Happy New Year!

Wishing everyone a very happy new year. I hope that 2012 is filled with personal growth, achievement, kindness, compassion, creativity, innovation, daring, and courage. Please have a safe New Year's eve, which is not an unselfish request as I happen to be on call.

Cartoon by John McCutcheon is in the public domain, from Wikipedia.

Intubating during a Code

I used to be terrified of codes. Some of the time, it's nothing serious, a precaution, a false alarm. But other times, it's acute respiratory failure, altered mental status, asystole. As the anesthesiologist, I have to figure out whether an airway needs to be secured and do it. Even though I feel pretty comfortable about intubating in the operating room, emergency situations are scary. I have to slow myself down; even though I am anxious to get the tube in, doing so without being prepared can be disaster. Like procedures out of the operating room, my environment is completely different; I have to check all the equipment, make sure I have things I take for granted like suction. I can't count on the people nearby to know what I need or how to help. I can't position the patient optimally. I don't have a lot of time to learn about the patient but have to select appropriate drugs and doses. Luckily the floor intubations at Valley have not given me unexpected difficulty. Most of them have been for respiratory failure, but all have allowed me five or ten minutes to set up everything as I need it. I always have supervision and backup. It is a satisfying challenge and I'm feeling more and more comfortable with it.

Turnover

Turnover is really important in the operating room. While patient care takes the first and foremost priority, when we are in between cases, efficiency becomes king. Once a patient is out of the operating room, the entire place needs to be cleaned and disinfected, the anesthesia cart restocked, the next case cart readied, and surgical equipment prepared. The goal is to have all this done within 15 minutes. From an anesthesia perspective, I need to bring my patient to the recovery room, make sure she is stable, sign out to the nurse, dispose of any opiates properly, finish documentation, meet my next patient, review the history and physical, place an IV, and then prepare all my equipment and drugs. Surprisingly, the most quiet time for an anesthesiologist may be during a case and the most hectic time that period from extubating one patient and intubating the next.

At Stanford, we even have outside consultants who look at our processes to try to optimize them. We get occasional emails telling us how different checklists have been changed, why we aren't getting our patients to the operating room soon enough, and displaying graphs on our efficiency. I don't particularly like it, but I recognize that this is the way to make things operate more smoothly which can ultimately save resources and make everyone happier.

Holidays

Does surgical volume increase or decrease around the holidays? I wasn't sure what to expect as I started work this week, but Santa Clara Valley didn't seem to change too much; the operating rooms are as busy as ever. Most of the cases are urgent and emergency rather than elective cases, but there are certainly enough of those to go around. I'm guessing volume is slightly lower at Stanford and the VA as there are systems there to figure out how many residents are needed each day. While it's a little hard to have to work during the holiday season, it is still much better than last year where I was on q5 call at the VA.

Burn Surgeries

Burn patients are a little different than regular patients. As Santa Clara Valley is a burn specialty center, we see inhalational injuries, deep burns, and burns involving large areas of skin. The surgeries vary widely; there are the typical skin grafts, but I've also done anesthesia for knee amputations for a burn that was too severe as well as dialysis line placements. Burn patients lose a lot of heat and water through their injuries, making the job of keeping them warm and resuscitating them difficult. Those with smoke injuries can have swelling of their airway. And the extent of their burns may limit IV access and other monitors.

Understanding the patient population of a hospital changes perceptions of things. I found out one of my patients got a whole-body burn "cooking." Astutely, my attending asked what he was cooking - turns out he was trying to mix meth and heroin. That is not an advisable hobby.

Image of third-degree burn is in the public domain, from Wikipedia.

Happy Holidays

May the holidays find you surrounded by those you love and those who love you.
-Craig

Image of Rockefeller Center Christmas Tree shown under Creative Commons Attribution Share-Alike License, from Wikipedia.

Crash

The Cesarean section can be done with various anesthetic techniques. A spinal injection into the cerebrospinal fluid will achieve surgical numbness. An epidural catheter can be bolused with local anesthetic to achieve the same effect. Both of these "neuraxial" techniques have the advantages of minimizing drug exposure to the baby and letting the patient see her baby once she delivers.

We only elect general anesthesia in exceptional cases and emergency "crash" sections. Although it is the fastest technique, exposes the baby to medications and involves a challenging airway in an urgent situation. I was called to a stat C-section for fetal distress. Fortunately, we had the room set up for an emergency and my attending was already present. When the patient rolled in, she was terrified, confused, and in pain. It was chaotic; normally, operating rooms are an exemplar of order, but here, people were yelling for assistance or medications or supplies. Although the patient had an epidural in place, bolusing it would take 5 minutes for surgical anesthesia, and we didn't have that much time. I pre-oxygenated, my attending put on monitors, the nurses opened the case cart, and the surgeons scrubbed. When the surgeons were ready to cut, we induced; ten seconds later, I took a look, saw vocal cords, and intubated the trachea. Immediately after that, my attending gave the okay and the surgeons cut. Before I had finished taping the endotracheal tube, the baby was out. I hadn't even given the surgical prophylactic antibiotics; there was no time. All the steps were compressed to minimize risk to the baby and keep the mother as safe as possible. Fortunately, the baby and mother did fine. It was an incredibly stressful moment but in that situation, I felt pretty calm; afterwards, I was trembling. Much of anesthesia is routine, but occasionally, we have to react under extraordinarily stressful and life-determining situations.

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

The Epidural

While we do epidurals for many surgeries, when most people think of the epidural, they think of pain management for labor and delivery. Right now, I find the procedure a little challenging, but I know it will get easier. Like IV placement, intubation, spinals, and other hands-on things we do, it simply takes practice and repetition. In a laboring woman, placing the epidural is a little more challenging because we have to do the procedure in between contractions. The procedure itself is quite safe and I am becoming more and more facile with it, so the question becomes: when should we do it?

I get asked this a lot, equally by patients as by other healthcare providers. Should I get an epidural or not? There's no easy one-fits-all answer to this. If a patient feels strongly one way or the other, I support them completely. Some people want as much pain relief as possible; others want the natural childbirth experience; I am happy with either. If she is uncertain, I don't press too hard but always leave the option available. Some people like to say, "If I were in your place..." or "If you were my mother, sister, or daughter..." but I never do that; I'd never be so presumptuous as to pretend to know what it's like to be pregnant, nor to recommend to a family member what to do in this situation. (I do use the "If you were my mother, sister, daughter," phrase in cases where I feel something is medically clear-cut such as whether to go to surgery for life-threatening appendicitis).

There are few scenarios in which anesthesia can empower a patient, but here is one; the choice is always up to the patient. For most surgeries, I don't ask the patient what kind of anesthetic technique he'd like; when I present risks, benefits, and alternatives, the alternative is not to do the surgery. But here, it is perfectly reasonable to choose an epidural or not, and so part of resident learning is presenting the options in the most appropriate fashion.

Image of an epidural catheter shown under Creative Commons Attribution Share-Alike License, from Wikipedia.

How Doctors Die

An article on "How Doctors Die" by Ken Murray, a family medicine doctor at USC, has been circulating the Internet. It's a fascinating read because I do think there's a dichotomy between how doctors and non-doctors view their deaths. A lot is written about the medicalized end-of-life, the dramatized ICU bed with tubes out of every orifice, no dignity, aggressive care that spirals into suffering, a drawn-out dehumanization with no end. And a lot is written about the so-called ideal death, surrounded by friends and family in one's own home, medications to ease any pain or suffering, and a quick end. Put that way, it's easy to choose.

But this article argues that patients overwhelmingly choose the first while physicians choose the second. Why is this? Is it a failure to communicate a faithful image of the end-of-life? Is it that we've seen what happens and understand the nuances of "do everything possible to keep him alive?" Is it that we think about death and dying far more than the average person? Is it that we view death as a natural part of our existence whereas others view medicine's abilities as limitless? Is it that we understand probabilities of survival given certain circumstances? Is it that we're more willing to give up on ourselves?

We can't impose our feelings on anyone else; if someone understands what happens with CPR, emergency surgery, the ICU, and dying in those situations, then I won't argue otherwise if that's what he chooses. But I can say clearly that even though I might become an intensive care doctor, there are very few situations in which I'd like to become an intensive care patient.

Anesthesia

Looking at it from some very strange way, anesthesia is the specialty of controlled overdose.

Lark

My friend Julia Hu invented a silent alarm clock, Lark, and founded a company based on it which has taken off tremendously. Since it is that time of year, I figured I'd mention it in case anyone is looking for a holiday gift. She came up with the idea after realizing that traditional alarm clocks are incredibly disruptive both for the sleep of the person waking up as well as any roommates or sleeping partners. She designed, engineered, and created a pleasant vibrating wristband that gently nudges the intended individual awake, leaving any others sleeping in peace. She's worked with sleep experts to create a personal sleep coach where the wristband monitors and records the quality of sleep at night. Since I started using it, I've been quite surprised to find how easy it is to sleep with, how pleasant it is to wake up, and how fascinating it is to track my sleep schedules. I've been getting even less sleep than I expected. For someone with a variable schedule, it's a great device; I've even tried it on call and found it perfect (soon, I hope they connect it to the paging system). In any case, I rarely write about products, but this one I like. Visit Lark for more information.

Image shown under Fair Use.

There is a Fracture

When I see a patient right before anesthetizing them, only a few things give me pause, and chest pain is one of them. On my last call, an older man came in after a motor vehicle accident; he was driving and suddenly lost consciousness, running his car into a pole. As a result of the accident, he also fractured his ankle. He extricated himself from the car and was picked up by EMS and brought to the emergency department. The workup was a little spotty; he had normal labs, including a troponin, and a negative head CT. No chest X-ray was done, though of course there were ankle films. Orthopedics jumped on it and said his open ankle fracture was an emergency. He arrived in the operating room ready for me to anesthetize.

When I spoke with him, he said his ankle wasn't really bothering him, but rather a substernal chest discomfort. He had a rather sizeable bruise as a result of the airbags, but I was concerned. Why did he lose consciousness? Did he have underlying heart disease? Could there have been an aortic injury? Was this pulmonic?

Although it disrupted OR flow and delayed the surgery, we decided to get a chest X-ray and EKG. Both were normal. We still decided against general anesthesia and did a combined spinal-epidural instead, so that the patient would be awake if his chest pain worsened or he had neurologic symptoms. Ultimately, the patient did fine, and post-operative workup was negative. We may never know what caused the accident, but we have to treat it with caution.

For Example

Being on call at the Valley means lots of pages, a little multitasking, and no sleep. On one call night, I started with a 10 year old requiring removal of an external fixator for an old tibia-fibula fracture. It was my first pediatric patient, but at least he wasn't a child. The attending walked me through the anesthesia for adolescents, from the way we explain things to dosing of medications to preparation of equipment to induction of anesthesia and securing the airway.

Once I had placed the breathing tube, however, I was called for a series of code blues. I went with the other attending and found one person with congestive heart failure and an oxygen saturation of 85%. I quickly got my equipment together, positioned the patient for intubation (difficult due to his underlying disease and shortness of breath), induced anesthesia, intubated the patient, and put him on a ventilator. Before I had time to clean things up, I got paged with another floor patient with acute respiratory decompensation. This one was far more challenging, however, because he was 300 lbs and septic with low blood pressure, necrotizing fasciitis, and acute renal failure. I was very nervous, and due to his renal disease, we decided intubate the patient without a muscle relaxant. Despite his weight and the non-ideal conditions outside the controlled and familiar operating room, I managed to get the tube in pretty easily. It was incredibly satisfying.

By the time I got back, we were ready with another case in the operating room: a cystolithopaxy to remove a kidney stone in a gentleman with acute renal failure. After I started that case, I was paged with two epidurals on labor and delivery, and so I rushed up to place those, including one in a woman whose body mass index was 60 (normal is 20-24). The evening ended with a straightforward appendectomy, and by that time, I was exhausted.

The cases come so fast that I can't even log them all, and after a call night, I have to think pretty hard to recall each anesthetic I provided. I've learned to just paste patient stickers on my sleeve to keep track of them all. On my second call night, I had two appendectomies, an incision and drainage of an abscess, a dilation and curettage, an epidural, and two C-sections, one done under a spinal. On my third call night, I placed two epidurals, managed two C-sections, intubated someone on the floor, saw two appendectomies, and took a patient to the operating room for a perforated viscus with air under the diaphragm. Despite the busyness, I really enjoy it, especially since it's often a lot of fast cases, good procedures, and solid learning.

Call at the Valley

Call at Santa Clara Valley is exhausting. Even though the shifts aren't long, it can be much more tiring than calls at other hospitals or on medicine. We arrive at 3pm and finish up cases or tackle add-ons. At around 5pm, we try to cut down to only two simultaneous operating rooms. By now, the add-ons start piling up, and around that time we start covering obstetrics as well. We have 3 attendings and 2 residents in the late afternoon and by 10pm, we're down to 2 attendings and 1 resident.

There are a lot of add-ons at Valley, and I'm not sure why; we see a lot of appendectomies, ectopic pregnancies, orthopedic injuries, and other urgent cases each night. There is a considerable amount of trauma at Valley so we have to be ready for a big surgery at any time. The on-call anesthesiologists also split up pre-operative evaluations for any inpatients for the following day so in between cases, I run around the wards to see patients and rifle through charts.

However, Valley call can be tiring because it involves a lot of things that first year anesthesiology residents haven't seen yet. We get the occasional pediatric case, and although attendings help us greatly for these patients, it's something I am less prepared for and less comfortable with. We hold the code pager, and there are a surprising number of code blues requiring intubation. I'm always supported by an attending, and the nurses, pharmacists, and respiratory therapists are outstanding in helping us with equipment and drugs.

The biggest challenge, however, is labor and delivery. I had not been up to L&D since third year of medical school, and relearning the nomenclature, pertinent aspects of pregnancy, and common peripartum illnesses took some time. But it is the place to learn about epidurals. These are still tough for me; I still struggle to find the best entry point, but once I'm in the right place, I've gotten more facile at the technique of placement. There's a lot of learning on call and even though it's very busy, I really enjoy it.

Generics

Within the next six months, a number of widespread brand-name drugs will become available as generics. Atorvastatin (Lipitor) which made Pfizer $11 billion in revenues last year, clopidogrel (Plavix), valsartan (Diovan), and montelukast (Singulair) will all become generic as the patent protection for big pharma runs out. Naturally, the pharmaceutical companies are doing everything they can to soften the blow through legal challenges, deals with the generic companies, marketing strategies, and hunting for loopholes. The truth is, much as I respect what they do and how challenging it is to bring a new drug to market, I don't have all that much sympathy for big pharmaceutical companies. I've seen too many patients who cannot afford the medications they need, spent too much time filling out insurance authorization forms, and struggled too long with the question of how to control healthcare costs that I think cheaper, generic versions of drugs, as long as they are equally effective as their brand-name counterparts will be good for our system.

Valley Logistics

There are just a handful of residents at the Valley, which means that we can get fairly complicated cases since there aren't a lot of senior residents vying for the "hard" rooms. In fact, on my second day at Valley, I was assigned to endoscopic abdominal aortic aneurysm repairs, cases that go smoothly most of the time, but if something goes wrong, it can be an instantaneous disaster. The cases we get are pretty diverse, and I got my mix of general surgery cases, urology, orthopedics, neurosurgery, and out-of-OR procedures like endoscopy. But I noticed that compared to the VA and Stanford, there were far fewer scheduled cases and far more add-ons from the emergency department or the inpatient wards. This may simply be a reflection of the patient population which uses Valley more as an emergency department, urgent care, and episodic care center rather than a long-term continuity of care facility. It may also reflect the fact that follow-up can be unreliable, and so if a patient has a disease that requires surgery, admitting them and doing the surgery may be better for the patient than discharging them with an appointment.

Santa Clara Valley Medical Center

My current anesthesia rotation is at Valley Medical Center in San Jose. I was last here about a year ago for my medicine rotation, and I am happy to be back. It's a little bit of a commute, but I love the county hospital feel. The underserved population reminds me of the importance of health care reform, the immigrant population allows me to practice my Spanish and Mandarin, the hospital's wide catchment area allows me to care for diverse diseases, illnesses, and injuries including trauma and burns. Although resources are quite limited, the heart and passion of providers to care for this community is overwhelming and inspiring.

The operating room setting feels like the Veterans' Administration; it's a small group of anesthesiologists and surgeons operating in about 12 rooms. There are some differences between Valley and the other hospitals though. Because resources are limited, we are extremely aware of wasted medications, turnover time, and costs. At night, there is no anesthesia tech so we make our own IV bags, set up our own equipment, and calibrate our own instruments. The hospital uses a hybrid electronic and paper medical record so we don't have all the information about our patients until we meet them. And yet, the efficiency is impressive; I feel that the pace is just as brisk as the other hospitals I've seen.

Image is in the public domain, from Wikipedia.

Why Are People Still Smoking?

This ashtray showed up in my Google Plus feed and I thought it was pretty clever.

Image is shown under Fair Use, in the public domain.

Operating Room Management II

The scheduler also has to deal with add-on, urgent, and emergent cases. Emergent cases are relatively simple; they must go to the operating room as soon as possible, and the scheduler just needs to find an anesthesia and nursing team. But how do you distribute urgent and add-on cases? At 5pm, it might not be reasonable to start a 5 hour case, but a 45 minute laparoscopic cholecystectomy should go. What anesthesia team does the cases? In theory, it should be on the on-call anesthetists, but they may still be in on-going cases. Do you assign someone who should be leaving soon to 5pm surgeries? At some point, there should only be a handful of surgeries going, and then just one or two rooms running as the hospital can't pay all the staff overtime. And as staffing ratios get slimmer through the night, the scheduler still needs to have the resources to respond to an emergent trauma case if necessary. I don't know how all of this works, but it's pretty fascinating.

If an emergency comes in and all the operating rooms are already assigned, then someone will be "bumped." That is, a surgeon's protected elective surgery time might be superseded by the emergency. How do you account for this? Does the surgeon get credits? Do his cases get greater priority in the future? As I go from hospital to hospital, I see various systems and committees dedicated to solving this problem.

Ultimately, money is important in operating room management. Operating rooms are incredibly expensive, and so you want them running at full efficiency if possible. Downtime means that a surgeon, surgical resident, anesthesiologist, anesthesia resident, circulating nurse, scrub nurse, technicians, and housekeeping are all idle. So part of managing the operating rooms is that puzzle of packing a suitcase: you want to get as much to fit in there as possible with minimum wasted space.

Operating Room Management I

After six months in the operating rooms, I have only a glimmer of knowledge about how operating room management works, and I can already tell it's incredibly complex. An anesthesia attending acts as the "scheduler," in charge of determining the order of cases, assigning the cases to anesthesiology teams, dealing with add-on cases, and probably playing a lot of roles I don't know about. For the most part, surgeons have protected block time when they do elective cases; each attending knows when he operates. But how do you determine the order of cases? Some cases have to be last if they involve an infection; others which may involve two surgical teams ought to go first when you know everyone will be free. But do you schedule a long case before short ones? When do you schedule a case with indeterminate length (such as a cancer surgery where it's unclear how extensive the resection will be)? If you schedule it early, then subsequent patients may be waiting inappropriately. If you schedule it later, then it can potentially go on past when you should be staffing elective cases. And a scheduler has to look at the big picture; not everyone can schedule cases requiring intraoperative X-ray at the same time, and not everyone can schedule a 2-hour case first thing in the morning because if all the patients arrive in the PACU (recovery room) at the same time, the nurses there will be overwhelmed. This may be the sort of problem that decision-making software and analyses can aid.

Signing Out Patients

Anesthesia is one of only a handful of specialties that allows the full responsibility for care of a patient to pass through multiple providers. At the end of the day, those on call will "relieve" the non-call anesthesiologists. We sign over the entirety of care to those taking over, something only seen in places like the emergency department. While on other services like medicine, surgery, or pediatrics, a night person often "covers" patients while the primary providers aren't in house, the main provider stays the same. So becoming comfortable with this new concept took me some time.

On some level, it makes a lot of sense. A surgery may be incredibly long, and fatigue is the anathema of the anesthesiologist (our motto is "vigilance"). We give each other breaks, and an extension of this is to sign over all the care of the patient. This means we have to encapsulate all our thoughts, our plans, and our anticipations for a case in a brief summary to another provider; it also means that if we're taking over, we have to quickly assimilate to a new situation to care for a patient safely. We have to deal with differences in anesthetic approach, quirks, or complex situations, but for the most part, this is fine; there are only so many ways of providing anesthesia, and all anesthesiologists need to be facile with managing any of them.

The trade-off is that we lose continuity of patient care, but we build a trust and relationship with our colleagues that is quite remarkable. This system also allows a shared responsibility for the burden of long cases and call; as a result, anesthesiology is known for its quality of life.

1400 (ish)

Image of Phyllis Siegel and Connie Kopelov, the first same-sex couple to get married at the Manhattan City Clerk's office, is shown under Fair Use.