Goodbyes

I wrote a few days ago about the changing of the guard, that July transition when each resident progresses a year in stature while new interns join the fray. But I didn't think too much about those who are finishing, those fourth year anesthesia residents who will now graduate as full-fledged independent anesthesiologists. The Stanford anesthesia family is by no means small; we have 24 anesthesia residents each year. And because of the nature of anesthesia, we don't often work with other residents. But over time, we get to know many of those in the classes ahead of us; they bestow upon us their wisdom and we admire them as the type of residents we hope to become. Congratulations to all those who have finished that long toil of residency. I am so, so happy for you, though I have to say I'll be a little sad not to see you in the breakfast nook or PACU or mailroom every day.

The Supreme Court Decision

By now of course, everyone knows that the Supreme Court upheld the Affordable Care Act and specifically the individual mandate as a valid exercise of Congress's ability to levy taxes. For me, this is a huge victory. By guaranteeing that everyone has insurance (or, as opponents may say, forcing everyone to get insurance), it shores up what I find one of the strangest paradoxes in American medicine. It always seemed odd to me that everyone should have access to care, yet not everyone participates in the pool that funds the care. Ethically, ability to pay should not influence how physicians treat a patient. Practically, EMTALA is a law that guarantees evaluation and stabilization of life-threatening injuries if anyone presents to an emergency department. Yet until now, there was no requirement that everyone have health care. Furthermore, prior to this law, personal health insurance had little regulation, leading to difficulty for someone to obtain it, keep it if they got sick, and use it meaningfully. And we have known for a long time that preventing disease and having a regular physician is far cheaper to the system than repeated emergency department visits and hospitalizations.

Like any big change, the Affordable Care Act will have its stumbling blocks. It will have its darker moments, its awkward transitions, and its unforeseen consequences. But it is paving the way for a future in which good health is a right and where we bear the responsibility of paying for that good health.

Superstition

I'm not too superstitious of a resident so I'm okay with saying that the unit is pretty quiet these days. It fluctuates a lot; we peaked at eighteen patients last week, and now we're down to half that. But it's interesting to watch some of the residents. Despite being scientists, physicians can be a silly superstitious lot. If things are going well, we never say, "things are quiet," because inevitably, that invites more admissions. We tread softly because those who go looking for trouble will find it. We characterize ourselves with "clouds"; those with white clouds have easy days with few admissions and those with black clouds are cursed with non-stop busy nights. I don't generally believe in all of that, but sometimes it's fun to pretend that we have some sway on luck and chance.

Anticlimactic

There is a little celebration between intern year and the first year of anesthesia. They throw us a party and we have a few days off. It feels like a big accomplishment, making it through the purported "hardest year of medicine." But now that I'm almost done with my second year of residency, there's little fanfare. In fact, my schedule seamlessly moves from surgical ICU to obstetric anesthesia without a skip in heartbeat. It's okay; I don't particularly care for big markers of moving from one year or another, but after decades of celebrating the end of one academic calendar and the start of another, it feels a little funny.

You Don't Always Need an Answer

Physicians and scientists love answers. When something is wrong, we want to know why. The most beautiful internal medicine notes are designed to explain the status of each problem, the possible diagnoses, the tests to probe each suspect, and the treatment plan. (Unfortunately, in the era of high volume medicine, this degenerates from a well-articulated thought process to a few unhelpful phrases, but when I teach medical students, I emphasize the importance of the proper method of thinking).

But in the intensive care unit, sometimes we struggle just to keep someone alive. They are dying, and instead of probing why (if it is not immediately apparent), we race to support each organ system. The note is organized by each of the body's core systems (brain, heart, lungs, kidney, nutrition, hematology, infections) and how we are protecting or rescuing each.

A woman with a complex cardiac history of multiple heart surgeries comes in with acute cholecystitis. This is a fairly simple problem; a gallstone gets stuck in the gallbladder leading to inflammation and infection. Before she had surgery, she was transitioned from one blood thinner to another; because she had artificial heart valves, anticoagulation was necessary to prevent clotting of the valve. The surgery (removal of the gallbladder) went smoothly, but afterwards, she had worsening pain, a dropping hemoglobin, and a CT that showed that multiple vessels in her abdomen were dissecting. Nobody could explain why; this is a strange phenomenon that causes us to think of rare rheumatologic or immunologic illlnesses. When she came up to the intensive care unit, her liver began failing. Her numbers were so scary, we called hepatology and transplant surgery immediately.

We did not know why this was happening and despite my fervent desire to know why, I knew that supportive care was what would keep her alive. Despite not knowing the cause of the liver injury or the dissecting vessels, I adjusted medications to safeguard those organs, transfusing blood as necessary, and balancing those risks of anticoagulation with the benefits. Over the following days, the liver enzymes returned towards normal, the skin lost its yellow hue, and the laboratory tests had fewer "critical value" flags. Soon she was ready to return to the regular ward. We never learned (and may never know) the ultimate cause of what happened, but in the immediate setting, why is less important than how to fix it.

Anatomy of the Emergent Airway

We (that is, young anesthesiologists like me) sometimes dream of the heroic emergency rescue: a man allergic to peanuts runs afoul of the legume and we rush over, pulling an endotracheal tube, laryngoscope, and syringe of epinephrine out of our pocket, saving his life. This, I guarantee, is not the day-to-day life of the anesthesiologist. The older crowd likes to avoid excitement; the good day is one in which everything is calm, planned, straightforward. My attendings remind me that we don't aim to have situations worthy of TV sitcoms. So perhaps it is only the emergency doctor or physician bystander who gets to make the dashing, daring, and frightfully decisive saves.

In the past two days, upon arriving at the hospital at 5:45am, I've been called for an airway emergency. I walk over to see the patient, planning in my head the absolute minimum I would need if that person needed to be intubated right then. But luckily, that was not the case. Much as I would have loved to be the TV show star, I knew the safest thing, the anesthesiologist way, was to plan everything out.

Both patients were in extremis; they were breathing at forty breaths a minute (try doing it, and see how long you can keep it up). But they were oxygenating and ventilating, which meant I had some time - whether five minutes or thirty minutes, I didn't know, so I dared not venture far from the room. But I examined the chart, looked at old intubation records, looked into the patient's mouth, and called my attending. We situated the room so that everything was available and ergonomic. Instead of having just the bare minimum, I set up every possible tool I could use, from a line of oral airways to the fiberoptic bronchoscope. This is a mantra in anesthesia: if you are prepared, nothing goes wrong. If you aren't prepared, you'll wish you were.

In both cases, despite rapidly decompensating patients, we kept our cool. We called a time-out. We prepared medications for every possible scenario. I took a look with a laryngoscope and intubated them smoothly. We brought the patients to the ICU and started the process of diagnosis and treatment. There were none of the frantic yelps and breath-holding crowds and sighs of relief of the heroic intubation. But I realized I don't need that.

New Interns

It is that time of the year when the residents turn over; chief residents graduate and new interns arrive, wide-eyed and bushy-tailed. All of us seasoned vets remember that first day of intern year, that overwhelming feeling, that fear and anxiety, and the absolute bewilderment at not knowing how to do anything. But we're put into a tough position. Breaking in an intern, walking them through the simplest things, is frustratingly time consuming. From logistics like how to page a consultant and how to put in an order to critical patient activities such as evaluating someone in extremis, we feel like we're doing double the work as we walk a newbie through. And looking at their shocked faces, we remember how hard it was and want to cushion things, to make it easier, to shy them away from the pain. But on days like today - when I had six admissions, one emergent intubation, a patient pass away from an unlivable injury, a family meeting, and a miraculous transfer to commandeer - I simply can't hold the punches. Sometimes you just have to be thrown in the deep end and come up swimming. All that being said, and this being a public blog, I do want to say that it is the responsibility of rising residents and our attendings to keep patients safe, and even in a time when freshly minted medical students struggle with the transition to being MDs, we do not let patient care become compromised.

Worst Case Scenario

Similar to the theme in the last post, in the surgical ICU, we see the post-op patients that have the complications. A kidney transplant is complicated by dissection of an iliac artery. A laparoscopic cholecystectomy is converted to an open one in a patient with heart failure and renal failure. A patient with a history of eighteen gastrointestinal surgeries comes because her IV for nutrition may be infected. When I look at these worst case scenarios, the things that have gone wrong, I overestimate the risk of surgical interventions. I wonder why a patient with cardiac and renal failure had an elective procedure or why a man with chronic abdominal pain keeps getting operated upon until he has no functioning gut. But of course for each patient that comes to the ICU, I don't see the many who do well and have no problems. It's odd to have this skewed view of things, but it also teaches me to appreciate the vast possibility of outcomes, even for simple procedures.

Trauma

In the surgical/trauma ICU, we see all the worst case scenarios. A motorcycle accident leads to massive bleeding from the liver requiring transfusion of over a hundred units of blood. A fall off a ladder leads to a severe brain bleed. A man playing casual football breaks six ribs and his breastbone. A horseback riding accident leads to multiple orthopedic injuries requiring repeat surgeries. It is heartbreaking to see these accidents. Families are stunned at how much can be lost by an uncontrolled car, too much alcohol, a miscalculation. These patients spend months in rehabilitation and only regain some of what they had before.

I write about this because seeing these patients makes me very wary of these activities, even though for the most part, they are safe. After just a few weeks on the service, I've vowed not to get on a motorcycle, bungee jump, ride a horse, or even drink. I've seen too many bad outcomes. It seems to me that the trauma surgeons are the same as well; despite doing middle-of-the-night surgeries to remove a knife or bullets, they live pretty sedate lives. On the other hand, I find it interesting that emergency physicians who see the same injuries, are a much more daredevil crowd. Perhaps it is because emergency medicine, like ziplining or jumping off cliffs or driving fast cars, has that adrenaline component.

Purple Drank

Sometimes we learn things from patients that we don't from our lecturers. I distinctly remember a moment in medical school where I was interviewing a patient with substance abuse and asked him how much heroin he did every day. He gave me the answer in a dollar amount, and after talking to him, I went to a computer and googled the cost of heroin. I immediately realized the hospital might be monitoring my Internet use, and quickly closed the browser lest I got in trouble.

For the vast majority of us health care professionals who have never had contact with drugs, it is a weird experience to realize the patients know more about street drugs than we do. Most recently, I admitted a patient who was intoxicated with purple drank, which I had never heard of. Apparently, it is a (terrible sounding) concoction of cough syrup, Sprite, and Jolly Rancher candies. Who would have known?

It Gets Easier

We have our medical students follow one or two patients in the intensive care unit. I remember being in that boat: arriving early to gather all the data, identifying each medical issue, reading about the disease or injury in a textbook, coming up with a plan, and discussing it with a resident. It was hard work, and I struggled to keep all the information in my head and synthesize it into something that made sense to me.

Then as an intern, I was responsible for up to ten patients, six of whom could be new each call day. At first, the burden of information was overwhelming; I had to be organized and detailed so I wouldn't mix patients up. That transition from just a few patients to a handful was challenging and in the first few months, I remember struggling with the overload of information, the worry I'd miss something, and the difficulty balancing learning about each disease with the limited time I had.

It all gets easier. Now finishing my second year of residency, I find that I can keep up with a dozen critically ill patients and a few new admissions without too much sweat. Part of it is simply experience and learning; I've seen some common problems so much that dealing with them now is straightforward. I recognize things that don't make sense, that feel weird, that need more attention, and I focus my energy on that. Rather than spending my time reading, studying, and investigating every single problem on each patient like I did as a medical student, I now rely on reflex and instinct to attend to those problems that are typical and straightforward and instead concentrate on those patients or problems that are changing, unusual, or concerning. This is not to say that the straightforward stuff isn't dangerous; indeed, septic shock is life-threatening and yet for me it fits a box I understand well and can act on without feeling overwhelmed.

It makes sense; this is what residency is about, developing that sense and ability to handle more and more responsibility. And yet, I don't notice it until I think about it, until I realize I'm in the ICU and managing a dozen patients, a feat I couldn't have imagined doing a couple years ago.

Surgical ICU

The frequency and volume of posts has dropped off in the past week, and the reason is that I've started my last rotation this year in the surgical intensive care unit. This operates on a 12-hour shift schedule, and last week was a bit hectic as I got to know the service and figure out how I fit in. Overall, it's not bad. We have a population of trauma victims from gunshot wounds, falls, or motor vehicle accidents. For the most part, they are otherwise healthy, and so we admit them to the ICU if they are intubated or require close neurologic checks. The other patients we have are post-operative; some come to the ICU after large surgeries like Whipple procedures while others are transferred up from the floor with illnesses like sepsis.

It's interesting and educational for me. The last time I was in a surgical trauma ICU, I was a medical student. There is much I don't know - I am less experienced at reading CTs, working with chest tubes, and assessing lacerations than my surgical colleagues. And yet, there is a lot that transfers over from my experience in anesthesia and medicine. I'm much more comfortable with managing ventilators, intubating, and extubating patients. Management of common problems like sepsis, shock, agitation, pain, and hypoxemia is the same for surgical and trauma patients as anyone else. Indeed, my experience from my pain rotation, cardiac anesthesia rotation, and medicine internship help me address issues often glossed over by the surgeons: pain management, vasopressor selection, antibiotic regimens, and even simple things like insulin management. I really think a multidisciplinary team gives patients the best care as we all have our particular expertise and deficiencies.

Hearts

Despite the occasional depressing posts, I actually loved my two months on cardiac anesthesia. These are ostensibly some of the biggest surgeries on the highest risk patients, and the challenge is thrilling. I've never been bored in a pump case. The management engages all my technical, cognitive, and problem-solving skills as I plan each case, tailor the anesthetic to the patient and the disease, select and place my invasive monitors, and support a patient and family members through a huge surgery. And each case is different; changes in the surgery force me to adapt, anticipate, and intervene. As each case unfolds, I learn more and more about the human body, how it responds to surgery, and how we mitigate the stress with our medications.

The teaching was outstanding, and I became much more comfortable with the extremes of physiology, the most potent of drugs, and the techniques of intraoperative echocardiogram. The teamwork with the surgeons, perfusionist, and nurses was key to keeping the patients safe. The hours were long but the days flew by. As I near the end of this academic year, I begin thinking about post-residency training and a fellowship in cardiac anesthesia intrigues me.

Organ Transplant

I had a middle aged patient with primary pulmonary hypertension leading to multi-organ system dysfunction. Primary pulmonary hypertension is a rare entity where instead of having high blood pressures in the rest of the body, it occurs in the lungs. While there many possible causes of this, in my patient, it was idiopathic - we did not know why he had it. When people get the common sort of hypertension, the left side of the heart adapts by growing thicker, pumping harder. But the right side of the heart does not adapt that easily; it is a fragile thing, and instead of growing thicker, it often balloons out and ultimately fails.

My patient, as a result of longstanding primary pulmonary hypertension, had a failing right heart and resultant congestion and injury to his kidneys and liver. He was at the top of the transplant list, and when we had a donor heart, lung, and kidneys, we called him in for a triple organ transplant.

I thought this was interesting. There are some centers that would only transplant the lung; others that would transplant the heart and lung, and some that might do all three. The theory is that the lung is causing all  the mayhem and replacing it will allow the other organs - heart, liver, kidney - to heal. But the counterpoint is that if the right heart has taken too much of a toll from pushing against high pressures, then it may not fully recover. Similarly, the kidneys are liable to take a hit from cardiopulmonary bypass and the immunosuppressants, so if they are dysfunctional at baseline, we should switch them out at the same time.

What's the right answer? On the one hand, if you're going to transplant a patient, you might as well maximize their chances of doing well after the surgery; it would be a shame to choose only to transplant a lung and to find that the heart and kidneys failed after the operation. On the other hand, organs are of such short supply and using two additional organs where they might not be necessary deprives other transplant patients.

In the end, we transplanted the heart and lungs en bloc, an amazing operation where there is a moment when the chest cavity is completely empty. However, it was a difficult prolonged procedure, and post-bypass, we had to transfuse a lot of blood products and support the blood pressure with multiple agents. Thus, we elected not to do the kidney transplant at the time, but rather to stabilize things in the intensive care unit and dialyze as needed until the heart and lungs settled in.

The image shown above is an amazing shot of Bruce Reitz and Norman Shumway performing the world's first successful heart-lung transplant in 1981, shown under fair use, from scopeblog.stanford.edu.

Time of Death III

This post finishes the thoughts on the two previous blogs.

The feeling is a dull misery. The unexpected death of a patient, and on an operating table, caught my breath. We question whether it was the right decision to operate. We ask whether we could have optimized him better or anticipated more. We wonder whether those obstacles we kept on hitting were inevitable or things we could have avoided. We question ourselves.

But after laboring so long to make happen something that ultimately failed, exhaustion takes its toll. There is a physical exhaustion, the kind that makes you want to get into bed without a shower, and there is an emotional exhaustion, the knowledge that I ought to be feeling something but feel very little.

I mourn for the departed. I struggle to understand what it means to be in an occupation that tries to heal, and occasionally hurts. Sometimes the good attendings commiserate likewise, helping me debrief. In the end, there is a sense that it could not be otherwise, that we did try to do everything. Whether this is true, or just me reassuring myself, I do not know. But along with that thought is a fleeting question of whether we should have given up when we did. Putting someone through pointless suffering and misery is unjustifiable. But at the time, we simply do not know.

It is a truly awful feeling to hold someone's hand and induce anesthesia and be the last person they see and to say, "I will take care of you," and fail to do so. I dwell on this a lot, and I hope that someday this experience makes me a better doctor somehow.

Time of Death II

Please see the previous post for the preface of this story.

I took the patient into the operating room at 6:45am. I started the lines I would need for the surgery and held the patient's hand as I began the anesthetic. He closed his eyes, and none of us knew at that time he would not awaken again. The rest of the anesthesia preparation went smoothly and I was quickly ready for the surgeons.

The surgery itself was hampered every step of the way. The patient's prior sternotomy for an infection years ago had caused much scarring and we encountered a lot of bleeding as the surgeons dissected down to the heart. An injury to the heart itself forced us to go onto femoral-femoral bypass, which luckily we had prepared. When the surgeons finally exposed to the heart, I looked over the drape to see the aftermath of rampant infection; the tissue was macerated, cold and dead looking.

After the surgeons dissected down to the valves, they realized they had to reconstruct part of the heart wall as well because there was so little viable tissue. It was challenging work, as they took synthetic mesh, pericardium, and prosthetic valve, trying to rebuild the heart. They even asked for the opinion of other cardiac surgeons during the operation. We were on bypass for over ten hours before we tried to reawaken the heart.

After reconstructing the valves and part of the heart, we tried to transition off bypass. But as we did so, we realized there was a severe injury to the posterior heart, behind where we could see. The mediastinum welled with blood despite aggressive suctioning. We went on and off bypass several times but the surgeons simply could not repair the injury. It bled too quickly, was located too posteriorly, and could not be repaired. Four cardiothoracic surgeons operated, but there was nothing we could do. With that prolonged bypass time, the patient was also very prone to bleeding; we resuscitated him with generous blood products but to no avail.

In the end, the surgeons called time of death. I gave the rest of my fentanyl and midazolam, turned off my monitors, and unhooked the ventilator. We cleaned him, took out our lines, covered him up. It was devastating. I left the room after midnight. The whole team - anesthesiologists, surgeons, bypass perfusionist, and nurses - had been working to salvage the heart for eighteen hours.

Time of Death I

I'm not sure whether this is the type of post I should write. Intraoperative deaths are awful occurrences, a terrifying thought for patients and physicians alike. And though they are extraordinarily rare, they still do happen and to ignore that is to paint a rosier picture of medicine, anesthesia, and surgery than is the truth. This blog, as well as providing me a place of reflection for understanding those tough emotions of residency, is also openly available to the public, forcing me to balance the wish to write things honestly with the desire to censor anything that might be misinterpreted. This post is not meant to say anything about the patient, physicians, hospital, or circumstances in which a death happened. It is instead a sincere wish to help me make sense of my own feelings, hesitations, sorrows, and ruminations. As such, details about what happened have been changed to de-identify the situation.

I was assigned to provide anesthesia for an inpatient undergoing a complex cardiac surgery the following day. As is my habit, I saw the patient in the hospital the evening before surgery. In looking at the chart, laboratory values, and echocardiogram, I knew this was going to be a risky operation. Using a validated model, I calculated the mortality of the surgery to be over 30%.

The patient was a vibrant young man who, unfortunately, had endocarditis - infection of the heart valves. He had several bouts of endocarditis in the past, one of which landed him with a prosthetic valve, and now the bacteria were eating through this artificial valve as well as one of his native ones. Antibiotics could not clear this infection, and he was getting sicker and sicker with progressive heart failure. His kidneys were infected and failing; his liver was congested and injured; he had already thrown a septic embolus to his brain. The only way to clear this infection was to go in and replace the infected valves. If we did not, he would die.

He shook my hand. I sat down. We reviewed his history and when I examined him, I saw spots on his fingers and toes, evidence of a systemic infection stemming from his heart. I could hear the whoosh of his incompetent valves, no longer one-way. He had crackles up and down his lungs. He had so much trouble breathing, he could not lay flat. I talked to him and his brother quietly about what to expect with the anesthesia. I told him the risks of the surgery, including the fact that he may not make it through - something I don't usually say, but I felt obligated given the mortality risk calculation I had made. He told me clearly, "I cannot live like this, I want the surgery." He shook my hand again, and I said, "I will take good care of you."

What did I mean by that? I say that often, to almost any patient apprehensive of surgery, to reassure them that they are not alone in this experience, that my job as the anesthesiologist is to take care of the patient, to weather them through the surgery, to protect the body from the injury the surgeon would inflict, to understand how the anesthetic and surgical stress intercalate with the patient's other medical issues, to support the cardiopulmonary systems, to protect the brain, kidneys, liver, and even the eyes and limbs, to ward away pain, discomfort, nausea, suffering, and to be that person who holds the hand as the patient takes a nap and whose voice rouses them from slumber. "I will take good care of you," I said, to this patient who was putting his trust in me for a surgery I knew to be extremely risky.

Weary

I'm worn out. I was recently asked by a group of undergraduates whether I have ever regretted my decision to go into medicine. I haven't, not in a truly meaningful persistent way. But I did qualify that statement by saying I have been more tired during moments of medical school and residency than I imagined I could be. It's a daze, a weird sensation of knowing what needs to be done but feeling very little: a pounding head, hunched shoulders, and a craving to just close one's eyes. No matter what the old-timers say, I don't learn in that sort of daze and it puts people in danger. I can feel my response times slowing, my train of thought dwindling away, my words escaping me. I can sense the microsleeps creep up when I am waiting at a red light. It's an awful feeling, and luckily with residency work hours reform, I don't have direct patient care at these times and I can take a nap in the call rooms before driving home.

But it's not only that exaggerated feeling after thirty hours on my feet. It's also the accumulation of years. It's a little sad how long it's been since I've felt completely well rested for more than just a day. And the emotional burdens compound the physical feelings. In the next few blogs, I will try to describe some of the hardest cases that have happened in the last two months. This hasn't been easy, which is not to say I haven't enjoyed it because I've loved cardiac anesthesia. But nearing the end of my first year as an anesthetist, I'm weary to my bones and tumbling from one exhausting rotation to another.