The Unit

I'm currently on my first ICU rotation this year, and it's really tough. I'm in the medical ICU at Stanford and our team has anywhere from 15 to 25 patients. The disease states vary widely; while we have typical diseases in the ICU like septic shock, respiratory failure, and post-neurosurgery patients, we also have a couple rarer entities like Guillain-Barre syndrome, myasthenia gravis, and tumor lysis syndrome. The patient population can be really sick; we have patients who've had multiple transplants or who are being evaluated for transplant. We have patients who have had neurologic catastrophes and overwhelming strokes transferred for neurosurgery. It's a busy service. There are two teams with 5 residents each and a few fellows, but even with this sizable group, we are hard-pressed to keep on top of everything. Call is every 4 or 5 days and absolutely exhausting. Even on non-call days, we work pretty late to help the call resident out. In any case, I will write about a few interesting patients and interactions, but a dearth in blogs is simply indicative of the busyness of the service.

Resident Retreat

Every year, the residency program sponsors a resident retreat at Lake Tahoe. I had an amazing weekend with my fellow residents. We left Friday afternoon (the attendings covered the operating rooms) and took a bus up to some wonderful cabins right at the foot of Mount Pluto. I hadn't skied for at least five years, but I had such a good time hitting the slopes. Lake Tahoe is gorgeous and it was absolutely exhilarating to be out there. It was also really fun to get to know my classmates and those in other years in our residency program. Stanford Anesthesia is amazingly generous to give us such a weekend to relax without worrying about clinical responsibilities.

Image is in the public domain.

Poem: Song

Song

Words nestle into the cadence of the heart,
the body's metronome. Time and sustenance marked
in this alien landscape, its orbiting moons gathering light
in handfuls and dispersing it on the body,
a body alien, framed in blue, rubbed deep brown
awaiting the brave and foreign to part its skin.

The heart knows, accelerando!
the anesthetized body's tongue. Even in this state
the heart has reasons that reason knows not.
Even in this state, the body sings.
We are interpreters of language.
Anesthesia is, willingly,
a fascination with the surrender of the body,
muting before interrogation, a reversal
of things natural, a conscientious poisoning.

The more we inhale those fumes,
the more we realize it is as much a snare
for the recipient as the giver, that as we
tame more and more of the wild,
we become more ambitious
in some quest to cure human ailment.
Where is that border? Where is that limit
beyond which the body no longer sings
but cries out, beyond which we, with all
our draughts and devices and guilement
cannot rescue the body from
the enchanted sleep we devise
and the sleep it craves?

ENT and Anesthesia

There is some overlap in the domains of ear, nose, and throat surgery and anesthesiology, especially regarding the airway. Surgeons operate on the mouth, throat, and trachea, giving them an intimate knowledge of anatomy and ways to access the airway. On the other hand, anesthesiologists are responsible for the patient's breathing during the surgery itself. And while anesthesiologists have an array of tools to help with placing the challenging breathing tube, surgeons have the ultimate back-up, the cricothyrotomy, a surgical airway involving cutting into the neck to get to the trachea.

Both specialists need to respect each other to keep the patient's safe. The ENT surgeon can often give insight into the airway as they have seen the patient in clinic and occasionally done a bronchoscopy. However, anesthesia is much more than intubating patients, and thus, the anesthesiologist has the expertise in understanding how to mitigate the stress of surgery given a patient's other medical problems. The anesthesiologist is central to the pre-operative evaluation, selecting monitors, and determining the best medications for each case. Teamwork and shared respect are key to a smooth surgery.

Neuroanesthesia

Some of the more interesting cases I've done are craniotomies for brain cancer, often intense all-day cases. Simply the preparation and anesthesia for these surgeries take a significant amount of time. After intubating the patient, we place extra IVs, an arterial line for moment-to-moment blood pressure monitoring, and a central line for access. Positioning the patient takes time as well; the surgeon often will place pins in the head to keep it in place, allowing him to use stereotactic imaging to precisely locate the cancer. The surgeries are often done with neurologic monitoring; a specialized technician places electrodes in various muscle groups, and throughout the operation, stimulates these to make sure that the brain surgery hasn't damaged any of the motor pathways to those muscle groups. This provides an anesthetic challenge as well because inhaled agents will interfere with neuromonitoring. Each institution has a specialized cocktail, and at Valley, it's an interesting combination of remifentanil, propofol, and low dose sevoflurane. Most of the time, the surgeries proceed pretty smoothly. The  neurosurgeons at Valley are outstanding and we rarely run into complications. I often enjoy watching the surgeries themselves; seeing someone operating on the brain is really quite amazing.

Image of brain surgery shown under GNU Free Documentation License, from Wikipedia.

When It Gets Hard

One of my favorite books as a child was Ender's Game by Orson Scott Card, a science fiction novel that depicts children trained to be military strategists in a war against aliens. There is a scene near the end of the book where one of the characters breaks down. In the middle of a battle, Petra is caught off guard and overwhelmed, and she suddenly falls apart. In the moment, she freezes, breaks into sobs, and needs another player to salvage the situation.

Things like this happen in residency. Both during my intern year and this year, co-residents have had overwhelming challenges that stress and exceed their limits. Sometimes so much is happening that we cannot function effectively; I've had situations where I've received so many pages, I cannot feasibly respond to them effectively. But more than that, something usually tips us over. Superimposed on a baseline of stress, we encounter a patient death, a delayed diagnosis, an iatrogenic error, a clinical mistake. And then we shut down; we cannot function effectively, we are overwhelmed with emotion, we stop thinking. When this happens, we rely on our co-residents to carry us, and as co-residents, we give as much support as we can. The enterprise of medicine is not an individual effort, and when one of us stumbles, the rest fill in to keep everything going.

Trauma II

For some, those who go into trauma surgery, there is an air of excitement when running down to the trauma bay. Anything can come through the door; there can be multiple injuries, some catastrophic; the interventions can be dramatic, even heroic. It is a challenge of triage, cool-headedness in the face of the unexpected. Many patients can come in at once. There is thrashing, body secretions, knives protruding, the stuff that makes horror moviegoers cringe. Yet in the end, patients who get into gun fights or jump off bridges or have tussles with industrial machinery may walk out of the hospital in a way that is immensely satisfying. That is the lure trauma has on some physicians.

I am not one of those people. I don't like the unknown, don't like the feeling of being unprepared. I don't like blood and vomit and who-knows-what. I am not a trauma guy. My stomach clenches when I see some injuries. I want to survey and catalog before jumping in and intervening. I don't like chaos. No trauma victim wants to be there. They want to jump off the bed, wrestle the lines and tubes out of them, and go home.

Nevertheless, clinical experience with trauma is important. The ability to assess a situation immediately, identify priorities, and accomplish them in the midst of a chaotic trauma bay is really important. From an anesthesia standpoint, quickly determining how to anesthetize, intubate, or support an unstable patient through multiple surgeries is invaluable. So even though I don't crave it, I try to get as much out of on-call trauma as I can.

Trauma I

A previously healthy young man is a passenger in an awful car crash, an accident that cleaves the car in two. All three other occupants in the vehicle die at the scene. The patient is thrown out of the car, and the impact of landing causes so many facial fractures that his nose and palate - the roof of his mouth - are essentially free-floating, their moorings released. He breaks his scapula, collarbone, and femur. The injury I find most disturbing is a ruptured globe - the eye is under so much pressure, it starts swelling out of the socket. We spend eight hours in the operating room fixing the eye, pinning the facial fractures, closing lacerations, performing a tracheostomy to breathe, pinning a femur, and nailing the hip.

In a separate accident on this MLK long weekend, a mini-van is T-boned at an intersection by someone running a red light. When I go down to the emergency department, I find the mother rushing between three rooms to see her two sons and her husband. One of them, a 10 year old I get to know well, is rushed to the operating room for a broken femur. While under anesthesia, ophthalmologists also have to clean glass shards out of his eyes.

The car crashes do not stop. A woman driving down the freeway, distracted by a cell phone, hits the median and flips the car. Her daughter dies at the scene. Her husband has a severe bleed into his skull. He's rushed to the emergency department where the emergency physicians cannot get a breathing tube in him. We hear an overhead page: "anesthesia stat to the emergency department trauma bay" and rush down. We manage to get a breathing tube in, but then the harder - perhaps hardest part - is talking to the wife who, stricken with guilt, must decide whether we should take her husband to surgery. From his symptoms, imaging, and labs, the chance of meaningful survival is nearly zero. We hold her hand as she decides to withdraw care from her husband.

PIPA and SOPA

Two bills before Congress, PIPA (Protect IP Act) and SOPA (Stop Online Piracy Act) will dramatically change the Internet, including search websites, blog networks, encyclopedias, and social networks. Many of these Internet giants are protesting these bills. I encourage everyone to learn more about it (https://www.google.com/landing/takeaction/) and make your opinion heard.

Arguments

Differences of opinion are common. But after watching surgeons argue about which surgery should go first, I have returned to the conclusion that nothing should be done for our convenience as physicians if it is not the right thing for the patient. We can complain about sacrifices we make, but that does not discount the necessity that we make those sacrifices to help those who depend on us.

January

The winter months are hard in residency. We often work through the holidays. We wish we could spend more time with friends and family. It is dark when we go to work, dark when we leave. Most of us crave sun and exercise and fresh vegetables (I have to admit, though, I am spoiled in California). We've lost the momentum with which we've started the year; our books fall to the wayside, we drag our feet through the day, what once excited us is now routine. And secretly, though most of us would not admit it, there is some grain of resentment that we do not have "regular jobs," that we are sacrificing some larger part of ourselves to this job which does not acknowledge sickness or holiday or the feeling of being burnt out, a job which demands all attention, saps us of our energy. I can't remember when I did not feel exhausted. Winter is hard. Hug a resident.

The Beginning and End of Things

I've blogged much on the start of anesthesia, but very little on the end of cases. Ending an anesthetic gracefully is really an art. The perfect anesthetic awakes the patient the moment the last surgical dressing is on in a smooth manner without any pain or coughing. That rarely happens. Occasionally we are too optimistic and the patient lightens before the surgeons are completely finished. Other times, we are too conservative and the surgeons wait while we get all the anesthetic gas off. Nobody is happy if the patient wakes up in severe discomfort or agitated or hypertensive. The art of the perfect wake-up is a combination of knowing the surgeons, titrating the anesthetic off carefully, and balancing oversedation from pain medications with the anticipated painfulness of the surgery.

Today, I had a case which did not end well. The patient was too weak upon extubation and although he could initiate breaths, his tidal volumes were simply too low. Prior to removing the breathing tube, he looked like he would fly; he was following commands with stable vitals; he was warm, reversed, and comfortable. Nevertheless, after taking the tube out, he wasn't looking fantastic so we reintubated him to give him extra time. Although it is a step backwards, we have to do what is safest for the patient. 

A Taste of Pediatrics

We occasionally get to do pediatric cases at Santa Clara Valley and so I had a couple days of anesthetizing kids. It's completely different, and fun. Since I haven't had my formal pediatric anesthesia rotation, the attendings supervise very closely and teach a lot. I've done simple mask anesthetics for ear exams and mass excisions in 5 year olds. It's fun because they bring their stuffed animals to the operating room and we reward them with stickers. They are generally pretty sociable (and become even more so after midazolam syrup which gives them the affect of being drunk) but still very different than adults. We flavor the masks with cherry or bubblegum chapstick, we try to avoid placing an IV if possible, and we induce anesthesia with inhaled gas.

The most challenging pediatric case so far, however, has been a two week old baby with a congenital defect in her abdominal wall. The surgeons had to try to reduce the patient's abdominal contents and repair the defect. The newborn arrived in an incubator and was so small I was hesitant to touch her. It can be a little hard working with these children; the patient had a nasogastric tube, central line, peripheral IV, EKG leads, and probably one or two more lines and tubes from her body. I had to recalibrate in my mind what normal vital signs were. We had to work to keep her warm. The intubation was tough; I used a tiny Miller 0 blade and managed to see vocal cords. I learned to limit my IV fluids, to calculate doses precisely, and to move slowly and gently when permitted but quickly and decisively when required. The patient made it back to the ICU safe and sound.

Poem: Perseids

Perseids

When you came, I left the hospital wearing scrubs onto the hill,
I tilted my head and listened for music. Droplets
flamed and retreated. How when I wished on a falling,
I was reminded of childhood, of the kind of succulent
that dwelt in my heart through teen years
and filled notebooks with poetry. I must be old now.
I don't recognize constellations. I don't write
in margins. I no longer perseverate for hours.
Last time you were here, I was not so practical,
I belted my passions and cared not who heard.

In one sun-tinged voyage, a Perseid year,
my maps unfurled, left me wanderlust.
I captain a ship that once fixated on a single point,
a pivot that deserved obsession, all dream and wish,
every one of those Swift-Tuttle rocks, and now
we flitter starlight to starlight, neither indecisive nor lost.
Everything seemed to shrink since you came last
but now, I look into the far edges of that canopy
and wonder where you came from, where you go next.

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

Wisdom

The Dalai Lama, when asked what surprised him most about humanity, answered, "Man. Because he sacrifices his health in order to make money. Then he sacrifices money to recuperate his health. And then he is so anxious about the future that he does not enjoy the present; the result being that he does not live in the present or the future; he lives as if he is never going to die, and then dies having never really lived."

Image of 14th Dalai Lama, Tenzin Gyatso, from Wikipedia, shown under Creative Commons Attribution Share-Alike License.

Waste of Time

We live in a world inundated with TV shows, junk food, social networking, video games, iPhone apps, mindless distractions. There's no question that my friends, my patients, even me - we waste some of our time with these activities. After a long day at work, I watch a mindless movie or scour social networks to unwind. But I can't help but wonder what the world would be like without these distractions. Is it wrong to say that exercise, cooking with friends, and reading books trump clicking through YouTube videos and (say it!) reading blogs? There's no doubt that for centuries we've had unproductive pastimes. But when I read an Economist article that argues video games are the future, I worry that the reason why a 25 year old doesn't have health insurance is not primarily a fault of health care laws or the job market but a surplus of instant gratification in society today. I know that if I slept more and wasted time less, I would be happier. But why can't I do it?

Year After Year

When I reflect on how I've changed in the past twelve months, I realize I've grown quite a bit. All those call nights and stressful moments do add up. My biggest change is gaining confidence. I have a better sense of when I need help and when I can trust my clinical impressions. I have moved from being a medical student watching doctors handle stressful situations to being an intern guided by my mentors in those situations to now being a resident approaching them with more and more independence. It feels comfortable. Soon I will have to be an attending, the end of the line. More than acquiring medical facts, which we learn from medical school and lectures and books, residency is about developing judgement, acumen, experience, and instinct. I don't notice this from day to day, but at the end of the year, I can tell I'm getting these intangibles.

Resolutions

Over a year ago, I wrote poems regularly, and somehow that faded away as I started residency. This year's resolution is to get back into the habit of creative writing. I miss reading, thinking about, and writing poems, and even though blogs provide an outlet for something, I want to broaden from just writing about residency.