Extra Time

is_leap_year = ( year modulo 4 is 0 ) and ( ( year modulo 100 is not 0 ) or ( year modulo 400 is 0 ) )

It never seems as though we have enough time, and here we have an artificially created day. Today is the day to try doing one of those things I've been putting off because "I have no time." It's a day to call my parents, cook something new, read something, and study. The truth is, it's just a regular full day in the operating room, but sometimes we need an artificial stimulus like this to help us long.

Poem: Dance

Dance

Medicine is dance: the hold and release,
the intuition, the half-light, illumination of
curve and angle. Before each song, each melody,
each figure, I follow the note to the end,
hear it vibrate in my mind.
It is dance before it starts:
impressions, donning gloves, taking a hand
and slipping in that IV.

Dance is the imperceptible nod,
the inflection of facial muscles that say
yes, I will carry you through
and we will awake together
that this waltz will transform me just as much.

It is a menage a trois; the music steps between us
and we move in concert. The monitors sing.
Each beep, buzz, tone, and chime guide my hands,
tell us how quickly to move, remind us
to move gracefully. The floor is crowded.
Each movement calculated and instinctual
as if I knew all along how to keep my partner safe.
The scrub and scalpel whirl by,
but only as close as I allow.

Break

If you ask any surgeon, they'll say anesthesiologists are all about the breaks. I can't deny this. Today, I was assigned to give morning breaks and lunches to attendings working alone in the ambulatory surgery center.  The OR environment is such that efficiency is a premium and an anesthesiologist has little free time. In between cases, we are busy getting one patient settled and the next one ready. During cases, things may be slow, but we're monitoring the patient and maintaining the anesthetic. There's no real downtime, and we have to keep what Mad-Eye Moody from Harry Potter calls "constant vigilance."

But like the nurses, we give each other breaks. More than just a nicety, it is important for us not to lose our focus and concentration during cases. In a long slow case, it's easy to relax that constant vigilance, putting the patient at risk. Furthermore, we have a type of practice where it's possible to temporarily transfer care to another practitioner. For many surgeries, I can get a quick sign-out from the current anesthesiologist, survey the workspace, and feel comfortable taking over that case pretty quickly. Thus, the work lends itself to this reputation of many breaks during the day.

Eyeballs

I had a day of ophthalmology cases. For the anesthesiologist, this is not the most thrilling surgery to be assigned. Most eye cases are done awake under monitored anesthesia care with a nerve block by the surgeons. Patients are usually older and have many comorbidities so the risk of general anesthesia isn't negligible. We have to walk that tight line between not enough sedation and having the patient move with sharp objects near the eye and too much sedation and having the patient stop breathing. The block itself has rare risks and working on the eye has its own unique physiology. But all in all it was a calm day without unexpected hiccups so the attendings gave me more independence.

Image of cataract surgery is in the public domain, from Wikipedia.

Diagnosis

The history and physical exam are the heart of medical diagnosis. The great diagnosticians of the past like Sir William Osler are remembered because of the symptoms and signs they discovered: Osler's nodes, Osler's triad, Osler's sign. And in the age of great technologies, we must remember that talking to the patient and laying hands on them are free and often much more revealing than a set of blood tests or films. Indeed, the old school approach to a sick patient often aids us in selecting what laboratory and radiologic tests we need. In my other blog Case of the Day, I try very much to capture the curiosity, fascination, intrigue, and excitement about diagnosis.

However, anesthesia is very different than medicine as practiced in the physician's office. The patient is asleep and nonresponsive; we get no history and our physical exam is limited. Our laboratory tests and other studies are limited and often not available in the time frame we need them. So when something unexpected happens intraoperatively, diagnosis can be difficult. We learn to listen to the ventilator to understand what the patient's lungs are saying. We learn to do intraoperative echocardiography to examine the heart. We learn to look at the urine to extrapolate information about the kidney. We can use a crude EEG to understand the brain. We have to know how the patient's pre-operative conditions, surgery, and intraoperative interventions and medications may interplay to make one diagnosis more or less likely than another. It's a detective mystery with our hands tied behind our back; we learn to use all our instincts and judgment to keep a patient safe.

The Commute

I forget how long and tiring days can be in the general OR. But as I walk home, I'm just starting to appreciate a glimmer of spring around the corner and it makes me quite happy. I live right over the bike bridge, and the stroll home is the most relaxing part of my day, and probably the only time during a work day that I really entertain exercise. I'll be quite glad when things start warming up and spring is really here.

Image of Bay Area sunset shown under Creative Commons Attribution Share-Alike License, from Wikipedia.

Back in the GOR

I'm back in the general operating rooms, which we fondly call the "GOR." They've recently renamed this to the "multispecialty division" to sound less gory, but the name sticks with the residents. I've had the usual hernia repairs, cholecystectomies, appendectomies, and gastric bypasses, but I wanted to write about the difficult airway.

We learn all the risk factors for a difficult intubation: obesity, short neck, poor Mallampati score, unusual incisors, large tongue, etc. But occasionally a patient without these risk factors presents with a difficult airway. Two patients, a thin older gentleman undergoing a cholecystectomy, and a young woman having an endoscopy, surprised me with unexpected trouble. These are the cases where prior to induction of anesthesia, I'm humming to myself, not too worried. Yet when I take my first look with a laryngoscope, I know it will be tough.

This reminds me why we spend so much time in training. For the routine, the easy and smooth, we don't need 4 years of undergrad, 4 years of medical school, and 3-7 years of residency. For the patient with chronic back pain needing refills or the child with sniffles or the pap smear, we don't use the breadth of our skill sets. Our knowledge, skills, and thinking as physicians are really tested in the unusual, unexpected, emergent, and scary moments of medicine.

In both circumstances, the patients did fine. I reminded myself to stay calm. I communicated with my attending; we continued to ventilate the patient with a mask and discuss our options. Both of us were unable to intubate using standard direct laryngoscopy, and so for one patient, we placed a laryngeal mask airway and then used a fiberoptic scope with an Aintree catheter to guide ourselves through the vocal cords. For the other patient, we actually used the gastroenterologist's endoscope to see the back of the oropharynx and intubate the patient under direct visualization. Remaining calm and in control of these situations is the most important thing; communication and rational thinking allows us to move on from what is not working to our backup strategies.

Neurocritical Care

In finishing up my posts on the ICU, I wanted to write about neurologic diseases. A substantial number of our patients have neurologic injuries, most commonly strokes and seizures. It has been a while since I've primarily cared for patients with these illnesses so I had a lot to learn. The managements of strokes, for the most part, is supportive in nature; the goal is to prevent further reinjury, to decrease brain swelling, to maintain the body's homeostasis. After many patients with these injuries, I came to know the routine and protocol pretty well. The most educational aspects, however, were learning to interpret my own films; although ultimately, we deferred to radiology and neurology, it is always very helpful to be able to look at scans immediately and make some sort of determination whether things were better or worse. I also got to practice my crude neurologic exam, relearn my antiepileptics, and have opportunities to place invasive lines for patients who needed close blood pressure monitoring and hypertonic saline.

Looking back, it was a whirlwind and exhausting month, but it reminded me how much I love medicine and things outside the operating room. It also showed me how spoiled we can be in the OR with less strenuous call schedules and fewer patients to worry over.

Image of intraparenchymal bleed with surrounding edema shown under Creative Commons Attribution Share-Alike License, from Wikipedia.

Comfort Care

Comfort care is the euphemism we use when we transition a patient from aggressive and invasive treatments to measures that will allow them to pass peacefully. In the ICU, we have several patients each week who become comfort care. It is a paradox of sorts; everyone wants to die peacefully but nobody wants to die. So when there's a 50-50 chance that a patient won't make it, do we push them with dramatic and heroic interventions knowing that they may die despite our best intentions or do we let them go quietly knowing that we had not tried everything? What if it's a 75-25 chance that they won't make it? 90-10? 99-1?

I can tell you the common response. In this situation, even for patients who previously documented that they would not want life-supporting interventions or dependence on machines, it is really easy to say, "let's just keep going one more day." It's also easy to tie the doctor's hands: "he'd want everything except a ventilator." And of course that is perfectly the right of the patient and the family, but is it the right thing to do? After just 4 weeks in the ICU seeing futile attempts to resuscitate patients whose illnesses outstrip the body's resources to cope, I am not sure.

I have written about the end of life a lot, and my conclusions are always the same: the death we want is not the kind of death that occurs in the intensive care unit, or the code blue, or the emergency department, or even the hospital. I believe this firmly. And yet, I feel my emotions clench when I advocate for someone to be comfort care even when I know rationally it is the thing to do.

A 100-year old gentleman comes in with a rip-roaring pneumonia, the kind that in the past was "old man's best friend" because patients passed quietly and swiftly. He wanted to live but did not want intubation. So we treated with antibiotics, tried to give fluid cautiously, and put him on noninvasive positive pressure ventilation. Fluid management was difficult because we felt like our hands were tied. His infection was severe enough to drop his blood pressures, and by textbook, we should be hydrating him aggressively to support his hemodynamics. But fluids will go into the inflamed lung, a risk factor for requiring intubation, and since this was off the table, we could not treat him as we should. He already needed BIPAP or noninvasive positive pressure ventilation. This is a last resort prior to intubation but not a long-term solution.

Day after day, we could not get this patient off of BIPAP. It was clear to us that our options were to intubate or to transition to comfort care, and given the patient's wishes, it was time for us to make him comfortable to pass. I presented this as best I could to the family, a conversation I played out in my head before walking into the room. But even as I spoke, I could feel my heart twinge because I was essentially saying that this patient would die. How do you approach that kind of situation? How do oncologists tell a patient that she will die from cancer? How do generals send soldiers into a battle where the casualty rate is mercilessly high? How does a pregnant woman decide to undergo an abortion?

Death is easy to talk about on paper, on blogs. It is easy for me to sit here and write that the ICU is no place for old men. But I don't mean to discount the process of determining how one will die and undergoing that process. I don't mean to imply that I know some secret about it that no one else does. Because I struggle so hard with it, and weeks after each encounter, I still think about that patient, the family, and how I could have made that transition to comfort care easier, smoother, more acceptable.

The Patients That Scare Me

Each physician has his weakness, and mine is the heme/onc patient. While everyone who comes into the ICU is critically ill, I know how to approach most of them. I'm generally okay with strokes, seizures, heart attacks, heart failure, arrhythmias, respiratory failure, hypercarbia, GI bleeds, kidney failure, electrolyte imbalances, septic shock, cirrhosis, even the patient who has been in the hospital for months. These are people I cared for in medicine and who I care for now in the operating room. I understand the diseases and the physiology well. But the one population of patients that scares me is the neutropenic crashing patient.

Cancer patients, especially during and after chemotherapy become susceptible to so many different kinds of infections, including all the weird ones. The cancer itself can wreck the body with phenomena like tumor lysis syndrome. Patients are often malnourished, with weak immune systems, suffering the side effects of their chemo. And when they come into the ICU, they are so ill. Since I did not do a hematology or oncology month as an intern, I sometimes find this to be a big black box. So it is my focus to learn as much as I can about these disease states, ask for help early, and recognize my vulnerabilities.

Sadly, we had a very young patient after a stem cell transplant for a hematologic cancer who had every infection in the book. Her gut could not tolerate any food because of CMV colitis. Her blood was growing multiple bacterial cultures. She had a history of fungal infection. Her kidneys had failed from the antibiotics. Her breathing was labored from a pneumonitis compounded by fluid overload from kidney failure. She was on continuous renal replacement therapy (similar to hemodialysis), experimental antiviral therapy, and a ventilator. In the end, she could not cope with her disease, and we had to transition her to comfort care. It's so hard for young patients. We want fervently for them to do well and try everything we can, but sometimes it is not enough.

Holiday

Despite my last post about the importance of laboratory tests and X-rays in the ICU, I am a big proponent of lab or X-ray holidays. One of my secret passions is scouring each patient's orders and reducing unnecessary labs. For example, liver function tests are often checked daily for ICU patients, but if they are normal and the issue has nothing to do with the liver, then why check them at all? Occasionally in a bleeding patient, we trend hematocrits so frequently that I think the blood draws are making the patients anemic. I also think daily chest X-rays are usually overkill. There are a fascinating story (or urban legend) that at a hospital nearby, radiology techs went on strike so only on-demand X-rays could be ordered. Routine daily films were canceled. There were no bad outcomes for patients. This has also been studied formally and the conclusion is that routine X-rays may be costly and unnecessary. So even in the ICU, I try to be as much a minimalist as I can.

Numbers

ICU is a specialty driven by numbers. Because many of our patients are sedated or altered, we cannot always rely on symptoms or history. We use laboratory tests to understand the heart, lungs, kidney, liver, infections, blood, and other systems. Much of "rounding" involves reviewing these lab assays, X-rays, microbiology cultures, and other data.

I admitted a rather young patient who presented with the most extreme numbers I've seen. Her arterial blood gas had a pH of 6.99. A normal pH of the blood is around 7.40, and the body regulates this extremely tightly because proteins begin to denature and enzymes begin to fail if this acid-base balance becomes awry. Why did this patient have such a low pH? Her lactate was greater than 20. If you remember back to high school biology, you will recall that the body makes energy through two mechanisms: an aerobic method and an anaerobic one. When cells have oxygen, they prefer the highly efficient aerobic oxidative phosphorylation. But when deprived of oxygen, they revert to anaerobic metabolism, which produces lactic acid. This patient came in bleeding from her gastrointestinal tract and her blood counts dropped so low that she could not carry oxygen sufficiently to her tissues. The cells, suffocating, produced such an overwhelming amount of acid that her pH was less than 7. While I managed to keep her alive overnight, she is currently in multiorgan system failure, and I don't know how she will do.

Asclepion

"Wherever the art of medicine is loved, there also is love of humanity." - Hippocrates

Image of statue of Asclepius shown under Creative Commons Attribution license.

Margin of Error

The thing about the intensive care unit is the margin of error is really small. While medicine is a delicate enterprise and each intervention we make or withhold has implications to someone's health, this is accented in critically ill patients. For example, last year on the medicine wards, I never thought too much about sending someone down to the MRI scanner if that's what they needed. But yesterday in the ICU, I was faced with a situation where we wanted to obtain an MRI on someone who had a tenuous respiratory status. Lying flat for an hour could be an ordeal; he could stop breathing and arrest. We ended up settling for a less ideal but more practical CT angiogram because of the confines set on us by the patient's illness.

Likewise, in the operating room, I manage fluids pretty nonchalantly. Whether someone gets 1.5L or 2L of fluids during surgery generally won't make a big difference in the run-of-the-mill surgery. However, in a patient in heart failure, the extra 500mL of intravenous fluids could be the difference between breathing on one's own and needing a ventilator; on the other hand, in sepsis, withholding that 500mL of fluid can lead to low blood pressures, higher vasopressor requirements, and kidney injury. The problem is that on my last call, I admitted a patient with both heart failure and sepsis. My margin of error is so small. How do I walk that fine line between not enough and too much? Sometimes, that space doesn't even exist.

The Post-Op Patient

The medical ICU takes a few types of surgical patients, mostly neurosurgery and ENT. For the most part, the management of these patients is pretty simple; the neurosurgical patients get hourly neurologic exams and the ENT patients are admitted to watch their airway and breathing. If all goes smoothly, they go to the floor the following day. But sometimes things don't go that well. We have a neurosurgery patient status post clipping of an aneurysm who has since developed intractable seizures. He's spent almost a month in the ICU, and the neurologists have struggled to get his seizures under control. Finally, with six antiepileptic agents, he's stopped seizing, but with all these medications, he's comatose. We're trying hard to find that balance (if it exists) where his seizures are manageable but he is awake and interactive. We also had an ear-nose-throat patient who in the middle of the night developed severe throat swelling that started to compromise his breathing. Three anesthesiologists, with all our tricks and rescue devices, could not get a breathing tube in, and so the general surgeons had to come and do an emergent "slash" tracheostomy. So while post-operative patients usually do well, it's a good thing we keep an eye on them.

Continuity

One of the often cited downsides of anesthesia is lack of patient continuity, and this is true. Anesthesiologists focus primarily on the intraoperative period and although we see patients pre-operatively and check them post-operatively, we don't see them over extended periods of time. We don't develop the close long-lasting relationships enjoyed by primary care physicians or pediatricians or even surgeons. We are a very episodic kind of physician, sort of like an emergency medicine doctor.

ICU, on the other hand, has some continuity. We see patients day after day, charting their progress, applauding their advances, struggling with setbacks. Even after patients leave the ICU, we try to check on them because there is a sense of ownership; this is my patient who I manged for a week in intensive care. We get to know families, especially in stressful and crisis situations. They learn to trust us, depend on us, or challenge us.

From a professional sense, continuity is crucial. It is medically important to know how each decision we make influences a patient's hospital stay or long term health. The tragic thing about anesthesia is that there are many ways of doing an anesthetic, but we don't always see the extended post-operative course. When we drop a patient off in the PACU, it's too early to know whether our tweaks make a difference. But they do; only with continuity do we understand how our anesthetics influence postoperative pain or nausea or time to recovery.

From a personal standpoint though, it is so much easier not to be in a field with constant continuity. When I am on a pure anesthesia rotation, I don't go home with anxiety, I don't stress at night about patients. But now in the ICU, I am constantly thinking, second-guessing, and following-up on my patients. I send late-night pages to the on call person. I feel incredibly invested in the care. And although this is ideal from a medical standpoint, I can tell you, I don't sleep as well. I don't feel as good.

Ducking Under the Boom

On my first call in the medical ICU, the airway beeper gives a squeaky buzz just as the overhead paging system blares "Attention: Code Blue." We become hyperaware of these announcements; sometimes, just standing in the grocery store, I start looking around when I hear "Attention: Pears are 50% off." The code is in the cath lab. When I rush in, the cardiologists are in the middle of an angioplasty and stent for a middle aged gentleman with a heart attack. During the procedure, his blood pressures started tailing off and he vomited. He was not mentating well and needed to be intubated.

I quickly strapped on a lead vest since the cardiologists were using fluoro (real-time X-rays). The patient was on the cath table and the cardiologists were taking lots of images, which meant that the boom (in the nautical sense) was swinging around the patient. I quickly prepared my emergency airway equipment and medications. The cardiologists told us to intubate when ready, but they were not going to stop since they were in place to open up the blocked coronary vessel. Even with the boom flying about the top of the patient's head, I managed to secure the airway. Meanwhile, we started several vasopressor drips to keep his blood pressure up. During the case, there were several rounds of compressions when we'd lose the pulse, but eventually, the cardiologists managed to open up the clotted vessel and reperfuse the heart. The patient ended up doing well.

In comparison to the last code I wrote about, this one was quite different. Although we knew the problem in both cases (the last patient was bleeding, this patient had a heart attack), we were already poised to do the best intervention for this patient while we couldn't get control of the situation with the prior case. This was really a case in which we "saved" the patient's life.

A Typical Day in the ICU

I get there at 6 and get sign out from the resident on call overnight. I pre-round on anywhere from 4 to 10 patients, seeing them, checking their vitals, reviewing their labs and studies, updating medication lists, and entering any important orders. We round at 8 as an enormous caravan. The team consists of the attending, two ICU fellows, four to five residents, a gaggle of medical students, a pharmacy resident and student, and occasionally a palliative care fellow or dietician. We also wheel around two to three computers. Seeing each patient and determining the plan usually takes two to three hours. Then we try to get procedures done, call consults, and write our notes.

X-ray rounds are at 11:30 so we tromp down to radiology and review films with a chief resident. After that, we grab some food for a didactic lecture at noon covering basic topics like sepsis, ventilators, and antibiotics. From 1-3, we continue doing "work," finishing up odds and ends, touching base with consultants, updating families, etc. During afternoon rounds at 3, we review the day's activities on all the patients and revise the ongoing plan.

The resident on call stays while everyone else tries to go home; although it sounds as though we can leave early, for the most part, we stay pretty late helping out. During the day, everyone chips in to take new admissions who can come from the emergency department, outside hospital, floor, or operating room. After afternoon rounds, the resident on call is on his own. There are usually two fellows around until midnight when one of them goes home. On call, we cover all the patients and new admissions, which can be quite busy.

Code Blue II

This is a continuation of yesterday's post.

In some respects, "running a code" is not hard. In a Code Blue, the first procedure is to take your own pulse (a mantra of the Fat Man in House of God). This is true. Everyone witnessing her first code feels her heart drop to her feet and panic take its place. We are frozen with paralysis, both physically and mentally. We forget the simplest things. We fixate on stupid details. We aren't helping the patient.

I took my own pulse. Then, I went to the head of the bed, ready to intubate. This is not the most important thing in a code; it's not even the first step in the new algorithm (which starts circulation, airway, then breathing). But in the ED where help is abundant, I recognized that the unique skill I contributed was airway management. The fellow "ran" the code, going down the algorithm. The patient was pulseless. Chest compressions were started immediately. I got my airway equipment out. I could mask ventilate the patient. The cause of the cardiac arrest was clear; he was bleeding to death. He had blood in his mouth and bloody bowel movements. We were transfusing as fast as we could, but to no avail. To secure the airway and protect him from choking on blood, I tried to intubate. I took me several attempts before I could do it; intubating in a code situation is never ideal and always stressful. I took my own pulse. Once I secured the endotracheal tube, my job was to bag the patient. Lots of other things were going on, but I kept my role. The ED resident and attending both tried to get venous access, a very challenging thing to do in the middle of chest compressions in a patient with no blood pressure. We activated the massive transfusion protocol, trying to give as much blood product as we could.

This went on for twenty minutes. With ongoing compressions, ribs were broken, the lungs were lacerated, blood started coming up the endotracheal tube. We got a weak thready pulse briefly, but it disappeared. At one point, we shocked the patient for a ventricular rhythm. We got central lines in and transfused more and more, but eventually we realized this was futile. After about twenty five minutes, we called the code and noted time of death.

There is a point in codes, amid compressions and shocks and needles and shouting, that the process sickens me. It is dehumanizing. Rarely, those situations we live for, the insult is easily reversed and the patient is revived. But more often than not, it is a messy prolonged protracted process, something we would never wish on anyone. It is why I think it is so important to talk to everyone about he'd want when he dies. Such things can be avoided, or pursued, but this decision needs to be made by an informed consumer. Medicine needs to empower patients to choose what they want for themselves.

At the end of codes, I also think debriefing is important. I had so many emotions that night. There are so many things about seeing someone die, being a part of the process, trying my very best and achieving so little, that I wish I had time to let it out. In medical school, there were people who tried to do this, but in the middle of the night in the emergency department, we simply did not have that luxury. So here it is. I don't think I could have saved that patient. And it is that vulnerability, that loss, admitting that very fact, that frightens me.

Code Blue I

I often write about code blues where I run in, intubate a patient, transfer them to the ICU, and save the day. But this is a minority of situations; the real code, the helpless one, the one sometimes shown on TV, the one we all dread, is much harder to write about.

A 90 year old gentleman with a history of high blood pressure, atrial fibrillation on anticoagulation, coronary artery disease, heartburn, and osteoporosis comes in "not feeling well." He had an episode in the morning where he almost blacked out. In the emergency department, he has very low blood pressure and is witnessed to vomit blood. IV fluids are started and stat labs are sent which reveal a hemoglobin of 5 (normal 13-17) and an INR of 25 (normal 1). Meanwhile, the patient has vomited blood again and is having melena (black tarry stools) in the bed.

Immediately, more IV access is secured, but a large hematoma forms where someone tries to get a 16gauge IV in. FFP and blood is ordered and started. The diagnosis is clear: the patient has a "supratherapeutic" level of coumadin; for whatever reason, his home blood thinner for atrial fibrillation has become way out of control. The goal is an INR of 2-3 in atrial fibrillation, and here, his value is way above that, a reflection of how thin his blood is. If he bleeds, he cannot clot. And he is bleeding; the symptoms show exsanguination from the gastrointestinal tract. By textbook, he has an upper GI bleed with hematemesis and melena. ICU is called.

I rush down to admit this patient. When I see him, he is responding slowly to voice, saying "I just feel so weak and dizzy." His heart and lungs are unremarkable but he does have some abdominal tenderness and is having a black bowel movement concerning for blood. The ED resident is doing a quick ultrasound to look at the heart. Both of us spend a minute talking about how we'd like better IV access since we only have an 18g and a 16g IV. The blood products are hanging. In my mind, I know the most important first steps: get IV access, transfuse, secure an airway, and then see if interventional radiology or GI can intervene.

I step outside the room to check the EKG, and three minutes later, when I look back, they are putting the patient in Trendelenberg (head down to help blood flow), wheeling the bed out (a bad sign that the airway has been lost), and calling for help. It seemed that moments after he and I chatted, he stopped responding; I may have been the last person he talked to. The rest of the post tomorrow.