Interview Season

The end of November marks the beginning of the residency interview season. I recently had dinner with anesthesia applicants, and how different it feels being on the resident side! No longer is it a scramble to get from place to place, to present oneself formally, to try to absorb a whirlwind of information about each program. Instead, it's great food with wonderful company, a time to share stories and meet potential residents. The process reminds me of all the hoops I had to jump through to get to where I am (and possibly portends the hoops I have yet to go), and it's kind of amazing I've weathered it all and still have a relatively decent attitude about it.

Graveyard Shift

My last week at Stanford Hospital was on the graveyard shift, from 7pm to 7am. Night shifts are always hard for me. Though I'm able to switch over, it's exhausting, and no matter how much sleep I get, I always feel behind. When I arrive at 7pm, I usually finish up late-running cases from the daytime. It feels a little odd, closing cases that I didn't start, but the system works best this way; those anesthesiologists who didn't expect to stay late (and presumably have to work early the following day) get to go home. Then I take care of any add-on cases that weren't able to be done in the morning. I check the trauma room. And if all goes well, I get to take a nap while waiting for any code blues, traumas, or emergency surgeries.

For the most part, something comes up each night. I had exploratory laparotomies for acute abdomens, appendectomies, ruptured ectopic pregnancies, and a fracture causing compartment syndrome. It's a pretty good mix and ensures that I have to be ready for anything. I don't have much time to prepare so I have to formulate and execute an anesthetic plan quickly. I didn't have any major codes or serious traumas during my nights and so it wasn't too bad at all.

Frequent Fliers

One reason why healthcare costs in the U.S. are spiraling out of control involves frequent fliers in the emergency department. I don't have any numbers or statistics, only a gut feeling borne of experiences in the emergency department, wards, and operating rooms. There is some small population of patients who utilize healthcare resources far more than anyone else, and furthermore, they use costly venues of healthcare delivery. These patients have chronic pain or uncontrolled psychiatric illness or social problems or addiction. They come repeatedly to the emergency department but aren't otherwise followed by a primary care physician. The E.D. places a band-aid on the problem, encourages them to get insurance and find a doctor, and sends them out. But we already know that they'll soon be back.

These repeat customers drain the system of resources. They drive up healthcare costs by hopping from one emergency department to another, getting a battery of tests, occasionally being admitted, and being sent home (or to the street) without a solid plan of care. Their diseases could be controlled in the right circumstance, but they have no incentive to do so and instead become frequent fliers on an episodic basis. Even some patients with chronic pain prefer to come into the emergency department to get boluses of IV opiates rather than control their disease long-term with a pain management plan.

I don't think this is either appropriate or sustainable. However, our solutions have not worked. There have been many initiatives to get patients like this a primary care doctor or medications or an urgent care clinic to visit, but the problem is still persistent. I think the only way to make headway on this problem is to get buy-in from the patients. We need to contract with them; if they come in with chronic pain complaints and have no other etiology for pain, then they only get pain medications they could have taken at home. If they frequently have psychiatric crises, they do not need the battery of laboratory tests we normally send (we usually send a complete blood count, electrolytes, liver function tests, HIV screen, thyroid function tests, urinalysis, urine toxicology, and EKG prior to admitting the patient to psychiatry). We find some incentive for patients if they are sent to the emergency department by an urgent care clinic or their primary physician. We need to search for solutions for this problem, especially as resources get more and more limited.

Not All Cookie Cutter

Some people perceive anesthesia as being fairly straightforward, and most of the time it is. Many surgeries have a routine: assess patient, start the IV, bring the patient back, place monitors, induce anesthesia, intubate the patient, give antibiotics, maintain anesthesia throughout the case, wake the patient up, extubate, and bring the patient to recovery. And there are many days when we do not deviate from this steadfast course. But like everything in medicine, it isn't the routine that pushes our skills as physicians, but the exceptions.

When a day goes smoothly, I am thankful and I learn things, but I await those cases that challenge me. Some may seem minor; for example, I anesthetized a patient who had nausea and vomiting after every other surgery in the past. So we took out all the stops, giving steroids at the beginning of the case, multiple antiemetics at the end, avoiding emetogenic agents, and maintaining anesthesia with an intravenous infusion of propofol rather than inhaled gases. The outcome? She was thoroughly impressed and very satisfied with the anesthetic after the surgery.

Other cases that stress us involve life-threatening disease states. While on call, I was asked to prepare a patient for anesthesia who had a solid organ transplant, a bone marrow transplant, and active chemotherapy; all her blood counts were flagged bright red in our electronic medical record. Prior to incision, we gave two units of FFP, platelets, and packed red blood cells. Her infected knee was likely causing a low-grade sepsis, she had altered mental status, and her kidneys were failing. While a knee incision and drainage isn't a serious surgery, this was a patient requiring us to use all our available tools to maintain homeostasis.

Lastly, it's not just the medical and technical aspects of anesthesia that are challenging. One morning, my first case of the day was for a patient with Down syndrome. Although relatively high-functioning for someone with trisomy 21, he acted more like a child than an adult. I had to sit with him and coax him to allow me to take a look at his veins. He was understandably scared and reluctant to have anything done, and it took me ten minutes to place an IV (luckily, I got it on the first try as I knew he wouldn't let me have a second). I had to develop a trusting patient-physician relationship before he'd let me do anything.

Black Friday

I don't really partake in the Black Friday craze, but the concept is interesting to me. How can a holiday be created by commercial forces? Five years ago, this day didn't even have a name, and somehow it has become a phenomenon which has retailers opening stores earlier and earlier, customers forming lines far in advance, and, most frighteningly, injuries from shopping.

All of this is fascinating to me because of the psychology involved. I don't know much about psychology, but as I talk to friends about this, I want to learn more. For example, right in Menlo Park, a jam study was held at Draeger's looking at whether customers bought more jam if more choices or fewer choices were given. While customers sampled more jam when offered more options, they bought more when offered fewer options. With Black Friday, I browsed some online websites and felt myself drawn to investigate deals on items I would never have bought otherwise. What's the psychology involved to lure me into spending more while thinking I was spending less? While many of us use supermarket "loyalty" cards (like a "Safeway card") because it affords us discounts, and we think supermarket chains use them to build up repeat customers, the true value of loyalty cards lies in allowing the retailer to track what we buy and learn our habits. This is an immensely powerful tool for them to tailor their sales strategies to individual customers.

These are just a few examples of how we as consumers are unconsciously influenced. I don't mean to judge whether they are good or bad; rather, I think they are quite clever yet scary in exploiting vulnerabilities in human psychology. But since it is Black Friday, I figured I'd spend a moment to jot something down about it.

Thanksgiving

I am thankful for those I love and those who love me.

Image of "The First Thanksgiving at Plymouth" by Jennie Brownscombe is shown under Fair Use, from Wikipedia.

The MRI

Like endoscopy, the MRI is a dreaded place for the anesthesiologist because it is a remote out-of-OR location. I had to provide general anesthesia to a patient who required an MRI but could not tolerate the positioning and duration. I went down to the depths of the hospital, uncertain of what I'd find. MRI is a tricky business because the strong magnetic field it creates limits the equipment that can accompany patients. Before entering the room, I emptied my pockets and even took off my badge. The MRI-compatible anesthesia machine and monitors were old and confusing.

We had a patient with a difficult airway and we were miles away from any other anesthesiologist. Although we initially tried an asleep fiberoptic intubation, we could not see the vocal cords, so instead, we did a direct laryngoscopy and managed to intubate the old fashioned way. While we were struggling to get a way to help breathe for the patient, I was terrified. In the operating room, we have so many more resources - other anesthesiologists, fancy equipment, nurses and anesthesia techs to help. But in MRI, we had only what we brought (luckily, we had anticipated this and brought the difficult airway cart).

The scan itself was a little scary as well. The patent's blood pressures required constant vasopressor support so I kept on popping in to give more medication. I had heard this from patients, but MRIs are loud and the noises they make are unpredictable. During the scan, we didn't have access to the patient's IV site, airway, or body (if we needed to start chest compressions). It made me realize that environment plays a lot in determining the difficulty of our jobs.

Image is in the public domain, from nihlbi.nih.gov.

The Person and the Procedure

At the beginning of anesthesia residency, we discussed three factors and how they influenced the morbidity and mortality of a surgery. What makes a surgery risky? Is it the patient and his comorbidities? Is it the surgery itself? Or is it the anesthesia? While of course it is difficult to tease all these factors apart, from what we can surmise, it is actually the stress of surgery that makes up most of the risk. Even though an appendectomy and a liver transplant both involve the same anesthetic technique, one is clearly a bigger procedure than the other. A knee surgery can be done under a spinal anesthetic or a general, but the difference in risk between the techniques is minuscule.

This is important to me because as the anesthesiologist, I am complicit in whatever we do, yet I bring the lowest risk to the table. There have been multiple times where I look at a patient or procedure and I worry. But most of the time, all we can do as anesthesiologists is to reduce the risk as best we can. We select more monitors, place better access, anticipate possible emergencies, and pre-emptively treat evolving clinical situations. This is the art of anesthesia.

I had to provide anesthesia for a middle aged man getting a tunneled dialysis line. This doesn't sound too bad until I realized that he had a cardiac arrest 9 days ago with pulseless electrical activity as well as congestive heart failure, atrial fibrillation, congestive hepatopathy, coronary artery disease, diabetes, and ascites. His cardiac arrest lead to acute renal failure, and now he is dialysis dependent. This is a scary anesthetic to provide; even though the procedure was minor and I would be administering as little as possible, the risk for something bad happening was very high.

Sometimes I feel that anesthesia is about tempering those dangers of surgery superimposed on a frail patient, and it is times like these that I feel I can utilize everything I've learned about medicine to use a gentle hand to guide a patient through a stressful situation.

Urology

I also spent two weeks doing anesthesia for urology cases. Similar to my orthopedic anesthesia rotation, the faculty have created a curriculum to teach the aspects of anesthesia that are specific to procedures like transurthetral resection of the prostate, robot-assisted radical prostatectomies, cystoscopies and ureteral stents, and kidney surgeries.

There were two urology surgeries that were particularly interesting. Both were surgeries for prostate cancer. For one, the patient had a recent severe heart attack with multiple cardiac stents placed. The ejection fraction of the heart, normally 55-70%, was merely 20%. In the second case, the patient had tetralogy of Fallot, a serious congenital heart defect that causes babies to be blue. He had this repaired as an infant when they had just started doing cardiac surgery for this anomaly. This, in fact, was his first surgery that didn't involve cardiopulmonary bypass.

I was paired with a cardiac anesthesiologist in both cases, and intraoperatively we examined the heart with a transesophageal echocardiogram (TEE), a probe placed into the esophagus that uses ultrasound waves to examine the heart from within the body. It was really fun and amazingly educational to see each chamber and valve. I always enjoyed learning about transthoracic echocardiograms (TTE) and this is an intraoperative analogue to help monitor the patient.

Diagram of TEE shown under Creative Commons Attribution License, from Wikipedia.

A Taste of Our Own Medicine

As an intern, some of the most common pages I got were: "patient requesting something for sleep" or "patient is itchy." Diphenhydramine (Benadryl), shown above, was an occasional response. I'm currently on night shifts (a future blog later) and so I took some diphenhydramine to help sleep during the day. It hit me hard. I got a ton of side effects, including dry mouth, ataxia, blurred vision, difficulty concentrating, dizziness, and irritability. It didn't even help me sleep all that well. It was a taste of my own medicine. It reminded me that even medications we consider routine can have potent side effects, and when given to elderly, sick, hospitalized patients, can lead to adverse events like falls. Nothing is completely safe.

Image shown under Fair Use, from myhealth.ucsd.edu.

Charon

Charon is the ferryman of Hades in Greek mythology who carries souls across the rivers Styx and Acheron to the land of the dead. Perhaps a morbid thought, but occasionally I have wondered if anesthesiologists are similar (but distinctly different) mariners. We dare to cross that threshold with the faith that our trips are not one-way. We take those, coin in eye, who have some need of transient depth, who trust us as navigators and cartographers. Are patients the modern day Heracles and Orpheus? Do we carry them across some mythical river and return them safely from their katabasis?

Image is Gustave Dore's illustration to Dante's Inferno, in the public domain, from Wikipedia.

Hodgepodge

Working in the general OR means that I get assigned to different cases each day, forcing me to think, plan, and learn about a variety of surgeries. I'm just starting to get over my fear of the spine. Spine surgeries are intimidating; they are long, can have large blood loss, and the patients are prone (on their belly). In prone cases, we have less access to the airway, there is a risk of damage to the eyes or nose, and flipping the patient is not as easy as it sounds. But after doing a cervical spine fusion and a couple lumbar laminectomies, I'm starting to feel a little better about spine cases. The cervical spine fusion was interesting; a neuro tech monitors specific muscle groups intraoperatively to ensure that the surgeons don't damage any nerves.

Of course I had my share of general surgery cases such as exploratory laparotomies, appendectomies, and cholecystectomies, but the most interesting cases were the sleeve gastrectomies. I spent one day providing anesthesia to morbidly obese patients getting weight-loss surgeries. These patients provide a unique anesthetic challenge because the dosing of our drugs doesn't scale linearly with weight; indeed, most medications aren't tested for patients above a certain weight. Thus, I had to learn about pharmacokinetic principles in the obese patient. Moreover, obese patients provide a challenge for intubation; there's less time because their lungs have less reserve, and there's more soft tissue that can get in the way of placing the breathing tube.

The other rooms I've been assigned to have been pretty typical: lymph node biopsies with ENT, breast biopsies with general surgery, more hips and knees with orthopedics, soft tissue mass excisions with plastic surgery. It's been a really good mix.

Image of spine dissection is shown under Creative Commons Attribution Share-Alike License, from Wikipedia.

Medication Shortages

When we think of limitations that prevent patients from getting medications, we think of insurance reasons, access to physicians and pharmacies, cost, language barriers, or education limitations. We don't normally worry that the drugs are not available because there's a shortage. But as an anesthesia resident, I have become painfully aware of medications with limited supply.

Today, I was reminded that there's been a six-month dearth of calcium chloride. This boggles my mind. Calcium isn't some fancy targeted immunotherapy. And even more, calcium chloride is a code medication used in emergencies. And it's not just calcium; we have shortages in fentanyl, morphine, atropine, labetalol, and a few other drugs.

How can this be so? How can we have a shortage of drugs we use daily or medications necessary in emergencies? Is medicine this vulnerable to the fickleness of supply and demand? Are there so few suppliers that if one gets into problems, no one can get the medication? And what are the issues for the manufacturers? Medications don't just grow on trees (well aspirin, taxol, and a few others do). But there are a lot of factors doctors don't know. Who makes the drugs? What regulations make it difficult to enter the market? What incentives are there to keep hospitals supplied? What backup mechanisms are in place if a company goes out of business?

Image of Bayer heroin bottle is in the public domain, shown under Fair Use.

Call

On call, I get paged for an emergency surgery. A patient is transferred to Stanford from an outside hospital for symptoms of a small bowel obstruction. He has inflammatory bowel disease, cirrhosis, hepatitis C, and a history of a small bowel resection and colostomy. He presented initially with nausea, vomiting, and abdominal pain; imaging was consistent with an SBO. The general surgeons told me that they expected to take down some adhesions near his colostomy, and the surgery duration would be less than an hour.

When on call, there's not much time to prepare, and so I set the room up for a general anesthetic, spoke to and examined the patient in five minutes, and put him to sleep. I noticed initially he was tachycardic with a heart rate in the 110s and slightly hypotensive with a blood pressure around 100/60 but I attributed this to his hypovolemia from dehydration and cirrhosis. The surgery initially seemed to go well but he needed intermittent vasopressors to keep his blood pressure going.

Suddenly, I heard a lot of talking over the drape (across the blood-brain barrier). Unfortunately, the surgeons had opened up the belly only to find frank peritonitis; the patient had perforated his bowel and was spilling gut contents into his abdomen. As if on cue, the patient's blood pressure and heart rate started reflecting widespread infection. He was septic. I immediately sprang into action, ordering colloid fluids and platelets given the cirrhosis, placing an arterial line under the drapes and sending an ABG, and starting broader-spectrum antibiotics. I had to start the patient on a vasopressor drip, obtain additional IV access, and secure an ICU bed. Fortunately, he did okay and although he had a short stay in intensive care, the surgeons were able to get the infection under control.

This call reminded me that anesthesia is a dynamic process and that what we expect going into a surgery may be entirely different than what we get and how things look coming out of surgery. We have to be ready to act quickly and escalate our care given rapidly evolving medical and surgical conditions. A situation that appears relatively stable can change rapidly and unexpectedly.

Ones

When I was in elementary school, I always got excited to see my digital watch create patterns of numbers, and 11:11 was one of them (so was midnight 00:00). There is something secretly magical about moments like these even though we know they're artificially created and silly to imagine. But today, and more specifically, a minute is an instance unlike any other, so make a wish, smile, celebrate.

Image taken by one of my friends.

Waste II

This is a continuation of yesterday's post.

Part of anesthesia is anticipating emergencies and treating them timely. Clinical situations in the operating room can arise so quickly that we have to be ready to act at any time. Thus, for every case, I draw some "emergency drugs," mostly to control blood pressure. But if at the end of the day I have emergency medications I didn't use, I have to throw them out. I'm not sure how to reconcile this problem. Emergency vasopressors such as ephedrine or phenylephrine can take a minute or two to dilute and prepare, and in a critical situation, this time and distraction can lead to patient harm. After medications expire, they should be discarded. There's no way around this; in order to keep my patients safe, I have to draw medications I'm not sure I'll use. What happens to vials that are drawn but not used (or vials that are broken)? I assume the hospital simply absorbs the cost, and that too, is another reason why hospital finances can be so tricky.

It's not just a problem with drugs. In the same way, prior to intubating a patient, I have two different laryngoscope blades available, one as a rescue blade if I run into trouble. I always have both available, but rarely have to resort to the backup. I used to take out two oral airways until we had a shortage; now I am a lot more conscientious of producing unnecessary waste. I used to have two sizes of endotracheal tubes available, but now I think of each patient to decide whether I need to have multiple prepared. These are all instances where I prepare more than the minimum equipment, thus using resources and my time. But a lot of these, at least in this stage of my training, seem to be necessary to ensure patient safety.

All I can do is to be aware of how much I use and how much I waste, and within the confines of what is safe for the patient, minimize anything unnecessary.

Waste I

We are in a world and a society that abhors waste. We recycle, reuse, reduce. We compost, ration what we buy and throw out, measure our carbon footprint. We are conscientious of how green we are. I have blogged on this in the past, but hospitals are immensely wasteful. They are slow to adopt this movement that has already taken other industries and lifestyles by wildfire. Anesthesia is no different. I got a comment on my last post about what happens to extra or unused syringes. It got me thinking about anesthetic waste.

Some of our waste is generated by single-dose vials. When I draw up succinylcholine, I draw up a 10cc syringe. Very few patients would require the full 10cc, and furthermore, there are few situations in which you dose succinylcholine twice due to risk of bradycardia and asystole. So for any patient who gets succinylcholine, some amount is wasted. Although I could calculate how much each patient would need and draw up a syringe with just the right amount, the vials are supposed to be single-dose; sterility is not guaranteed if I use a vial for multiple syringes. So like every other anesthesiologist, I draw up the full dose even though I never intend to give it all. This costs the system not only the additional drug, but also the biochemical disposal of the extra medication and the financial costs. This boggles my mind; why haven't we figured out a way to reduce this? And the topic raises other concerns; should patients be charged for the amount of medication they receive (such as 5cc of succinylcholine) or the entire vial (10cc, even though 5cc was simply discarded)? Should manufacturers change their vial sizes? Should we start pushing for multi-dose vials?

Electroconvulsive Therapy

Electroconvulsive therapy is a psychiatric intervention where seizures are purposefully induced in a patient through shocks delivered by electrodes placed on the temples. It's used for refractory depression as well as other psychiatric illnesses like bipolar disease. The therapy is charged with controversy; no one knows how it works, shocking the brain to cause seizures sounds barbaric, it has a history of use without informed consent, and the patient population may not have rational thinking in deciding whether to pursue this. Nevertheless, it is an amazingly and surprisingly effective treatment for refractory psychiatric illness. I've met patients who say that they've been tried on many, many antidepressants and have had no response or too many side effects, but ever since trying ECT, their lives have completely turned around. I don't know all that much about the psychiatry behind it, but I wanted to talk about the anesthesia.

When we are on pre-operative clinic, we provide anesthesia for ECT in the morning (since clinic doesn't start all that early). It's really fascinating. Usually 4-6 patients show up a day, and many are repeat customers; ECT is sometimes given up to 3 times a week. This allowed me to develop relationships with a few of the patients. The therapy itself is short so I have to set everything up beforehand in order to keep things moving.

I get there early, draw up a ton of medications. While the therapy is short, the anesthesia is complex. We occasionally give caffeine to potentiate seizures. We give patients toradol for post-treatment pain and ondansetron for nausea. Then we give remifentanil as a rapidly acting opiate, induce general anesthesia with etomidate (which promotes seizure activity), and paralyze the patient with succinylcholine (in order to minimize post-seizure pain and injury). After general anesthesia is induced, we hyperventilate the patient with a mask, and the psychiatrists deliver their shock. They monitor the patient's motor activity (through a limb with a tourniquet so it does not get the succinylcholine and will display seizure activity) and electroencephalography. If all goes well, we're done. But I'm prepared to break the seizure with benzodiazepines. I can treat blood pressure with esmolol, nitroglycerin, phenylephrine, or ephedrine. All of this requires the preparation of a cocktail of drugs. I remember drawing up close to 40 syringes one morning.

What's amazing is that it works. After inducing a seizure in a patient, we wake them up, and they have no pain or recollection of the treatment. Most of the patients are completely satisfied with things and go home within half an hour, ready to come back for their next treatment later that week. This experience shows me the diversity of anesthestic techniques and introduces me to interventions I'd not seen before.

Image shown under Fair Use, from psych.med.umich.edu.

The Fifth of November

Remember, remember the fifth of November,
Gunpowder, treason, and plot.
I see no reason why gunpowder treason
should ever be forgot.

Image is in the public domain, from Wikipedia.

To Be a Doctor

When I applied to medical school, I had some preconceptions about what it was to be a doctor, and many turned out to be false. I wanted to write about one in particular. How many of us, before seeing what medicine actually was, thought of a doctor as someone who could encounter a life-or-death situation and nurse someone back to health? That being a physician meant that a call would be announced overhead on a plane and we'd rush to the side of a frightened, anxious person and be able to diagnose and cure the malady. That we'd stop at a car accident and make some heroic intervention that saves someone's life. Of course, no one goes into medicine expecting that this will be their everyday expectation. But perhaps we have some faint hope that medicine gives us a skill set that is remarkably versatile, spontaneous, and applicable to any situation.

Unfortunately, this is far from the truth. Even those in specialties that see a lot of undifferentiated illness, like family practice or emergency medicine, depend highly on the setting and allied health care professionals. Gone are the days that doctors carry all they need in a little black bag. Sure, we can diagnose and name treatments for most things, but away from an acute care setting or clinic, there is little we can do. And how many of us (who are not anesthesiologists) remember how to place leads for an EKG or put in an IV? How many of us know how to reconstitute an antibiotic or make a splint from scratch?

Medicine has evolved into a complex beast, one that requires many different people with complementary skill sets. Though some of us dreamed of that time where as a lone physician we could face everything, we quickly realize that such thoughts remain dreams.

A Little Downtime, and Add-Ons

I apologize for the lack of updates; it's been busy. I've been getting assigned to a bunch of add-on cases after my scheduled cases finish, and it's been extraordinarily draining. Add-ons can be a little daunting because I spend a good amount of time preparing my daily cases. I do a thorough chart review, think through the anesthetic plan, review everything in my mind before going into each case. But with add-ons, we get called after our last scheduled case, and upon learning the urgency of the following surgery, I rush to prepare my room, scan over the chart, meet the patient, and talk to my attending. Often, add-on cases are sicker patients, admitted to the hospital with a pertinent medical condition. Their vital signs are abnormal, they are undergoing antibiotic therapy, their labs are off, they have less reserve. This compounds the fact that I don't have as much time to prepare.

But separately, add-on cases are also highly inefficient. I hear about a case, but it takes everyone an hour to get the room prepared. The equipment and case cart need to be brought in and opened. A team of a circulating and scrub nurse has to be identified. For cases with prosthetics, the representative from the biotech company must be available. We have to assure availability of surgery and anesthesia residents and attendings. So while scheduled cases are expected to turn over in 15 minutes, these add-ons drag on, and it's exhausting. But I'll be back to blogging regularly once my days permit.