients would expect on the day of surgery.

5 Year Reunion

This weekend was my five year college reunion, and oh, how remarkable it was. It was amazing to me how quickly five years passes and yet how much people accomplish in that time. Although I am still on the Farm, I loved the transformation of experience to the college I remember - the friends, the beautiful campus, the fun, the conversations, the memories. Friends came from so far, people I love very much but don't see very often, and I had a satisfyingly exhausting time.

Practice Makes Perfect

Anesthesia is a specialty that achieves a good balance between hands-on and intellectual processes. While learning the science and art of the practice is a residency-long and life-long activity, it's reassuring to me to find that the hands-on side improves rapidly with time. When I started, I was hesitant, inefficient, and uncertain about procedures like placing an IV and intubation. I required a lot of assistance and help. Now as these become daily activities, I am becoming more and more successful, finding them easier and smoother.

The Entitled

Medical care should never be different based on a patient's attitudes and behaviors. However, I can say that how patients treat their caregivers and the medical system changes how they are perceived and treated. The entitled patient, self-righteous, demanding, abrasive, and condescending, raises a lot of hair on our backs. This is the kind of patient where we itch to abridge the conversation, find our jobs frustrating, and let the patient's demands dictate care more than it should. Sometimes the patient insists on a specific test or treatment, and we acquiesce even though it is not appropriate. Sometimes the patient only wants to see certain people on the team, and this slows their care down. Sometimes the patient starts taking resources away from others.

Working with the so-called "difficult patient" is hard. As physicians, we have to remain impartial of our own feelings and biases, put aside those negative reactions and interactions and care for everyone with the same exacting standard. This is not easy, and we get training in medical school and beyond on how to work in these situations. However, patients do better if they put themselves in the right light. They must strike a delicate balance between assertiveness and aggressiveness, making sure they advocate for themselves without endangering the relationship with their providers.

Laboratory Tests

There's no good way of showing this chart without enlarging it, but I wanted to share it on this blog because it is a somewhat mindboggling display of normal ranges for laboratory values for an array of tests. I really like it as it captures some of the complexity of medicine in knowing when to send all these tests and how to respond to the results. Surprisingly, after doing a bit of medicine, many of these reference ranges feel intuitive.

Image is from Wikipedia, shown under Creative Commons License.

A Day in the Life of a Stanford Anesthesia Resident II

Occasionally, I hear anesthesia characterized by "hours of boredom punctuated by moments of sheer terror" but I keep myself busy. During the case, I do serial surveillance sweeps, making sure all the equipment and IVs are working, the monitors are appropriate, and the patient's positioning and airway haven't changed. We pay close attention to the progress of the surgery, anticipating when dangerous, difficult, or specialized things may happen such as dissection near a large vessel or using cement for a joint replacement. We catch up and maintain the anesthetic record as well as prepare our next case, resupplying our airway equipment and drawing up new medications. Sometimes the attending will discuss salient learning points for the case.

As the surgeons finish up, I begin to lighten the anesthetic, give antiemetics and reversal, and get the patient breathing on their own. Once the surgeons finish, we're again under time pressure to have the patient extubated safely as soon as possible. After extubation and taking off unnecessary monitors and tubes, we move the patient to the gurney and take him to recovery. There, I give the nurse report and fill in the rest of the record. I go straight from recovery to the pre-op area for the next patient to consent them for anesthesia, answer questions, start my IV, and put a note in the computer.

The day proceeds pretty similarly. The pressure is higher when I do a lot of short cases that require fast turnover. Occasionally I have more breathing room with longer cases. If there's extra time during a case, I pre-op my patients for the following day, looking up their history, physical, labs, and prior anesthetic record in the computer.

At the end of all my scheduled cases, I give the scheduler a call. The scheduler is an attending who "runs the board," manages the OR flow, and fields requests for emergent or add-on cases. I'll help with any add-ons or emergencies, but hopefully I'm done with the day. I return my narcotics to the pharmacy, change my scrubs, and head home, usually between 5-7pm. That evening, I give my attending for the following day a call, reviewing the cases we have and my anesthetic plan. I make dinner, perhaps do a few chores, and then sleep pretty early.

A Day in the Life of a Stanford Anesthesia Resident I

I get up at around 5:15 to make it to the hospital by 6am. Getting things going on time in the morning is incredibly important and a little stressful so I make a bee-line to pharmacy to check out my narcotics and then back to my room to set-up. After a quick survey to make sure all my emergency airway supplies (like an Ambu-Bag and O2 cylinder) are available, I set up the bed and machine the way I like it. The technician usually does the full machine check and I simply make sure the most important steps are working. I set up all my airway supplies, checking my largyngoscope blades and lightsources, making sure I have tape and a bougie handy, and testing my suction. It's usually 6:15 by now.

Then the tedious task of drawing up medications. I usually label all my syringes first, then draw up everything I need to start the first case: midazolam, fentanyl, lidocaine, several syringes of propofol, succinylcholine, rocuronium, cefazolin. I dilute my emergency phenylephrine and ephedrine, occasionally making atropine, esmolol, or nitroglycerin if I anticipate needing it. If I am early in time, I go ahead and draw my neostigmine, glycopyrrolate, and ondansetron. Some cases require preparing other medications like a propofol drip, hydromorphone, morphine, or bupivicaine. I usually have my IV start kit ready before I get to the hospital so at 6:35 I scurry out to meet the patient.

I meet the patient in the holding area and have just a few minutes to establish rapport, answer the patient's questions about anesthesia, review my pre-operative history and physical (which I researched the prior night), and consent the patient for the anesthetic. I then start an IV and fill out a quick note in the chart. After the patient is checked in by the nurse and meets their surgeon, then we're given clearance to roll back to the OR.

Once in the operating room, we get the patient positioned, hook up our monitors, perform a spinal or epidural if appropriate, and pre-oxygenate the patient. Then the pace slows down. The crux of the anesthetic, induction and intubation, demands attention to detail and care. While all of the foregoing things can be efficient and pared down, once we are ready for the start of anesthesia, we control the pace. I've written about intubation before, and right after the airway is secured, the speed of things returns to its prior intensity. Along with the surgeon, we position the patient, make sure pressure points are padded, start a warming blanket, and place any additional IVs, arterial lines, temperature monitors, or orogastric tubes. Then we're ready for the surgery.

Usually, the attending gets me out for a fifteen minute breakfast once the case is underway. Stanford anesthesia provides an amazing breakfast array with hardboiled eggs, english muffins, toast, cheese, nutella, bananas, yogurt, and other goodies. It's a short break to catch my breath, reflect on the morning, and prepare for the rest of the day.

The Real Residents

Although we are called residents and housestaff, most days of the week, I get to leave the hospital and go home. Over the last few weeks, I have noticed some people around the hospital who are here even longer and later than I am.

We don't often think of our patients' families. Of course, when they are at the bedside and asking questions, when we run into them in the hallways, when we are giving discharge instructions, we are glad they are around. But I often don't realize how hard it must be to be present when the intern pre-rounds at 6:30am, to ask questions when the attending comes later in the morning, to help the patient get to the bathroom, to assist the physical therapists, to accompany their loved one to radiology or endoscopy or other tests, to bring food in the evening, and to hold their hand and watch television at night. It's a full time job, caring for someone in the hospital, and family members are the underappreciated. So next time I see a caregiver, I give them a word of encouragement, a smile, an understanding that they are as central to the healing process as we are.

Intern Year Revisited

After doing my medicine internship here, it's incredibly fun to see my previous co-interns now as residents, running their teams, teaching, rotating through the ICU, and consulting on patients. I see their notes, run into them in the hallways, and stop by their team rooms to talk about patients. When I was on pain consult, I knew all the residents and some of the attendings for the medicine patients we saw. The bonds we formed in intern year really carry through, and we will do favors for each other and try to make each other's lives easier. It's great to be able to talk about our shared patients with different perspectives and expertise; we teach each other, help each other, and support each other.

Chartomegaly

The suffix "megaly" means large; cardiomegaly is a large heart, hepatomegaly is a large liver, even acromegaly means large digits. Chartomegaly means someone's chart is out of control. Unfortunately, I think with medical records, everyone is starting to get chartomegaly. It bothers me that now with functions such as copy and paste or printing pre-determined phrases, the majority of a medical record is completely useless. For example, before every anesthetic, I click a button that creates a note that says "The patient's history and physical were reviewed and the patient's condition is appropriate for anesthesia. Please see anesthesia pre-op note for full details." This is a completely useless note and creates unnecessary clutter in the chart. Indeed, patients who go to the emergency department can have dozens of separate nursing notes that say things like, "Consultant at bedside" or "Assisted patient to bathroom." While perhaps somewhere there is legal or financial reasons to keep such information, it dilutes the chart down so that we cannot find what we're looking for.

With paper records, we lamented that we could not find old documents when we needed them. Things have not changed with the electronic record. There is great faith in the electronic medical record by the government and those who champion systems solutions, but in my mind there is a long way to go before useful, manageable, efficient, and informative charts are in place.

Book Review: Hunger Games

I waffle back and forth on what to read for fun during residency. During the day we are so inundated with complex information, journal articles, diagrams and tables, that occasionally we go home and simply want something to entertain. The Hunger Games by Suzanne Collins did just that. A science fiction novel similar to Ender's Game, it features a futuristic dystopia where a child protagonist is pitted against an all-powerful evil government. It's not an incredibly sophisticated book, but it's an easy page-turner that kept me up past my bedtime. Although it could have done more as a moral and psychological bildungsroman, it instead sells itself as a thriller. However, the rest of the trilogy disappointed me; it seemed as though the author lost control of her characters and plot. But the first book of the series was definitely a diversion from residency.

Image shown under Fair Use, from Wikipedia.

The Spinal Anesthetic

Orthopedic anesthesia is a great rotation to learn the spinal anesthetic, shown above. The spinal is pretty much the same as a lumbar puncture; a long needle is placed into the low back to access the spinal or subarachnoid space. In a lumbar puncture, fluid is taken out and tested for meningitis or other diseases. In a spinal, local anesthetic or opiate is injected to numb the nerves supplying the legs. Many people are afraid of the "spinal tap," and from the outside, it feels like a terrifying procedure. People are afraid of the spine, cannot see the needle going in, and have to maintain an uncomfortable position. But from a medical standpoint, the LP or spinal anesthetic is one of the more minor procedures where the risks are far lower than the benefits.

I offered a spinal anesthetic for all my hip and knee joint replacements. With total knees, a spinal anesthetic numbs the legs so that the patient does not need a general anesthetic; the case is instead done under deep sedation. With total hips, the patient still receives a general, but the post-operative pain and overall opiate consumption is much less with a spinal. Indeed, the difference between two patients, one who elected for a spinal and one who didn't, was remarkable; it's amazing to be able to wake someone up from surgery and have them be completely comfortable.

Learning the spinal was a good experience. I'd done LPs in the past, but these are different because in the operating room, there's always time pressure. I didn't have time to dilly-dally, and I had to be confident of my movements. But over the course of the last two weeks, I really became comfortable with the procedure, planning everything in advance, understanding exactly how things felt, and knowing when I was in the right space. I'm starting to feel like an anesthesiologist.

Image of spinal anesthetic shown under Creative Commons Attribution Share-Alike License, from Wikipedia

Orthopedics

I just finished my two week orthopedic anesthesia rotation, which was a perfect re-introduction to the operating room. The orthopedics rotation is designed to teach us about specific anesthetic concerns regarding joint replacement. We work with a small group of anesthesia attendings and surgeons and do mostly hip and knee replacements, which allow us to learn a few surgeries very well. There's a syllabus that covers much of orthopedic anesthesia, from the use of tourniquets to rare events such as cement emboli to proper neuraxial anesthesia techniques. Early in the year, I feel that it's so helpful to have a routine, and when I look at my schedule and see three knees and a hip, I know what to plan for and how to structure my day. I learn to anticipate what surgeons will do at each step of the procedure. I get to do a good variety of spinal anesthetics, general anesthetics, and cases with deep sedation. While at the VA, I approached knee and hip surgeries with one anesthetic plan, on this rotation, I got to see the range of possible anesthetic approaches and how patients did with each postoperatively.

Image of a knee X-ray after a joint replacement shown under GNU Free Documentation License, from Wikipedia.

Stay Hungry, Stay Foolish

I rarely write about current events and almost never write about people, but I wanted to take a moment to acknowledge how profoundly our world has changed due to Steve Jobs. Listening again to his talks at the 1997 Apple Worldwide Developer's Conference and the 2005 Stanford Commencement really helped me realize how visionary and instinctive he was. He's inspiring as a leader in a way few people are. Stay hungry, stay foolish.

Image is by Jonathan Mak Long, from tumblr, shown under Fair Use.

Pain and Philosophy

Pain is a fascinating philosophical concept. We have been thinking about it for years, and many seminal philosophy papers deal with the nature of pain. What is it? Why does it happen? How do we quantify it? How do we experience it? Someday I'll probably study this again, but I wanted to share some specific questions that interest me in particular. In medicine, we regard it as a "fifth vital sign," yet unlike other vitals, it has a subjective element to it. A 10/10 pain is different to a child than to a woman who has had three children and kidney stones. The same surgical incision may elicit completely different pain scores from two different patients. It contains a relativistic component; when we say "a 10 is the worst pain you can imagine," imaginations differ widely and experiences differ widely. Pain is contained within the experience of the person who has it, and it must undergo some interpretation for that person to quantify or qualify it to someone else. Every other vital sign is objectively measured, but pain is not. Yet rapidly evolving sciences may someday devise a way to measure someone's pain with a device or instrument. Will we one day quantify the number of C-fiber neurons firing and correlate that with a severity of experience? What will that mean? Is that a fair thing to do?

Pain and suffering also have etiologic questions. Why do they exist? Certainly, there is a survival benefit to withdrawing one's hand if one encounters a fire. But there are a lot of other pains that don't seem to have an obvious Darwinian benefit. Are migraines protective in any way? Why does chronic neuropathic pain occur? Shouldn't a crucially important pain such as angina be more specifically felt by a patient than just "chest discomfort?"

These are just some of the philosophical issues about pain that fascinate me. Pain is much more than something to treat with morphine. It is an experience that profoundly changes patients' lives, their sense of well-being, their hormones, their psychology. Perhaps thinking of pain in a philosophical sense isn't for everyone, but for me, I find it enlightening.

3x5 Cards

In Samuel Shem's The House of God, one of the residents, the Fat Man, claims anything can fit on a 3x5 card. Every single patient is summarized neatly on an index card, incorporating all the pertinent findings, laboratory values, diagnoses, treatments, medications. As a medical student and intern, I quickly realized this did not work for me. I copiously scribbled every possible bit of information, needing full-sized sheets of paper.

Now on anesthesia where our scope is much more narrowly defined, I find that I am using 3x5 cards again. It's really quite satisfying to capture all the important details of all the patients for a day on index cards that fit neatly in my pocket.

Image shown under Creative Commons Share-Alike License, from Wikipedia.

The Small Things

I'm finally in the Stanford operating rooms now. After spending a month on acute pain, I'm slowly relearning the basics of anesthesia in the big house. So much of what matters early on is logistic and not medical. My first day in the Stanford OR was so hard because I didn't know how things worked here. Small things like familiarity with the anesthesia cart has everything to do with efficiency. I can tell you what each drawer in the VA anesthesia cart contains. I know exactly where to reach for each medication. But I had to familiarize myself with the set-up at Stanford. Medication vials look different. Each drawer contains different equipment. Even small things like the patient gowns are different. Why does this make so much of a difference? Patient gowns at the VA unbutton at the sleeves but they don't at Stanford; this means that IV's have to be threaded into the sleeve so taking off the gown doesn't get in the way. The first day consisted entirely of learning these details.

Other things I didn't anticipate also posed challenges. The anesthesia machines were different, so I had to re-orient myself to where data appears, how to change settings. Figuring out paper charting and billing feels like a hassle. And simply understanding the process by which a patient in the holding area is deemed ready for surgery, getting them to the right OR (for some reason, OR 21 is nowhere near OR 15-20), and identifying the right PACU slot was time consuming. There was little orientation so being thrown into the mess was a little terrifying, but that's simply part of learning a new system.