Another Orbit Around the Sun

I love this picture of sea foam on Ocean Beach in San Francisco. There is some sort of symmetry in the Earth's Sisyphus-like wandering and the rhythm of the tide. Here we are again. To 2013, a year where we do those things we meant to do in 2012, and more!

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

The Humanities and Medicine

No matter how much physicians try to resist the notion, a lot of medicine has an algorithmic, cookbook, or heuristic nature. I am one of the people that really dislikes this notion. We wish to think the art of medicine magical, that our years of training, nights poring over books, experiences seeing thousands of patients, and Socratic method teaching imparts on us some wisdom that allows us to lay hands on a patient and diagnose. But the truth is, rapidly improving technologies, faster computational algorithms, advances in machine learning, and the complexity of human wellness and disease mean that computers have begun to challenge even the most experienced and well-respected physicians. Physicians dislike patients who come to appointments carrying printouts from Google searches of their symptoms, but we cannot deny that often, our clinical expertise can be matched by technology.

That being said, I still believe the art of medicine is an art that challenges the humanity within us. It's probably evident from this blog, but I strongly feel that the humanities are integral to medicine. Emotions, stories, artwork, reflection, discussion, and debate challenge us to hone those skills of taking care of a person. A computer may make the diagnosis, but a physician broaches the delivery of that diagnosis, cultivates that relationship of trust necessary for compassionate care. We don't respect that skill set enough. It is not easy to go to work every day and care for people who hurt themselves, are going to die, cry on your shoulder, feel terrified, or distrust the health care system. The humanities, with respect to medicine, are about understanding how humans experience illness and disease and placing that within a context of diagnosis, treatment, and care.

Full Circle

I started my anesthesia residency at the VA, and a year and a half later, I'm back. Seeing the attendings who first taught me everything, who guided my hands and made me think out loud reminded me how far I've come. The small group of nurses, surgeons, and technicians also watched me at my fledgling stages, and I remember them and feel honored to work with them again. The veteran patient population feels the same, a group that has weathered so much, that is always appreciative of the care we give. These are some elements of the VA that make it feel like home.

The thing that struck me most is the difference in culture. The VA operates at a much slower pace than Stanford does. While at Stanford, there is a flurry of activity to get rooms turned over, patients in the room, and cases started, at the VA, I'm always ready before everyone else is. There is no pressure from the surgeons to move things along. Things take their own pace. It's good for trainees as we can really take the time to prepare ourselves, do things correctly, and learn and reflect, but the pace can also drive me a little crazy. There are days when our caseload could be finished a lot quicker, but we end up taking all day. But that's the VA.

Happy Holidays

The holidays are a time to reflect. We encounter a new planet, an untread world. We reconfirm a president but face a potential fiscal disaster. We confront the behemoth of health care. We live in a world marred with civil war, shootings, tragedy. A hurricane reminds us of the strength and power of nature. We celebrate the Olympics. We have a great deal to be thankful for, and a great deal more to do to make the world a safer, more beautiful, more loving place.

Image of Christmas tree display at the Galeries Lafayette, Boulevard Haussmann in the 9th arrondissement of Paris shown under Creative Commons Attribution Share-Alike License, from Wikipedia.

Unravelling Bolero

Seeley et. al published a fascinating paper entitled "Unravelling Bolero: progressive aphasia, transmodal creativity and the right posterior neocortex" in Brain, 2008. I don't discuss a lot of papers as I think they're dry and not everyone can get access, but I came across this one and found it curious. One way of approaching neurologic injury is to localize a disease process ("where's the lesion?") and then see what deficits result. For example, a stroke in the motor strip of the brain will lead to contralateral weakness, and so it can be inferred that the affected anatomy has something to do with motor function. But the authors discuss an interesting idea: some lesions in the brain can stimulate new artistic or musical talents. Maurice Ravel was a French composer best known for his orchestral work "Bolero." Near the end of his career, he developed a progressive language and motor disorder. There are hypotheses that as his speech declined, his musical prowess heightened. The authors of this paper present a case study of a patient with frontal-insular primary progressive aphasia who paints. They follow her art from her preclinical phase through her progressive dementia and study her brain imaging. I love the paper because its figures are artwork, from a representation of the number pi to a visual image of Ravel's Bolero. You can see how this patient's paintings change over time, presumably due to her neurologic illness. As her language and speech function disappears, her expression through artwork becomes more and more beautiful. It reminds me how little we know of the brain and how this story can give insight into something as strange as the development of a new talent.

Clasp

This time of year gets quite busy for me as I try to scrub rust off those interests, passions, relationships, and goals I haven't cultivated for a while. I've been procrastinating on figuring out what I want to do after residency, a little slow in sending holiday cards and emails to those I haven't talked to in a while, and neglecting my reading as the in-training exam begins to loom nearer. I have some writing projects to work on, a lot of cleaning to do, and a big to-do list to catch up on. So I'm going to take a break from this blog for a week. Thank you for following along; I've run into a few people who've known about this blog, and it's always fun to hear that other people do actually read this. See you next week. - Craig.

Image of rust-laden links of a sea-sprayed chain of Golden Gate Bridge shown under Creative Commons Attribution Share-Alike License, from Wikipedia.

Pre-Op Clinic

Now that I'm back in pre-operative clinic, I think of how it's evolved for me over time. I started as an intern, prior to doing actual anesthesia. Although this may seem strange, pre-anesthesia evaluations are more medicine than anything else. I had a lot of questions for my preceptor and I did really thorough medicine evaluations. I remember examining for lower extremity edema and JVP, trying to palpate the liver and spleen, and discussing exercise and behavior changes with most patients.

Now well into residency, I have a much firmer sense of what's directly relevant to anesthesia. I still try to be a good citizen and physician, encouraging patients to stop smoking, discussing side effects of medications, and probing psychiatric overlay. But I can see a patient so much faster because I know the types of medical problems that worry anesthesiologists, the tests I would want to see for a particular surgery, and the common questions that come up about going under. I know specific surgeon preferences and I often give heads-up pages to anesthesiologists to prepare them for cases. I understand the ins-and-outs of the system, and as a result, pre-op clinic is smoother and more straightforward now than a few years ago.

Poem: In Memoriam

I heard about it right after I finished my ECTs, when I went to the physician lounge for a bagel. Strange how we sense something isn't right; I can't identify exactly when I knew, but I knew before I parsed the words from the television. My heart aches for all those involved. My prayers go with the victims and victim's families. I am a little numb with shock, and struggle to understand my thoughts (and to avoid Claudius' folly in Hamlet: "My words go up, my thoughts remain below. / Words without thoughts never to heaven go."). Everyone has their way of coping, whether posting on social media, petitioning a senator, mourning, or gritting teeth and plowing on. I write. First drafts are never clean, but I hope that my words and thoughts are married and carry my deepest sympathies.

-
In Memoriam

lip of wax tumbles headlong
melting a rosary bead wake
chill caresses fingers
ache entombs brain
steady flame quenched
acrid stink, disfigured
candlelight darkens

i danced with a blind woman
held a cancer patient's hand
peeled an orange
listened to latin chants
and heard of the twenty
who will never have

twenty christmas trees
long of child, twenty
siblings find no counsel
twenty priests turn away
twenty politicians arise
twenty insomniac families
twenty candles to light

a child is who we wished
we could be, who we wished
for, who we wished could
see do hear taste play love
and to say we love a child
is to use the best word
for why our heart squeezes
so damn hard
but the word still falls
so so short.

ECTs

This week, I have been doing anesthesia for electroconvulsive therapy. I have written a blog on this in the past so I'll leave out the technical details, much of which is the same. But ECTs are interesting because we work with a particular patient population, those with refractory depression or bipolar disorder. Interacting with these patients reminds me of my psychiatry rotation; their behavior, affect, speech, and interaction all give clues about their underlying diagnosis and the efficacy of their treatment. It can also make consent issues challenging, though it is helpful that psychiatrists are experts in determining a patient's capacity to consent. The other aspect of providing anesthesia is that we have to be cognizant of the patient's nonpsychiatric issues, especially since these can be overlooked by their mental health professionals. Depression, bipolar disease, schizophrenia, eating disorders, and other psychiatric illnesses are accompanied by physical changes and symptoms. Patients may overeat and become obese. They may neglect their health and develop diabetes, hypertension, hyperlipidemia. They may overdose on medications, leading to kidney or liver insufficiency. Suicide attempts may result in severe trauma. So these cases are not medically benign. Although the anesthesia for ECTs is more or less cookbook - we use a standard cocktail of drugs to help induce a seizure, provide adequate anesthesia and amnesia, and facilitate a quick wake-up - patients still respond very differently and can have severe cardiovascular changes during the ECT. It is a good reminder that even for quick cases that generally go smoothly, we have to be cognizant, vigilant, and aware of what we're doing to the patient and how to rescue them in the event of an emergency.

Canceling a Case

An older gentleman who has multiple medical problems including insulin-dependent diabetes, amputations of both legs, dependence on a caretaker, and spinal stenosis presents for spinal surgery. In past anesthetic records, it's noted that he is a difficult intubation and has required multiple attempts and rescue techniques. When I meet him in the pre-operative area, however, I find out that he ate solid food for breakfast.

The reason why we have patients "NPO" (nil per os or nothing by mouth) before surgery is to reduce the risk of aspiration. If induction of anesthesia causes vomiting, a full stomach can go down the lungs, and that can be lethal. In cases where we cannot wait for a patient to be NPO, like an emergency trauma, we induce anesthesia and intubate as rapidly as possible. For this case, we were stuck against a rock and a hard place. The clear defensible obviously-correct answer is to delay the case until the requisite time is met. The risk of aspiration is unacceptable in someone who just ate solid food and is undergoing an elective surgery. We even considered doing the case with a rapid sequence induction, as if it were a trauma, but the history of difficult intubation makes that hardly ideal. We toyed around with the idea of an awake intubation, but that puts the patient through more discomfort than necessary.

The problem with delaying, however, is that the complexity of the case and the hardware needed makes daytime the best time to do the case. It was scheduled to be an incredibly long procedure and would need consultation with biomedical reps to get the appropriate equipment. Starting the case in the afternoon might mean the surgeons wouldn't have access to what they needed in the evening. They did not want to start the case that late, and so we had to cancel.

We do not cancel cases lightly. We fully recognized that this patient cannot leave his home independently, depends on his caretaker, and needs specialized transportation. Furthermore, adjustments to his medications on the day of surgery, especially insulin, makes his sugar and blood pressure management difficult in the case of a canceled operation. But after discussing all of this with the surgeon, the patient, and the caretaker, we decided to do what was right despite the inconvenience and disappointment to all involved.

Purple

There are really quite many amazing and beautiful places in the Bay Area. This is Pfeiffer Beach in Big Sur, and for reasons I have still to investigate, the sand has a gorgeous purple sheen. We don't get a lot of free time as residents, but when we do, we have to take advantage of it.

Interview Season

Already, we find ourselves halfway through the interview season for potential residents. For those who've stumbled upon this blog looking for anesthesia or Stanford's program, welcome and good luck! I really enjoy meeting all the prospective residents; they have amazing stories, interests, and backgrounds. I know it's the time of year when applicants feel pretty worn out and residents realize they have seasonal affective disorder, but I really do feel strongly about putting an honest, open, and supportive face to our program. I remember the red-eyes, the hotels, the wrinkled suits, and I try to welcome all our potential applicants warmly. It's a really tough time, and also a really eye-opening experience. If anyone comes across this blog and has a question about our specific program, I'm happy to answer comments to this post.

Running an Operating Room

We had a grand rounds on operations management, and the discussion helped me realize how complex it is to "run the board" - that is, schedule and manage the surgical flow of 21 operating rooms. Even simple decisions become convoluted. When should the day end? Should there be an end time? Having an expected end-time simplifies staffing; shifts can end at 6pm except for a skeleton crew to accommodate emergencies. Setting and meeting expectations helps well-being, allows planning, and keeps operations organized. But this must be balanced against the increased revenue that can be obtained by letting surgeons book as many cases as they want. The more cases a hospital does, the more money the hospital makes. And if a surgeon is willing to operate, why restrict him to 6pm? Yet if there is no set end-time, how do you manage staffing of anesthesiologists, nurses, and technicians far in advanced? How can we plan our lives if surgeons can add on a non-emergent case, and we have to be available to do it?

Then there are problems at a more micromanagement level. Say you have one room that has 4 cases scheduled: one very long, two short, and one of variable duration. Do you schedule the longest case first? This would allow the other cases to be shuffled to different rooms if other rooms finished earlier. It would also mean that if a case had to be canceled because the room ran over, it would be a short case and not the long one. But there are risks; what if the long case is canceled, and none of the other cases are ready to go because they expected to be in the afternoon? How do you fill the gap?

Lastly, there are a lot of problems specific to medicine. As opposed to a production line or a senator's schedule or the fast food rush, surgeries can be incredibly variable in length of time. The same operation can take much longer or much shorter than expected, and it's hard to accommodate for this. The most extreme example is pancreatic cancer surgery. Despite a comprehensive workup, a surgeon can open up the belly expecting to take out the cancer and find that it is much more widespread than he thought. In this case, the best decision for the patient is to close the abdomen without doing the surgery because surgery will not help. But from an operations standpoint, this changes a 6 hour case to 30 minutes. How do you deal with that?

Intuitively, I favor a computer algorithm or calculation that can look at past cases, take into account all these rules and preferences, and spit out an answer. But after listening to the ground rounds, understanding the pros and cons of different approaches, and seeing the practical result of our daily case scheduling, I'm not sure it's that easy.

Book Review: The Song of Achilles

Madeline Miller's ambitious novel, The Song of Achilles, was ten years in the writing. I loved it. Set in Ancient Greece, it traces the lives of Achilles and Patrocles: their childhood friendship, education and training, intimate relationship, and role in the Trojan War. She creates a wonderfully magical world; I was enchanted by the interaction, interpretation, and co-existence of mortals, half-gods, and deities. We are swept into the culture, lifestyle, values, and people of this beautifully-depicted time. The writing is amazing: smooth, sweeping, vivid, and lyrical. The integration of events and characters we knew from childhood with the imagined hinges of the plot is seamless. It made me realize how much I miss and love myths, history, classical literature, and storytelling. I could not put this book down, so I encourage you to carve away a bit of time before picking it up.

Image shown under Fair Use, from Wikipedia.

Measurements

Isn't it interesting how we can use things daily but not know all that much about them? For example, I routinely use orogastric tubes and large bore central lines that are measured in "French" without knowing exactly what a "French" is. This may seem strange, but how many of us worry about the number of megabytes an attachment is or the miles per gallon we get on our car? It's easy to use something practically without focusing too much on extraneous details.

But out of curiosity, I looked into it. A French sized catheter is three times the diameter in millimeters, a system invented by Joseph-Frédéric-Benoît Charrière, a 19th century French surgical instrument maker. In thinking about this, I realized I didn't know where needle gauges came from. Apparently, needle sizes are derived from the Birmingham Wire Gauge system (also called the Stubs Iron Wire Gauge system) that specifies the thickness or diameter of metal wire, strip, and tube products. According to Wikipedia, it is the only wire gauge system recognized in the United States by an Act of Congress. Strange how history plays out and becomes ingrained in something we use every day without recognizing its odd nomenclature and past. Good thing I don't have to learn about sutures.

In Defense of the Humanities

I recently read an article about the declining interest in the humanities in higher education. In the last decade, graduates seem to be majoring more and more in the fields of science and engineering and less and less in those perennial mainstays, English and history. Even fewer are doing the smaller disciplines like classics, philosophy, or art history. With the tech boom, the entrepreneurial bravado, the start-ups, and the worry over finding a job, fields like computer science, mechanical engineering, economics, and biology seem more practical. After all, understanding Shakespeare is nowhere as marketable as understanding business.

I was a humanities child, and I am writing in defense of the fuzzy fields. In true humanities fashion, I don't have data or numbers or evidence, but instead a story. In college at Stanford University, my most influential, memorable, mindboggling, and inspirational teachers were all in the humanities. I loved it; I drank it up; I wanted to emulate them. Lectures about morality, discussions about a short story's narrative decisions, and essays on free will - these were epiphanies, they made sense of the word philosopher, lover of wisdom. The humanities broadened my perspective, engaged me in debate and conversation, guided me into the depths of human emotion, passion, reason, and motivation, and challenged me to ponder and articulate my own thoughts and interpretations.

On the other hand, science was, at least at the introductory level, the memorization and mastery of a new language, codex, book of rules, set of equations, and facts. It tested other equally important skills, the consumption and comprehension of a vast body of knowledge, the logical progression of proofs, the application of the known world to the unknown. The struggle was working through a problem for which we knew there was an answer; we just needed to get there. In the humanities (at least philosophy and creative writing, which I did), an answer was never guaranteed.

Here I am. I was always good at the science, and I knew I wanted to become a physician. But the humanities, which I was not good at, defined me. I struggled all through college with essays, short stories, reading large texts, parsing arguments. I knew I was not going to pursue it as a career. But as education? I would never have given it up.

So I tell those who would be doctors - or economists or businessmen or accountants or scientists or journalists or engineers or pretty much anything - that the humanities in college offers a new skill set, a new world of exploration, a new body of literature that may not offer a high salary career but will offer a depth and meat of living, a different way of thinking, and a new appreciation for the human life and context that is invaluable.

Image of Plato by Silanion is in the public domain, from Wikipedia.

Ethics

The further you get into clinical medicine, the fuzzier ethics seems to become. When I looked at theoretical ethical frameworks as a philosophy student, I studied things like deontology or utilitarianism or cultural relativism. At the time, the arguments appeared easy. Physicians should follow these absolute rules: do no harm, respect a patient's autonomy, uphold a patient's dignity, advocate for justice and fairness for all. Healthcare systems should be designed to give the most good for the most people; we should allocate our resources and make decisions based on the utility of those actions. We need to respect differing values of different cultures and elicit the things patients find important.

But as I delve into clinical situations, I find these black-and-white generalizations difficult to parse. Often, multiple prerogatives or imperatives conflict each other. Sometimes, it's not clear whether what we're doing is harming a patient or respecting autonomy or preserving dignity or fair to other people. The system does not know how to allocate resources evenly, and people suffer as a result. We often struggle to understand a patient or family member's perspectives or opinions. And this occurs with well-meaning, well-intentioned physicians. The complexity of a clinical situation is compounded by the social situation, and what results can be an ethical quagmire. Thus, although I always strive to do the right thing, sometimes I struggle to figure out what that is.

Book Review: The Book of Lost Things

I recently read John Connolly's The Book of Lost Things, a fairy tale for adults. A child escapes into a fantasy world, not unlike Narnia, where he goes from adventure to adventure which vaguely mimic fairy tales. But the fairy tales presented are twisted, warped, strange, and grotesque. It is a bildungsroman story of growing up, adapting to family changes, finding self, but it wasn't satisfying to me. I wasn't able to fully grasp the symbolism of each fairy tale, wasn't tracking the main character's growth. I didn't find epiphany or closure at the end. Nevertheless, it was an interesting retelling and revisit to the world of childhood that so many of us have left and forgotten, and I appreciated that reminder of what fairy tales feel like.

Image shown under Fair Use.

Ortho Trauma

Now I'm back in the general OR pool and assigned to orthopedic trauma for two weeks. Ortho trauma has its own anesthetic concerns. Patients vary from the young, healthy, and foolish who get into a brawl or car accident to the old and medically ill who fall and have a hip fracture. Since cases are urgent, there's little time to get to know the patient and optimize them medically, so the anesthetic course can be a little rocky. For example, I had a young patient with a hip fracture who drank a bottle of whiskey every day and went into active alcohol withdrawal right when we started the case; we had to design a benzodiazepine heavy regimen to smooth the wake-up and prevent seizures. Another man who had been shot multiple times had extremely complex fractures that required many hours to fix. A woman found down and altered could not give a medical history so we went in not knowing much about her. A patient who had just eaten and was actively vomiting needed a washout of an open fracture before it became infected. Unfortunately, these patients are not happy to be in the hospital, and working with them can be challenging. Such is the life of an anesthesiologist at a trauma center.

Image of implants for right radius and ulna fracture is in the public domain, from Wikipedia.

A Truncated Thanksgiving

Holidays feel like a thing from childhood. The feeling is a little wistful, a trace of longing, when four day Thanksgiving weekends were expected; now, having two days is precious and cherished. On days like this, I get a keen appreciation of what it means to be in a world that churns on, 24 hours a day, 7 days a week, 365 days a year. (Barring natural disasters) the hospital never closes. Thankfully, anesthesia is a little more holiday-favorable. There are no elective surgeries so we only cover emergent cases. Then again, holidays bring a lot of accidents. Last night, we had two craniotomies for a bad motor vehicle accident, and that kept me up all night. So when I say this, it is mostly for your benefit but a little for mine: stay safe this holiday season, don't drive recklessly, take care of your family and friends, don't get sick.

Finishing Up the ENT Rotation

As I finish up my ENT anesthesia rotation, I reflect a little on the airway devices I got to learn. The key is to use the advanced techniques over and over so that muscle memory settles in, the steps become intuitive, and troubleshooting becomes natural. I welcomed the days when I would focus on one technique, try it on several patients, read and think about it. This is much more satisfying than the sporadic use of tricky devices on a general rotation. So over the last month, I've become much more proficient at using nontraditional blades like the McCoy blade, introducers like the bougie, the flexible LMA, the intubating LMA, different video laryngoscopes, and the fiberoptic bronchoscope. Although I was learning these techniques, the attendings were careful to ensure patients were not at any risk or danger. Indeed, I feel that patients fared even better than usual with the intense focus we had on perfecting the anesthetic. At the end of the rotation, I feel a lot more comfortable with situations that may involve difficult airways and intubation.

Thanksgiving

There are so many things for which I am thankful, but upon thinking about this blog, I realized most are conventions. I am thankful for the people I love, friends, family, teachers, and mentors; I am thankful for the things that make me happy every day, the challenges, the excitement, the fascination I have with medicine; I am thankful for my passions and hobbies. But it's more interesting and more important on a day like this to ponder those unusual or seldom-acknowledged things we are thankful for. I am thankful for imagination. I feel like I had such an imagination growing up, that I would create worlds and populate them, that I became obsessed with novels. During medical school and internship, some of that drifted away, but now I have rediscovered it. I am thankful for books and libraries, and the return to cultivating imagination which I had left for so many years. I am thankful for the opportunity to write, and for you, readers, who I invite into my thoughts. I am thankful for the bike commute I take to work, the sunlight and wind and calm rustle of leaves. I am thankful for that warm silence that overtakes me right before I fall asleep. When we think of the things for which we are thankful, we realize most of them are not really things. Possessions do not thrill us. People, experiences, values, stories, and the world we live in are the things that are important, the things that lead us to write, on occasion, awfully cheesy posts.

Sux

Many surgeries require some form of muscle relaxation or paralysis. For example, when a surgeon works on a vocal cord, it is imperative that the vocal cord does not move inadvertently, and in many abdominal surgeries, tensing of the abdominal muscles makes the surgery much more difficult. Broadly speaking, muscle relaxants fall under two categories, the fast-acting short-lived succinylcholine (shown above) and the longer acting non-depolarizing agents. We almost exclusively use succinylcholine for intubation only, and one of the long-acting drugs for surgical relaxation. But in some cases where absolute paralysis is required but the surgery is very short (for example, a vocal cord surgery), neither is ideal. Succinylcholine achieves the best conditions but wears off too quickly. Rocuronium or vecuronium lasts too long. Thus, I got to try a fairly arcane technique, the succinylcholine infusion. Continuous succinylcholine drips were popular before the advent of long-acting nondepolarizing agents. Indeed, when I did a literature search, the articles that came up were from the 1980s (a more recent article in 2004 was published in Poultry Science). Nevertheless, the technique, though old, still works quite well in carefully chosen cases, and so I got to employ a seldom-used technique in anesthesia.

Image shown under Creative Commons Attribution Share-Alike License.

Lasers

I had a case where the surgeons were using a laser to excise a lesion on the vocal cords. This sort of surgery has fairly unique considerations. We use a special endotracheal tube made of stainless steel to prevent damage from the laser. This is particularly important because laser will ignite oxygen; airway fire is a real risk in these surgeries. Thus, we run as little oxygen as possible to reduce the risk of setting something on fire. Endotracheal tubes have cuffs that are usually inflated with air. But these laser tubes are equipped with two cuffs and we inflate the proximal one with a dye, methylene blue. Thus, if the laser goes through the cords and cuts the proximal cuff, the surgeon will see the dye; hopefully the distal cuff will remain intact. Laser surgeries have their own safety requirements. We all have to wear laser goggles to prevent eye damage and laser plume masks that are safer for any aerosolized tissue. It surprised me to learn about all these laser-specific considerations, and I thought it was interesting enough to make a blog post.

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Growing Up

How life changes. In high school and college, I would spend hours on end with my friends; part of the education was the socialization process, the cultivation of relationships, the discovery of self. While I appreciate the education - figuring out my study habits, reading those core biology textbooks, immersing myself in learning - what I take with me is those friendships, those people for whom I'd drop everything to help. I remember the late nights studying, the bonding over personal crises that seem so trivial now, the trying new things together. At the time, I thought this life, this active and exhausting process of going out into the world with my friends, would last forever.

Slowly, it dissipates and we start settling into the life that for so long I associated with adulthood, a quiet private life, one which no longer courts spontaneous witching hour conversations sprawled on the floor, but which instead invites carefully scheduled appointments over coffee. I have noticed this change happening over the last few years. I love my co-residents, but the bond we share is forged over work and challenging anesthesia cases and mutual learning, not heart-to-heart revelations, ponderings about our future, questions of our childhood. I can depend on them, but I don't lean on them. It's a strange realization, the difference between professional relationships and truly personal ones. It's not a bad thing at all, it's a transition in life, a point of maturation, a sign of growing up.

Deep Brain Stimulation

One of the more impressive advances in neurosurgery is placement of deep brain stimulators (DBS). Electrodes are placed in specific parts of the brain and electrical impulses can be sent through a generator. This has been pretty successful in medication-resistant Parkinson's disease, chronic pain, tremor, dystonia, and even depression. While much of neurosurgery deals with anatomic problems, this is a functional approach that seeks to treat disorders by altering brain signals and impulses.

The placement of DBS electrodes is a pretty involved multidisciplinary affair. A 60 year old man with severe Parkinson's disease despite multiple medication trials presents for DBS electrodes placement. I bring him back to the operating room and minimize the medications I give because I don't want to interfere with intraoperative neurologic testing. I administer a low dose propofol drip while the surgeons drill holes into the skull where the electrodes will be placed. Then, after the brain is exposed, we wake the patient up. With enough local anesthetic, the patient tolerates this quite well. Because of the underlying rigidity and tremor from Parkinson's disease, a massage therapist attends to the patient's comfort. As the neurosurgeons place the electrodes, a neurologist does serial exams. As the electrodes get closer to the right location, the tremor diminishes, the joints become more flexible, and the patient's symptoms improve. A PhD and severe technicians are in charge of the electronics. And of course we have a circulating nurse and a scrub nurse as well. Once the electrodes are in the right place, we have the patient go back to sleep as the surgeons close. Other than the local anesthetic, very little pain medication is given. It's a large affair that requires the right patient who can tolerate being awake during a brain surgery.

Image shown under GNU Free Documentation License, from Wikipedia.

The Spine

For me, spine and back surgeries evoke a lot of complex emotions. For some patients, surgery is clearly indicated, as is the case for an unstable fracture. But a lot of people fall into a grey zone for which spine surgery may or may not help. I feel that these patients are between a rock and a hard place. Chronic back pain, shooting pain to the legs, limitation in exercise and movement are real life-altering conditions. When they afflict young active people, they can be devastating. After failing medications, physical therapy, steroid injections, and other interventions, it's no wonder that these patients turn to surgery as a magic bullet. A lot of times, surgery works. But I also see patients for whom back surgery yields little benefit, and occasionally, those patients who need to return to the operating room over and over again. Watching this, I feel like these patients are trapped in a vicious cycle where each surgery begets further surgeries. They no longer live the lives they want. It's one of the hardest things to see. The spine is such a complex structure and the orthopedic and neurosurgical interventions we have are not perfect. It's one of those surgeries for which I really think about the impact of the disease and its treatment on the patient's life.

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

Half-Way Point

It's pretty close to the half-way point of my anesthesia training. I'm through with a year and a half of the three years of dedicated anesthesia learning. What is it like? I feel pretty confident with most anesthetic cases. I can be given nearly any kind of surgery and look at a patient's other medical conditions and identify a reasonable anesthetic plan. Although I continue to read about different surgeries and anesthetic techniques, I have a pretty good understanding of the key points in most surgeries. Even rare procedures I haven't done before, I can make pretty educated inferences about. The same applies to various patient conditions and medical problems. While I would find the management of multiorgan system failure tricky, I at least know where to begin, what to avoid, and what goals I have.

After a year and a half of putting in IVs, breathing tubes, arterial lines, central lines, spinals, and epidurals, I feel like I could troubleshoot most procedures. I don't think I can get everything in perfectly, but I know where to begin, where I get hung up on, and how to fix problems that crop up. Even recently, I had a patient I couldn't intubate with a direct laryngoscope. Neither could my attending. We did not panic and simply asked for another tool and intubated the patient smoothly and safely. I think over time I have become much better in responding to changing circumstances, emergencies, problems, deteriorating patients, and complex situations. I may not always know what to do, but I don't panic and I start with the basics and do things step by step.

All of this is quite reassuring. I don't have to be an independent anesthesiologist for another year and a half, but I feel like I could handle the majority of things independently. The rest of residency, then, is to find and work on my weaknesses, refine my technique, and study the material in greater depth so that I feel comfortable with any operation, procedure, or ICU patient.

Construction

I've learned to tolerate hospital construction. Whether it has to do with California laws about earthquake retrofitting or the desire for academic medical centers to continually expand, both UCSF and Stanford are in a constant state of construction. I've gotten used to the sight of scaffolding, the detours, even the hammering (like the Wings of Zock in Samuel Shem's House of God). But the recent changes to Stanford's access has been dramatic as we prepare to build a whole new hospital. Although the grumbling by physicians and staff is tolerable, I worry about the patient experience. Simply parking and getting to the hospital or clinics is now an ordeal. Despite the signage, volunteers, and shuttles, I feel that the construction of the new hospital is really harming the patient's perception of care even before they get to the door. Hospitals ought to treat their patients like businesses treat customers, and I think we could have done a better job here.

Worst Case Scenario

An obese patient with obstructive sleep apnea presents for OSA surgery. He will have much of the soft tissues in his upper airway resected - a tonsillectomy, removal of part of his tongue, and resection of his uvula and soft palate. Hopefully, this will allow him to sleep better without obstructing and snoring as much. The anesthesia for these cases can be tricky though; because patients are often obese, their oxygen desaturates quickly and their pulmonary reserve is poor. Obesity and obstructive sleep apnea can make intubation challenging. Post-operative pain must be managed appropriately because too much sedative can lead to further obstruction and oxygen desaturation.

The case begins smoothly enough; I use a video laryngoscope, see a good view of the cords, and place a small oral tube. The patient's glottis is surprisingly deep and the tube is a little deeper than I would have expected. I secure it, but because the surgeons are working in the mouth, they request a little slack on the tape so they can move the endotracheal tube as needed. We turn the bed 180 degrees so that the head is facing the surgeons and away from the ventilator. The surgeons begin working on the tonsils.

After half an hour, I have an abrupt loss of the ability to ventilate. There is a large air leak around the endotracheal tube, and I have a strong suspicion that the tube has slipped out of the windpipe. I alert the surgeons and go take a look, and see that the tube has come out of place. This is one of the anesthesiologist's worst nightmares; I've lost the airway after the surgeons have started on a fairly bloody procedure, I'm turned away from my ventilator and supplies, and this patient will desaturate quickly and be difficult to intubate. I grab a conventional laryngoscope but can only see blood and uvula. I simply cannot see the vocal cords. I calm myself and remember to start with the basics. I am able to mask ventilate the patient; he never desaturates. Then, I optimize my positioning, give additional anesthetic and muscle relaxant, suction out the blood, and take a look with the technique that worked the first time, a fiberoptic laryngoscope. After reintubating the patient, I make sure I secured the tube tighter. The rest of the case goes just fine.

Trauma

Stanford Hospital does not get a lot of trauma. Fortunately, there are not a lot of gunshot or stab wounds, and we're in close proximity to other major trauma centers. But as a resident, it is important for me to see and experience trauma cases. A drunk woman in her twenties is involved in a motor vehicle accident. She is minimally responsive, intubated, and rushed to the scanner where a CT shows an epidural hematoma as well as multiple facial fractures. Upon seeing this, she is taken straight up to the operating rooms for an emergency craniotomy and evacuation of hematoma, and I'm called to come and anesthetize this case.

Traumas cause a release of epinephrine for me because I don't have the time to investigate, prepare, and plan the anesthesia. By the time I arrived in the room, the patient was being moved over to the operating table. I had to quickly survey the scene, figure out what I needed, and make a quick judgment about the patient's health. Although the patient already had good IV access and an endotracheal tube, I had to pop in an arterial line, begin my anesthetic, and figure out what I needed in terms of drips, blood, and other medications. Because of the patient's young age and lack of other medical problems, the case went smoothly, but it reminded me of the necessity of efficient evaluation and response as well as continuous communication with the surgeons and nurses. It also gave me awareness that trauma patients may have other undiagnosed injuries, some of which (like a pneumothorax) could be fatal if undiagnosed. Vigilance and constant reassessment are absolutely essential.

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

Fentanyl

One of the first medications we learn in anesthesia is fentanyl. If you were to ask most physicians, they would describe it as a potent rapid-onset short acting pain medication, ideal for transient discomfort but not for lasting pain because of its limited duration. Most physicians would probably dose it 25 or 50mcg a time and give it every hour or so. For severe persistent pain, most physicians would gravitate toward longer-acting opiates like morphine or hydromorphone. Before this week, this is how I viewed fentanyl.

I was assigned to a 12 hour long plastic surgery case. A woman who had bilateral mastectomies for BRCA positive breast cancer presents for breast reconstruction. These cases are tremendously long, requiring a lot of fine microdissection to ensure good blood supply to the breast flaps. I think a typical way of managing post-operative pain would be fentanyl for the start of the case and titrating hydromorphone to give a good tail coverage of pain as the patient wakes up. However, I was challenged by my attending to use only fentanyl. We modeled the pharmacokinetics of the drug and loaded the patient with quite a bit up front; instead of the usual 100mcg or 150mcg for intubation, we used 500mcg, almost a cardiac induction. We started a constant fentanyl infusion at 500mcg/hr and cut this in half every ninety minutes. Using computer simulation and modeling, we predicted the serum and effect site concentrations of fentanyl. The goal was to saturate the adipose tissue with the drug so that this became a long acting medication rather than a short acting one. Normally, a bolus of fentanyl disappears in effect because the drug goes to the fat tissues. But this time, our goal was to use the fat tissues as a depot for the drug. By the end of the case, we used over 4000mcg of fentanyl - an astonishing amount. Despite this, the patient amazingly woke up right when I said, "Open your eyes," and had absolutely no pain at all. I'd never done anything like this before, and it was a confirmation of the power of pharmacokinetic modeling.

Image of molecular structure of fentanyl is in the public domain, from Wikipedia.

The Socioeconomic Milieu

As the election is coming up, I wanted to write a quick post to say that health care is determined by so many factors beyond which hospital one goes to, the doctors one sees, the drugs one can obtain, the insurance one has. For example, education, profession, and poverty have a remarkable effect on one's health; a study of civil servants in England showed a dramatic difference in mortality based on one's job. We cannot tease out cause and effect, correlation and causation, but it reminds me that our responsibility as physicians extends beyond thinking of just health care delivery, pharmaceutical companies, and questions of insurance but also those other public goods which will, in time, translate to healthier, happier, more active patients.

Patient Participation

Should patients be able to access their charts? Of course, everyone can get their medical records, but doing so is often a big hassle, requiring signatures and time and visits to medical records. But recently, some practices have started opening up their charts to patients through secure internet connections. Indeed, a study of a small primary care office showed that patient satisfaction increased when they could see their providers' notes and that this did not increase burden on providers.

How do I feel about this? Obviously, anesthesia won't be affected much, but in thinking about it more broadly, I am a little apprehensive yet see the world moving towards more open information. If you knew a patient was going to read your progress note, would you be a little more wary with what you write? Would you say "a 50 year old obese woman" or "a 50 year old woman with BMI 32" or omit it completely? Would you mention psychiatric assessments? Would you write down that innocent heart murmur? We worry that patients will go through what we write with a fine-needle comb or take offense or contest our assessments. Would we start getting more phone calls and emails and visits? Small studies have suggested that this isn't the case. And there are so many reasons for patients to know our findings, assessments, and plan. It seems unethical if there were a disconnect between what we tell patients and what our charts say. Though one carries jargon, they ought to say the same thing. Furthermore, one way to solve the problem that electronic medical record systems between hospitals don't communicate is to give that information to patients so that when they show up to a different provider, they know what tests they have had and what their last provider was thinking. In a world where everyone else - politicians, companies, industries - are encouraged to share information openly, there is no reason why physicians should be exempt.

The Nose

The ENT anesthesia rotation gives us a lot of opportunity to do nasal intubations. While perhaps the notion of nasal intubation seems scary - after all, how many of us think we could breathe adequately through only one nostril - it turns out that patients tolerate the tube and breathe easily. We use a nasal endotracheal tube for cases where the surgeons are in the mouth and don't want any obstacles to work around - surgeries for obstructive sleep apnea, jaw surgeries, dental rehabilitation. There are a few ways of putting them in, and they're fun to practice. The simplest way is to carefully introduce the breathing tube into the nose, take a look with a direct laryngoscope in the mouth, and use forceps to advance the tube into the trachea. But I've recently become fond of using a video laryngoscope and watching the tube go through the cords without lifting the jaw too much. Doing so helps me appreciate that these nasal tubes are often positioned to go smoothly into the trachea without much manipulation. In the past, anesthesiologists used to do blind intubations and simply advance the tube, listening for breath sounds. Although this sounds precarious, it seems to work. The last technique we practice for nasal intubations is using a flexible fiberoptic bronchoscope, guiding the tube in over a flexible hand-controlled camera.

Image shown under GNU Free Documentation License.

Voice

What is it like to lose your voice? An elderly gentleman with a cancer of the vocal cords presents for removal of the larynx or voice box. There is a lot about this case that is interesting from an anesthetic standpoint - securing an airway is challenging because of the mass, decreased range of motion of the neck, and a history of radiation therapy. But I wanted to write about this case because of the notion of voice and identity. After the surgery, the patient cannot talk, though with long-term speech therapy, he will be able to communicate through an artificial valve. This struck me profoundly; I was the last person to talk to him. As we rolled back to the operating room, I asked him about his time in the military, about the job he had for thirty years, about his family. At the time, I was just chatting; a conversation quells the nerves right before surgery. But now I cherish that moment. For so many of us, voice defines. In those five minutes, I learned who this man really was, and I think how brave he must have been to walk into a surgery where his voice would be stripped away.

Image of the larynx shown under Creative Commons Attribution Share-Alike License.

Current Events

A lot has been going on in the world, and some of it has penetrated that insulation of residency. To everyone affected by Hurricane Sandy, I hope you and your loved ones stay safe. For the San Francisco Giants fans out there, congratulations and thank you for the lulls during games and the storm of emergency cases right afterward. And lastly, it is amazing to me how the internet has transformed this election with rapid widespread dissemination of information as well as the viral spread of parodies and commentaries.

Image of Hurricane Sandy is in the public domain.

ENT Anesthesia

Finally, I'm back in the general operating room pool on a rotation specifically for ENT anesthesia. It's actually been 6 months since I last did general adult anesthesia; I've had two months of cardiac, two months of ICU, and two months of pediatrics, and it's a weird feeling stepping back into the main ORs where I spent the bulk of my first year. Fortunately, it's been a smooth transition; so much of anesthesia has become muscle memory that although some things are initially rusty, it comes back quickly. This month I'm on a rotation to learn techniques for the difficult airway. ENT surgeries have some unique characteristics including sharing the airway with the surgeons, using highly-potent opioid infusions, managing difficult intubations, and facilitating a smooth extubation and rapid recovery. It's been great being introduced to advanced airway techniques and medications I usually don't pick up, and I think I'll learn a lot in the next four weeks.

Medicine

If I didn't choose anesthesiology, I'd be an internal medicine doctor. Although there are many things about the field I didn't like - and I ultimately chose not to go into it - I do miss some aspects, especially differential diagnosis. My last admission to the ICU was a fascinating medical conundrum. He was an elderly gentleman found with altered mental status. No one knew his medical history, medications, or anything about him. He was confused and oriented only to his name and age. He couldn't tell us where he was or what year it was. He kept on perseverating on odd subjects like his high school or his brother. On admission, his vital signs were completely normal - no fever, heart rate 95, blood pressure 120/60, normal oxygen saturation on room air.

But he was ultimately admitted to the ICU for several odd reasons. His blood counts showed a white blood cell count of 1,000, a hemoglobin and hematocrit of 4/11, and platelets of 60,000 - all of these were extremely low. His kidney function was poor with a creatinine of 1.7 (with an unknown baseline). His INR - a measure of coagulopathy - was elevated. A CT scan showed that most of his intestines were up in his chest in what was called a Morgagni hernia. What was going on? No one really knew. The decision to admit to the ICU was pretty soft, but I took him.

Trying to tease everything out was very fun. This is what internal medicine physicians live for. Was this a problem with bone marrow? Did he have a primary malignancy somewhere? Could this be occult liver disease? Or a state like TTP-HUS? Did severe nutritional deficiencies or hormone imbalances present like this? Or some strange atypical infection? What drugs and medications could be playing a role? Was his confusion due to the other things going on in his body? How did this weird hernia fit into the picture? In the end, I sent a panel of tests that ranged from a blood smear to copper and zinc levels to protein eletrophoresis of the urine to thyroid function studies. I hope that the hematologists and probably a bone marrow biopsy will give us the answer.

Electronic Anesthesia Records

Electronic medical records are an incredibly pragmatic and exceedingly boring topic to think about, but currently, the main operating rooms at Stanford are switching from paper charting to electronic charting, and that's got me thinking. Although the activation barrier is high (there are a dozen training classes to get every anesthesiologist at Stanford plugged in), it's likely to increase overall efficiency, accuracy, legibility, and effectiveness of documentation. I write this blog because it always seems to me that the design team of electronic medical records (EMRs) don't employ a resident, and that's who they need. Residents do the grunt work from the physician side of the hospital. We navigate the chart, put in orders, follow-up tests, look at radiology scans. But the current system is horribly inefficient; I have to sift through completely useless notes ("Please see dictated note"), load up EKGs, and search through reams of PDFs (from consent forms to insurance requisitions to outside records) to find old anesthetic charts. When I admit patients, the general order set does not include things like IV acetaminophen or insulin or electrolyte replacement scales. There's the ability to customize things, but it's not the easiest to navigate, and so I wish the design team got input from a resident to start.

Old

You may notice that my posts about the ICU often carry a theme of how to approach the end of life. We see so many patients here who face that question and have given it very little thought. When the circumstance is sprung upon them, they are adrift. Consequently, as I wade through their troubled ICU course, I ruminate on it, and meandering thoughts find their way here. The other day, we had a patient who was a hundred years old come in with septic shock as a full code. He wanted everything done for him if necessary - chest compressions, mechanical ventilation, long term artificial nutrition, shocks. Of course, that is his right. But it got me thinking about age. I'd like to think I don't discriminate on age, that I don't look at a hundred year old patient any differently than a third year old. But the truth is that elderly patients are frail, they have little reserve, and they cannot weather the strain of the ICU as well as they could years ago. That colors the way I look at code decisions. The survival odds are clear; a young person is much more likely to make it if their heart stops than a little old lady. But words like this run afoul of being condemned a "death panel." I'm not out to kill any grandmothers. But I feel that it is a disillusion and disservice to pretend that an octogenarian has a good chance surviving cardiac arrest. I'm struggling with this right now, and maybe I'm wrong, but at least I'm thinking about the issue.

Sleep in the Hospital

We underestimate how much discomfort we put patients through simply by admitting them to the hospital. Imagine being woken multiple times at night for someone to poke and prod, shine lights in your eyes, take a blood pressure. Imagine, even worse, in the ICU when machines begin beeping every five minutes, when you cannot get more than an hour of uninterrupted rest, when you cannot eat, when you cannot count how many lines and tubes are coming out of your body. When I think about how cranky I can be when I am awoken by a page, I can't imagine what it must be like to be in the ICU. Furthermore, patients with a breathing tube often cannot communicate, and that must compound that feeling of being trapped so much more.

One condition we see quite often in the unit is ICU delirium, a state of confusion seen in elderly, sick patients where their mental status waxes and wanes. No wonder they cannot think straight. We subject them to so many discomforts, and I worry that some of these are against their will. So many family members want "everything possible done" for their loved ones, but everything has its risks and benefits. I have come to appreciate the consequences of simply being admitted to the hospital.

Stages of Life

It always impresses me when I talk to a resident who has children and a family. I think it's incredibly difficult to achieve any balance in trying to manage a home life when one is working 80 hours a week. I can barely juggle work, studying, errands, and fun, and I don't know how those residents in our program who have multiple young kids do it. It also reminds me that we're all at different stages of life; back in college and even med school, everyone more or less progresses together. But by residency, the group has become so diverse that we're all in a different part of growing up. Although the camaraderie feels different, it's also enlightening to see how everyone settles into his or her stage of life.

No Rest for the Wicked

Usually, I can get pockets of sleep on a call night in the ICU. Once things settle down, I go from room to room and check to make sure the patients are stable and the nurses don't need anything. Hopefully by warding off nonurgent calls, I can get a little bit of rest. But occasionally, a call night comes when the work just does not abate. On one of my recent calls, a patient with acute myeloblastic leukemia develops a heart attack, a patient with a recent duodenal ulcer starts bleeding profusely, a new admission from the emergency department has overwhelming sepsis, a patient whose brain is herniating needs a central line for hypertonic saline rescue, and a patient with ongoing seizures needs intubation to protect her airway. Times like this are thrilling and terrifying, and the adrenaline keeps me awake. I have to prioritize effectively with the fellow to get everything done as efficiently as possible. Sometimes, it means relying heavily on my consultants (I called the cardiologist and said, "I'm intubating someone right now, but I just found out this patient's troponin is sky high - I don't have time to give you much more information, but I'd really appreciate it if you could see the patient and help"). But I made it through the night, and more importantly, so did all my patients.

The Multidisciplinary Approach

One of the great advantages of the tertiary academic center is that you can get a lot of specialists. Patients who undergo complex neurosurgery and come to the ICU are overseen by their surgeons, a team with expertise in neurocritical care, and us - the medical intensivists. By having multiple people look at all the data from different viewpoints, we hope to harness different expertises and skill sets. The neurosurgeon manages the extraventricular drain, the neurologists adjust the antiepilpetics, and we take care of the antibiotics. And if an unclear clinical problem arises, we put our heads together to try to solve it. Or at least, we're supposed to. The problem with having multiple teams is akin to too many cooks in the kitchen. Occasionally, we don't see eye-to-eye on all the active issues or we find that the primary decision makers have different priorities than we do. It reminds me how crucial communication is for all the teams to come to a consensus about what's best for the patient.

Pedigree

Many years ago, when I was an undergraduate, I worked in a lab that studied adrenergic receptors, G-protein coupled receptors that bind catecholamines in the body. Recently, the Nobel Prize in Chemistry was awarded to two of the founding fathers who first began to understand adrenergic receptors: Brian Kobilka and Robert Lefkowitz. Strangely enough, they are almost research grandfathers to me. My principal investigator for my undergraduate research did his PhD in Dr. Kobilka's lab. When I interviewed at Duke for the MD/PhD program, I had an interview with Dr. Lefkowitz and chatted to him about his research. It's funny how small the research world is, and I'm thrilled that the Nobel prize was awarded to these two amazing pioneers who have not only elucidated receptor chemistry but also touched my life as well.

Image is in the public domain, from Wikipedia

Choosing When to Die

A woman in her 60s who has fought a battle with breast cancer presents with odd symptoms of an ascending paralysis. An unclear neurologic illness has slowly picked off her cranial nerves one by one to the point that she cannot even swallow, cough, or gag and has to be intubated to protect her from choking. A PET scan shows a concerning mass on the same side of her body as her original breast cancer, and after multiple tests, we determine that her cancer is causing this odd paraneoplastic paralysis. She is, however, still able to communicate by writing on a notepad.

The oncologists and neurologists sit down with the patient and her family to discuss options. They believe that with aggressive chemotherapy and radiation, they could suppress the cancer and would expect slow return of the patient's neurologic function. The patient, however, does not want this. She communicates completely clearly to us that she would not want to undergo chemoradiation, and in fact, wants palliative care. She has decided it is her time to pass on. She chooses to do it with dignity, without the uncertainty, fear, hair loss, pain, nausea, discomfort, and risk of chemotherapy. She says her goodbyes - hour-long heartfelt tearful farewells - and asks to be extubated. Although we did not think she would pass so quickly, she died in the next few hours. It was as if she had chosen to die.

We choose how we live, how we act, what matters, why we do things. Why should we not choose how we die? This woman surprised me because so many other patients want absolutely everything done to live. But she resolutely and stoutly chose not to try chemotherapy, even though it offered a chance at recovery. Her passing, and the way and timing of it, was entirely of her choosing.

Teaching

One of the best parts of the intensive care unit rotation is the privilege and opportunity to teach medical students. I have always loved teaching and feel that my passion for medicine was very much fostered by the mentors and role-models I had in medical school. Unfortunately, in anesthesiology, there's not as much of an opportunity to teach students. Few students rotate through, and rotations aren't long enough for a medical student to pick up more than the basics. But in the intensive care unit, there's so much opportunity to cultivate enthusiasm and curiosity. I love walking medical students through simple procedures, talking to them about landmark trials, and examining patients with them, especially when the story is still evolving and uncertain. There's something to learn for everyone - from antibiotics and EKGs for the medicine-bound to chest tubes and line placement for the surgery students to treatment of delirium for psychiatry students to evaluation of airway for those interested in emergency medicine or anesthesia. I also try to encourage students to step out of their comfort zones and learn about aspects of ICU medicine that frighten them: pressors and ventilators, end of life conversations, nutrition, lines and tubes. I learn things every day, and I try to make it a priority to teach something every day as well.

Moribund

It may be creepy to say, but sometimes just by seeing a patient, I know they won't make it. After being in the unit long enough, I've seen enough people to get a sense of the ones who, despite everything we do, will die. I met Ms. A in the emergency department a week ago. She had end stage cancer and looked like a stiff wind might knock her over. At first, I thought her frailty encompassed mind and body alike, but then I saw her bat away a nurse trying to place an IV and argue loudly to get a dinner. As her physical strength waned from a battle with chronic disease, her spunk had increased such that she was always ordering her caregivers around. I managed to get her out of the intensive care unit pretty quickly to a medicine floor team but I never quite forgot about her.

When I met her again, she looked completely different. The medicine team called because her blood pressures were sagging, she had a rampant infection, and her mental status was getting worse and worse. When I saw her, I knew. She no longer fought with the nurses. She no longer argued with me. That part of her which was so strong on admission - her will and mental stamina - had given out. I knew she wasn't going to make it. An hour later, she had a cardiac arrest with asystole. Although we regained spontaneous circulation, we soon made her comfort care afterwards.

Occasionally, I see a patient like Ms. A, and even without looking at labs or imaging or the chart, I know what will happen. It is a strange intuition to pick up in medicine, a sort of insight that seems to skirt past scientific explanation, a feeling that settles in the back of the mind and aches until I pay attention to it. I always hope I'm wrong, but most of the time, it happens to be true.

Being a Doctor

On call yesterday night, I admitted an elderly patient with sepsis to the intensive care unit. He needed an arterial line for close measurement of blood pressure and frequent labs. It was one of those non-stop whirlwind call nights, running from one emergency to another, and by the time I brought the arterial line box into the room, it was 3AM.

One thing I have learned about placing arterial lines and IVs is to sit down if you can. It's much better for the back than stooping, it optimizes positioning, and at 3 in the morning, a chair is a welcome reprieve. When I felt the patient's pulse, I knew there would be no problem placing the line; he had a clearly demarcated radial artery. But instead of rushing through the procedure, I took my time and asked him to tell me about his life. While I positioned his hand and prepped his wrist, I learned about how he met his wife, what his children were doing. When I placed the lidocaine, he told me about a daughter he adopted and how proud he was of her despite developmental delay. In the next few minutes while I entered the radial artery, I began to learn of his grandchildren. As I sewed the catheter down, I learned of his job. The entire thing took ten minutes, and by the end, I felt like a primary care doctor, holding a patient's hand, sitting at the bedside, cherishing what it means to be a physician.

Anesthesia's Political Landscape

I don't want to make this blog a forum for anesthesiology's political agenda, but I feel that I should advocate for my specialty. As a resident, I think it is important for me to learn about and understand issues facing the field, and one of these is the role of certified registered nurse anesthetists or CRNAs. CRNAs are a valuable and vital component to the anesthesia team. Nurses who undergo additional training can be licensed to provide general anesthesia, and they work at many places, from community hospitals to academic centers. They are generally supervised by an MD anesthesiologist unless a state opts out of that requirement. California has done so, so in this state, CRNAs can practice independently. The state society of anesthesiologists has objected to this "opt-out" but it seems that it is here to stay. What should you (the public) know about CRNAs? For the most part, they provide anesthesia for low acuity cases; some studies have shown that much of the Medicare billing by CRNAs are for colonoscopies and cataracts. For most anesthetics, CRNAs are a perfectly appropriate provider. However, their training is different than that of anesthesiologists; a nurse's skill set, approach to clinical problems, and background is very different than a physician's. The California Society of Anesthesiologists feels that this is significant enough to warrant physician oversight of CRNAs. I personally cannot comment on it as I haven't worked all that much with CRNAs. Many hospitals, despite the "opt-out," still have physician supervision of CRNAs. There are also other issues with CRNAs, especially in performing pain procedures, and again, anesthesiologists as a whole are reluctant to allow them to practice independently. In any case, all patients should know who their providers are and be aware whether a CRNA is practicing with an anesthesiologist or independently.

Book Review: The Gone-Away World

Although I ought to be studying anesthesia, lately I've been hankering for some immersing nonfiction, and a friend recommended Nick Harkaway's The Gone-Away World. His first novel, it attempts to be and succeeds as an epic all-encompassing science fiction stream of consciousness that dallies in mysticism, philosophy, the industrial complex, physics, ninjas and mimes, identity, and love. It reminds me of Kurt Vonnegut's Cat's Cradle in creating a world teetering on the edge of collapse and following it through. The writing is witty, crisp, hilarious, and tongue-in-cheek, almost Douglas Adams in nature. It does have some of the hallmarks of a writer's first foray, however, and is quite long and occasionally loses itself in tangents and diatribes. But it's been one of the most fun new reads I've had this year and figured I'd mention it on this blog.

Image shown under Fair Use, from www.nickharkaway.com.

A 14 Gauge Needle and Strong Arm

In Samuel Shem's satiric novel, House of God, there is a housestaff rule: "6. There is no body cavity that cannot be reached with a #14G needle and a good strong arm." Though quite blunt, this is not a completely ridiculous adage. Over the last two and a half years of training, I have become much more comfortable placing a needle into someone who needs it. During intern year, I'd done a number of paracenteses: the drainage of fluid from the abdomen. Patients with liver disease often accumulate a lot of fluid in the belly and occasionally, it should be checked for infection or drained for symptoms. I hadn't done a paracentesis for over a year, but when a patient came into the ICU with end stage cirrhosis and severe ascites, I felt comfortable doing the procedure. I begin to see things in the way I imagine surgeons see them. Using a few basic principles, it's not too hard to access a vessel or body cavity with a needle. The skills of using ultrasound, the Seldinger technique, careful intentional movements, and manual dexterity apply to central line placement, arterial line placement, epidurals, spinals, thoracenteses, paracenteses, and other procedures. With a 14 gauge needle and a strong arm, any body cavity can be reached.

Emergent

As part of the intensive care team, I have to be ready to respond to emergencies and rapidly changing clinical situations in the hospital. The anesthesia residents carry the airway pager and respond to code blues. But even in the intensive care unit, our patients are so tenuous that emergencies arise daily. One patient who was recovering from a severe neurologic illness was becoming close to transferring out of the intensive care unit. He had been in the ICU for 2 weeks, most of that time on a ventilator. Because of a progressive disease that took out cranial nerves, he didn't have much of a gag reflex or a strong cough. Unfortunately, that put him at high risk for aspiration - choking on secetions. When we were called to bedside, he was hypoxic and minimally responsive. After mask-ventilating him to bring his oxygen up, we used a flexible fiberoptic bronchoscope to take a look and saw a lot of junk down one of the lungs. We decided to reintubate him and put him back on a mechanical ventilator. I then took a look with a bronchoscope to suction out the airways and do a bronchoalveolar lavage, testing for infectious organisms. Despite the hope of having the patient leave the unit, one small event set him back two weeks of recovery. This reminds me that even patients who seem to be doing well can easily have setbacks, whether from new infections, a blood clot from not moving, or deconditioning from prolonged illness. Although we hope for a smooth trajectory of recovery, patients often have a much more day-by-day progress-and-obstacle circuitous route to leaving the unit.

tPA

Tissue plasminogen activator or tPA may actually live up to its name as a miracle drug. It dissolves clots and is primarily used to treat acute ischemic stroke. An older gentleman with no significant past medical history has a witnessed change in mental status. He is eating with his daughter when he suddenly stops talking, "acts oddly," then falls to the ground. At that point, the daughter realizes he cannot move his left arm or leg. He is emergently brought into the emergency department. There, a head CT is negative for bleeding, and tPA is given. When I first meet the patient, the tPA has not yet had effect; the patient can only say his name and cannot move the left side of his body at all. He has a prominent facial droop and it is difficult to understand his speech.

Several hours later, after the clot is dissolved, I go see him. He tells me his name, the city, and gets the date right within a week. He wants "cerveza" and chocolate. Although his left side is still weaker than his right, he can grasp my hand and push his toes down reasonably hard. His left facial droop is nearly gone. Two days later, he goes home and soon will be back to tending his garden. After seeing the remarkable and dramatic neurologic improvement, I really gained a new awe for tPA.

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Futility II

How do you approach a family to say that medical care is futile and ought to be stopped? How do you look at a patient on cardiovascular drips, a mechanical ventilator, artificial nutrition, continuous renal replacement therapy, and broad-spectrum antibiotics and decide to stop them? Even if a patient will never get better, they are alive now, and what does it mean to stop those interventions keeping them alive? Modern medical ethics makes a point to say that withdrawing support is ethically equivalent to not beginning the support in the first place. Had we known this patient was not a transplant candidate and would not get better, we would not have intubated her, started pressors, continued CVVH. But now that we have started these things, it's so much harder to stop them, even if nominally there's no difference.

I spend two hours in family meetings over two days. End of life conversations are never easy. But over time, I've become better. I make a point to plan things out. I find a quiet room. I introduce everyone, learn everyone's names. I ask family what their understanding of the situation is. I explain the medical issues as clearly as I can; I avoid vagaries. I survey responses, from "I cannot stand her suffering; I think we should let her go in peace" to "I'm not God, I don't know what to do" to "I don't understand, why is this happening" to "I need more time" to "I think a miracle might still happen." When asked, I make my medical recommendation, that futile care should not be prolonged, that the patient is suffering, and that we should move to comfort care once everyone who needs to be here has arrived. With each meeting, I inch toward that goal. Although medically, we can unilaterally transition the patient to comfort care, my job now is to care for the family and help them cope.

Futility I

Medical futility refers to an intervention that has no expectation to help at all. It is often raised in circumstances near the end of life when families push for treatments that physicians feel are futile. Ethically, a treatment does not have to be rendered - even if requested by a patient or family member - if it is futile. As a silly example, if a patient asked me for antibiotics for migraine treatment, I could decline simply because it is futile. Since it has no benefit, there is no circumstance in which the benefits outweigh the risks. This becomes infinitely more complex in the case of a terminal illness. In someone with end-stage cancer, how do you know that antibiotics won't help? Or herbal treatments? Or surgery? But if a physician feels these are futile, they need not be entertained.

A patient is admitted with fulminant liver failure; she is confused from hepatic encephalopathy, has gained 20 pounds, has massive fluid in her abdomen, and begins to bleed. No one knows why her liver has failed; she has cryptogenic cirrhosis. Subsequently, she develops hepatorenal syndrome and requires dialysis. During the hospitalization, she has a cardiac arrest requiring chest compressions; she's intubated and placed on a mechanical ventilator. She is admitted to the ICU where I meet her. With tenuous blood pressures, she no longer tolerates hemodialysis and requires CVVH. Unfortunately, because of her medical comorbidities, she is denied a liver and kidney transplant. Despite maximizing all our medical interventions, she does not get better, and now that she cannot get a transplant, we have nothing left to offer. She will die from multiorgan system dysfunction, and though our interventions can stave off that moment, none have the possibility of stopping it. This is, we feel, futile care.

1600

This is the 1600th post! When I wrote the blog several days ago about pharmaceutical companies, I realized I wanted to comment on ads. I made a decision long ago not to put ads on this blog. At that time, it was sponsored by UCSF and I didn't need or want ads. Over time, I have had several inquiries about placing links, advertisements, or commercial sponsors on this blog and my Case of the Day blog. Although I like the idea of making money, I decided that it was best to keep them pure, unmuddied, and unhindered by outside influences. Now that we're here at post 1600, I'm pretty happy about how everything's turned out.

Back in the Medical ICU

I'm back in the unit. It's been a little rough because even though things are easier each time around, I feel like I'm shouldering more responsibility. As an anesthesiologist, I'm used to doing everything myself; since we often work alone, we develop a craving and knack for independence. We are also completely and solely responsible for our patients. We become obsessive about details. As a result, the intensive care unit can be tough for us as we navigate team dynamics and relinquish our micromanaging tendencies. The issue I am finding with the team dynamic of the ICU is that residents come with differing levels of experience, knowledge, strengths, motivations, and standards. Certainly, I have gotten much better as a result of my 4 previous months in the intensive care unit (2 as a medicine intern, 2 as an anesthesia resident). But it means that I feel responsible for every detail for every patient on the service, and that becomes completely exhausting. Although it may be good for patients that I catch things other residents overlook, it's unhealthy for me. I obsess over things that seem small but that I find important - nutrition, lines, prophylaxis, antibiotic regimens, frequency of labs, wound care. Most of the others on the team, especially if it is their first month in the unit, forget these things, and I try my best to catch anything that falls through. In the big picture, this extra work probably doesn't translate to huge gains in care, but I feel obligated to do it nevertheless.

So overall, I have mixed feelings back in the unit. I love the medicine, the procedures, the evidence-based decisions, the complexity, the teaching (both as a student and to students). But it will be a tiring and hard month, and I'm bracing myself to learn to delegate more, obsess less, prioritize better, and take care of myself during this rotation.

False Negatives

Old school general surgeons will say that if you don't get false negative appendectomies, then you aren't operating enough. That is to say, the diagnosis of appendicitis is not specific enough for any surgeon to be 100% sure for every single patient whether she has appendicitis or not. If every time he operates, he finds an inflamed appendix, then he is missing the diagnosis in some of those cases in which he thinks there is no appendicitis. Only by overoperating - that is, performing an appendectomy but finding a normal appendix - can he be sure that he has actually gotten all the cases of appendicitis.

In the same way, in the ICU, one could say that if you aren't re-intubating patients, then you aren't aggressive enough in extubating them. I believe this; the duration of intubation has a lot of risks, especially ventilator associated pneumonia. But to be aggressive enough in extubation so that everyone gets a chance at being extubated early, some subset of those patients won't fly and will require re-intubation. This is often seen as a failure, but in truth, if we waited for the tail end of that bell curve, everyone else would have the tube longer than necessary.

I kind of like this thought process (though articulating it is tough). I'm not sure whether it's true or not, but as I progress in residency and get a better sense of risks and benefits, I begin to find this sort of justification compelling.

Pharmaceutical Influences

Meetings of the local chapter of the California Society of Anesthesiologists (CSA) are sponsored by a pharmaceutical company. They take place at a nice restaurant, have a guest physician speaker who talks about a new product on the market, and present an update of political topics by anesthesiology leaders in the CSA.

I attend these. Partly, I feel that it is important to participate in the local community of anesthesiologists, to be aware of the issues, to network, and to get a sense of the broader direction of medicine. In the insulated world of residency, our perspectives and viewpoints are limited. How do big changes in healthcare affect the livelihood of physicians, specifically anesthesiologists? What issues are we advocating for, what are we lobbying for? I also go because admittedly, the dinners are quite good. I don't feel strongly about the talks; I know they are biased and designed to persuade me.

The problem, of course, is that I am influenced by these pharmaceutical companies. I've read some of the data about the subconscious effect of dinner talks and gifts, and I've heard ex-pharmaceutical reps speak about their methods of persuasion. I know that the purist would abstain from these meetings, and so I feel quite morally ambiguous about attending them. I write this to explore, ponder, and verbalize these ethical conundrums.

Perioperative Medicine

Although most people think of an anesthesiologist as the gas-man during surgery, we often fill the role of the perioperative medicine physician to the surgeons before, during, and after surgery. Yesterday, I provided anesthesia for a patient with congenital prolonged QT syndrome and one with severe restrictive lung disease from scoliosis. Of course, these patients had been seen by their cardiologist and pulmonologist prior to surgery, who helped with optimization of medications and acquisition of appropriate tests. However, as the anesthesiologist for these patients, I was the one who had to interpret the data and recommendations. How do we plan an anesthetic that minimizes QT prolongation and reduces risk of arrhythmia? What rescue medications and monitoring is required? I realized that the surgeons didn't have a good grasp of the syndrome when they asked me if the patient could get any opiates. (In our electronic medical record, opiates trigger a warning because methadone prolongs QT and similar drugs alarm the system). For the patient with a precarious pulmonary status, I had to decide whether to extubate the patient, and even if extubated, whether an intensive care bed was more appropriate. I advised the surgeons with regard to medications to avoid, therapies to reduce atelectasis, and pain control techniques to reduce splinting. All this reminded me that even if patients see their specialists, anesthesiologists are often the doctors who remind surgeons how best to address the nonsurgical issues.