Lucille Packard

Pediatric and obstetric patients are at Lucille Packard Children's Hospital, a separate hospital connected to Stanford. It's a bit confusing. When transferring a patient from one side to another (for example, from a Stanford ICU to the LPCH post-partum ward), we actually discharge the patient from one acute care hospital and admit them to the other, even though the wards are next to each other. Physicians can have rights at one hospital but not the other. The pharmacies are completely separate, and often we have shortages of a drug at Stanford that is available at Lucille Packard. It's very strange, and I'm not sure I fully understand the reason unless it is historic in nature. For residents, it can be a bit frustrating since the electronic medical record, protocols, and systems are different, yet some of us see patients in both places.

The Art and Diversity of Approaches

Like almost every field in medicine, anesthesia has multiple ways of achieving the same outcome. For example, adequate anesthesia for an ankle surgery can be provided through peripheral nerve blocks, a spinal anesthetic, an epidural anesthetic, or a general anesthetic. Selecting the best technique is, for lack of a better cliche, the art of medicine. Most people, including other physicians and surgeons, don't think of anesthesia that way. It is easy to see it as a cookbook endeavor, with simple recipes to create surgical conditions for this or that. But over the last year, I realized some of the subtlety and nuance has to do with choosing, adapting, and refining the anesthetic technique for the patient, surgery, and surgeon. For example, I've had two pregnant patients who've had severe fetal bradycardias with epidurals in place requiring emergent C-section. For one, I induced general anesthesia and for the other, I bolused the epidural for a surgical block. Deciding to do one or the other was a real-time moment-to-moment decision in conversation with the obstetricians, looking at the overall patient and fetal circumstances. It's been a really good experience seeing how these anesthetics are chosen and administered. I've also been encouraged to step out of the box and try different approaches for the same circumstance. It's a good reminder that although now I can reasonably manage an anesthetic for most patients, I still have a lot to learn about alternate approaches and practices.

Pain and Expectation

Does anticipation of pain worsen the actual experience of it? I've noticed, for example, that many patients jump when I put a lidocaine wheal in the back as local numbing for an epidural. I warn the patient it is coming, and this anticipation is worsened by the fact that the patient can't see what I'm doing. Does all of that make the subjective experience of pain worse? Since I use a tiny 30 gauge needle, I don't expect most people to jump. Perhaps the rigmarole around placing the lidocaine heightens the sensitivity of needle-phobic patients, making their overall experience worse. I imagine this is important in children scared of shots. They have fallen, scraped their knees, banged their elbows, stubbed their toes, and yet a tiny shot scares them far beyond playing outside. Knowing this, then, I wonder if we should be catching patients off guard rather than warning them. Maybe I should inject on "2" when counting "1-2-3." Is that ethical? Is that appropriate?

Complicated

The vast majority of pregnant patients are young, healthy women; although some may have asthma or hypertension or diabetes of pregnancy, for the most part, they are much less complicated than patients in the general operating room. In fact, this is crucial to the success of pregnancy. If the average Stanford surgical patient (70 year old with hypertension, hyperlipidemia, coronary artery disease, diabetes, chronic obstructive pulmonary disease, arthritis) were subjected to the stress of delivery or C-section, there would be significant morbidity and mortality. It is the young healthy body's resilience that allows the parturient to fly through pregnancy without difficulty.

However, we do have a few patients with complex medical histories or high risk obstetric states. One patient has a congenital anomaly that makes all of anesthesia difficult. With missing limbs, IV and arterial line access become limited. Her height and weight make spinal and epidural dosing difficult. Severe scoliosis makes placement of the neuraxial block challenging. She has a fixed cervical spine and so emergent intubation is out of the question. With only one lung, her breathing is quite risky.

She is scheduled for an elective C-section, and we spend a long time planning the anesthetic. An epidural is placed for post-operative pain control but not intraoperative anesthesia (since the dose is difficult to estimate and there is no margin for error because emergent intubation is impossible). She then undergoes an awake intubation with a fiberoptic bronchoscope prior to induction of general anesthesia. The surgeons deliver a healthy baby, she goes to the ICU intubated due to her lung disease, but is extubated and transferred to post-partum the following day.

A separate case, in which I was not involved, is a mindboggling story. A patient with placenta percreta is scheduled for a C-section. In this disease, uterine tissue (chorionic villi) is found outside the uterus, and in this case, in the bladder. The problem is that this tissue is highly vascular and bleeds profusely. In order to minimize general anesthetic to the fetus, multiple IVs, an arterial line, a central line introducer, and an epidural are placed awake. The epidural is used while the urologists place ureteral stents. Then general anesthesia is induced and the baby is delivered by C-section. The bleeding is uncontrolled, massive, ongoing hemorrhage. Over 12 hours, 75 units of blood is given along with fresh frozen plasma, platelets, cryoprecipitate, and recombinant factors. Interventional radiology, vascular surgery, urology, and trauma surgery are all called to help stop the bleeding. A balloon is placed in the aorta and inflated to decrease blood flow to the lower body. At one point, the patient has a cardiac arrest requiring compressions and epinephrine. Yet in the end, the patient makes it to the ICU, is subsequently closed with bladder repair, and is now doing fairly well, extubated and happy.

These stories remind me to respect the physiologic changes that occur with pregnancy; most of the time, everything goes smoothly, but planning is required for those high risk cases that could potentially be life threatening.

Inception

Image shown under Fair Use.

Men

It's pretty interesting seeing how different husbands (or boyfriends or fathers of the baby or significant others) act during their wife's (or girlfriend's) labor, delivery, and C-section. Some want nothing to do with it, are afraid of seeing anything, spend their time getting coffee. Others try to be helpful and supportive, almost to a fault; they are the ones who bring up every detail they read in a book or heard in a class. Sometimes, they can be destructive, yelling at their partners, becoming frustrated with the process, unable to empathize with the woman's experience. I had one husband who, throughout an entire C-section, was on his phone. I also had another husband who answered all the questions for his wife, refusing to let her speak for herself; in fact, I wasn't sure she understood English until I had a moment with her alone and asked. And there are husbands who are the opposite; their wives order them around with ferocity. Many husbands parade cameras around, even as their wives are in intense pain.

It's a weird world, and everyone adapts to it differently. For some couples, pregnancy and childbirth may be the first big stressor. I hope that with each relationship, both people find the right roles for them to best support their partner.

Feel

A lot in medicine is based on feel. The internal medicine doctor taps the belly to identify the liver, places a hand on the chest to feel an abnormally dilated heart. The obstetrician determines how dilated a cervix is, where the baby is within the birth canal. The orthopedist and rheumatologist estimate the amount of fluid within a joint. The neurologist assesses the tone of all the limbs.

It wasn't until I got facile with epidurals that I understood feel. Placement of an epidural catheter is primarily a tactile activity, and once I figured that out, I found it immensely satisfying. Like placement of IVs and arterial lines, I quickly learned that identifying the right location to start makes all the difference. Although it is a weird thing to say, touch is something that can be learned. Over this rotation, I have really begun to understand what the spine feels like, and consequently, I've become much more successful with epidural placements.

Part of the epidural is advancing a large needle through the tissues of the back into the proper space. As I've become more attuned to the process, I've learned the nuances of each type of tissue as I pass through. By the feel of the needle and the resistance I am getting, I know where I am, which ligament I'm in, and how close I am to the epidural space. It's a really fun epiphany and makes the process of placing the epidural extremely satisfying.

Cesarian

Although Cesarian sections were done in Roman times, there isn't evidence that Julius Caesar was born through one. Indeed, they appeared to be done for mothers who died in childbirth as it was against the law to bury someone who was pregnant. In any case, the C-section has been described many times through history, but it isn't until the last century that its safety has really improved.

What interests me about C-sections is that its incidence is so high. The rate in the United States is about 30%, and it is even higher in some other countries. Why are we doing so many surgeries for childbirth? Part of it is self-sustaining; after one C-section, many patients elect to have future C-sections because of the risks associated with trial of labor after Cesarian (TOLAC). But it still strikes me that we are doing more C-sections than we need to be.

Of course I don't make that decision as an anesthesiologist; if an obstetrician calls a C-section, I prepare the patient for surgery. While the ideal technique is a single shot spinal - local anesthetic into the intrathecal space giving surgical numbness - we occasionally do a combined spinal-epidural technique and rarely, the general anesthetic.

One issue I see is that we don't have great monitors of the fetus during labor. While fetal bradycardia and nonreassuring decelerations worry the obstetricians and can lead to a stat section, most of those babies do great after delivery. We simply cannot differentiate between true fetal distress and false positives. And the legal environment doesn't help; it is easy to sue someone for not acting and having a poor neonatal outcome rather than acting, even if that meant unnecessary surgery. I also wonder how long someone ought to be laboring without progress before a C-section is called for arrest of descent. I'm not sure anyone really knows, and perhaps that is leading to the wide variation from country to country in the rate of C-sections.

Image of baby being delivered by Cesarian shown under Creative Commons Attribution Share-Alike License, from Wikipedia.

Death and Dying II

In the archives of this blog, you can find many posts where I explore the process of death in a modernized medical era. I argue that perhaps the death most people envision for themselves is not the type of death that occurs in hospitals, intensive care units, and cancer wards. I want to try to balance that notion that we ought to do absolutely everything we can for everyone because I don't think that's the right way to do medicine.

Since having a grandparent in that situation, I have definitely found that it is easier said than done. This is the kind of argument which makes sense from a faraway lens, looking at economics of medicine or generalizations of intensive care or risks and benefits of interventions. But when it is staring at you in the face, when it involves someone you know, when it suddenly becomes real, I find that the situation becomes much harder. Rationalizations cannot quell emotion. I know perfectly well that the end of life my grandfather wanted is consistent with hospice values. But I cannot help thinking down the line of "what else can we push medically?" There is a large whiteboard with my grandfather's entire history, all the chemotherapies tried, all the lab values, and I cannot help dwelling, trying to make medical decisions even though I know the ethical and caring decision is to let all that go. So I am beginning to understand, to some degree, the internal conflict families feel when I approach them about a code status or goals of care or whether it is time to stop.

Death and Dying I

When palliative care physicians, the caretakers of those at the end of life, speak to families about a loved one who is dying, they ask, "What was he like when he was well? What are your best memories of him? Tell me about his personality." I did not realize the importance of this until now. These questions were always the ones I forgot when I lead a family meeting, the questions I thought were small talk. But recently, one of my grandparents passed away, and now I really get why the palliative care doctors ask.

When I think of my grandfather, I don't think of those last few months suffering from metastatic cancer. I don't think of the progressive indignities he went through, the loss of bowel function and the ability to eat and the ability to walk. I don't think of the transition to hospice, that mixed feeling of relief and giving up, that release to the certainty of time. No, I think of the fierce pride he had in his children, the stoic persistence to work late in the night, the soft care for his wife, the unrelenting trust he had in people, to a fault. I think of his grasp as he shakes my hand, the way he communicates with facial expressions, the quiet customs he keeps.

I know now why that period of mourning, for some people, means recalling and remembering the person they knew, and why palliative care doctors ask. Especially in modern medicine, patients can be depersonalized near the end, and we must not forget the persons we love, even as they are dying.

Medical Noise

Because of how busy residency is, I haven't really mingled all that much with the blogosphere. There's really been an explosion in social media in the last few years; when I started blogging in 2001, there was only Blogger, Xanga, and Livejournal. Each teenager (mostly) carved out a little space in the internet for him and his friends to read. There were some discussion boards, and ASCII was all the rage.

But now, people are Twittering from planes, spreading viral videos on Facebook, trying to get +1 momentum on Google+, teaching classes via podcasts, collaborating over wikis. Careers, fortunes, and reputations have been made on the Internet. I pretty much missed the boat. This blog has been trucking along  for years and I haven't really cultivated a lot around it. It's never been a high priority to garner readers or engage with other bloggers, though I did make some inroads with UCSF Synapse, the student newspaper.

In any case, I did catch the attention of a reader, David, who works for a JRS Medical Supply, who referred me to Jason, editor of the blog Medical Noise. They did a quick interview which is posted here. Thanks for supporting me, and hopefully this small attempt to drum up some more attention will turn out well.

In the same vein of things, my other blog Case of the Day can be found here.

Epidural

Epidurals are interesting interventions. For thousands of years, laboring women have not had the option of having one. Yet since the advent of epidurals, many women consider it an essential component of childbirth. It is a charged topic. Upon meeting patients, almost everyone has an idea of what they want. Some emphatically want an epidural as soon as possible, others only want an epidural-free natural childbirth, a few want to see what happens. Obstetricians and anesthesiologists have their opinions too. And family members and friends and baby books and Internet discussion boards all have something to say.

I try to remain as neutral as possible. The most ethical thing is to explain, as plainly as possible, the risks, benefits, and expectations of an epidural. I have done the unfortunate wet tap leading to a post-dural puncture headache. I have also done dozens of perfectly working epidurals for wonderfully satisfied patients. I have also cheered for the woman who elects not to have any neuraxial blocks. I try to be as supportive as possible for women to choose what they want.

This is not the case for all anesthesiologists. In private practice, there is an incentive to do more epidurals because it is how anesthesia gets paid. Even ignoring financial incentive, there are patients in whom we may recommend an epidural. If a patient may possibly have an emergency requiring C-section and is a poor candidate for general anesthesia, we really press for an epidural so it could be used for surgical anesthesia during a crash section. For example, I saw a patient with poor neck mobility from prior surgery who was having a VBAC/TOLAC (vaginal birth after cesarian or trial of labor after cesarian) and recommended an epidural. The VBAC/TOLAC puts the patient at risk for uterine rupture, an indication for emergent surgery, and having an epidural in place for the C-section may reduce the risk of a failed intubation and complications from general anesthesia. (This being said, uterine ruptures can be so emergent that we'd default to general anyway.)

L&D

Obstetric anesthesia has a pretty regular routine. The two day residents arrive at 7AM to get signout. We check on pre-existing epidurals and then prepare for the scheduled operating room cases of the day. Throughout the day, women are admitted for active labor, induction, or obstetric concerns such as preterm contractions. We see everyone with any complicated medical or obstetric history as well as those who may need labor analgesia. About 70% of patients at Lucille Packard Children's Hospital request epidurals so with 15 potential labor rooms, it can get pretty busy at times. In between, we see our post-op patients and ensure that those with ongoing epidurals are getting relief. At around 2:30PM, the night resident arrives, and if there is time, the attendings try to do some teaching while the fellow covers the service. We sign out at around 4:30PM.

Labor and delivery can be very variable. For the most part, the flow of patients is unexpected, and turnover can be really quick. Occasionally, multiple patients need epidurals at the same time and we have to triage and multitask as best we can. Situations that seem to be progressing well can turn into a stat C-section without warning. So even though there are only a few things we do and see as anesthesiologists, we have to be ready to intervene at any moment.

Friday the 13th

This month I'm on obstetric anesthesia, a very different world than both the intensive care unit and the general operating rooms. In theory, it shouldn't be too bad. There are only a handful of anesthetic interventions we need to learn: the spinal, the epidural, the combined spinal and epidural, and the general anesthetic for the parturient. There are only a handful of medical states to learn: pregnancy, pre-eclampsia, induction of labor, twins, fetal bradycardia, post-partum hemorrhage. So it is easy to get into a routine of sorts and focus on perfecting these specific anesthetic skills.

There are usually 4 to 6 scheduled procedures each weekday, mostly elective C-sections and occasionally tubal ligations and cerclages. However, as today is Friday the 13th, there were no scheduled C-sections. Funny how superstition can be.

Library

I have rediscovered the library. Once a treat of childhood, a staple of high school, a dungeon of college, I seemed to have lost it for a few years and now found it again. Perhaps this is anesthesia allowing me some breathing space to read for pleasure. I picked up a few books including Anne Lamott's Bird by Bird, a humorous and candid portrayal of life as a writer. It reminds me that to be a writer, one must read and read fervently. One must also write those awful first drafts, the spillage of racing thoughts onto print, and in some ways, that is the composition of this blog. Maybe one day, this will coalesce into something coherent and solid, but for now, thank you for following my ramblings, and if you have suggestions for things to read - anything - please let me know.

SICU

All in all, the surgical ICU was an interesting and educational rotation but not an incredibly pleasant one. It was important for me to see the post-operative management of complex or complicated surgical cases. It felt very much like anesthesia working with these patients the night after surgery, trying to adjust their medications, wean their ventilator, and determine how much fluid or blood was necessary. Other cases were those admitted with severe infections, hypotension, or respiratory issues from the emergency department or the floor; this felt very similar to the medical ICU. Lastly were trauma patients who I was least comfortable with but who I got to understand over the rotation. We even had one patient who was an anesthetic complication: negative pressure pulmonary edema from laryngospasm after extubation. The one cool skill I developed over the rotation was the use of bedside transthoracic echocardiogram to take a quick look at the heart. I became more comfortable with putting in arterial and central lines independently and intubating patients in the unit.

The rotation reminded me how pleasant it is to be an anesthesiologist with one patient to worry about, to have absolute control over each parameter, to make and carry out each intervention. Instead, as a resident in the unit, I ran from room to room, put orders into the computer, tried to take in and understand the complex histories of a dozen patients. I have always been interested in the ICU, and I still am, because I think being an attending will be far easier than being a resident. Although I like the extremes - monitoring a patient one-on-one closely or overseeing a panel of patients - I don't like the in-between, the floor work feeling of having to be in a dozen places at once.

ICU and the Cost of Healthcare

A man who takes very little care of himself comes in with diabetic ketoacidosis - uncontrolled sugar levels causing severe electrolyte disturbances - and overwhelming sepsis - infection of the bloodstream. The source of his infection is obvious; he has the largest decubitus ulcer I've ever seen. Decubitus ulcers are one of those things (similar to a bowel regimen) that we never learn in the basic science years of medical school yet we see them all the time in our clinical years. They are pressure ulcers or bedsores that happen mostly in bedbound patients from sitting or lying on a bony prominence too long. This patient's decubitus ulcer must have been brewing for weeks; it was over a foot long, deep into the muscle, an awful nonhealing infection. It was clear that no one had been taking care of this gentleman's health for a long time. He was brought to the operating room to debride the wound and take out nonliving tissue, then transferred to the ICU for further management.

The patient has been in the intensive care unit for three weeks. Each day in ICU costs around $20,000 as a baseline. Furthermore, for much of the stay, he required a ventilator, multiple drips for his blood pressure, hourly glucose checks and insulin titration, an array of wide-spectrum antibiotics, and multiple operating room debridements. I wouldn't be surprised if the hospital bill is over a million dollars, and that won't count the rest of his stay, his long-term rehabilitation, and the home care he will need if he makes it out. I'm not even sure he will; the bacteria he is growing are highly resistant, he has an abysmal nutritional status, and he is unlikely to ever fully heal that decubitus ulcer.

I don't want to pass a judgment on this type of patient, but we see it all the time. These patients have no resources, ability, or willingness to care for themselves, and as a result, their disease progresses so far that they ring up million dollar bills for an outcome we find upsetting. Are these endeavors worthwhile? Are they cost-effective? It's easy to say on a population level or a policy level that this type of care is not sustainable, but how do you say that to the individual person dropped off in the emergency department?

The hope, I believe, is that universal health care will ameliorate this problem; since everyone will have access, we will hopefully see fewer disasters of neglect. But it still does not obviate the problem of economics; what makes sense? What is ethical? And what is practical?

Emotions

Plutchik's Wheel of Emotions is a pretty fascinating way at looking at how we feel. I think the older I've gotten, the harder it is for me to characterize how I feel. When I was young, I could easily identify whether I was happy or afraid or bored or amazed. Now, perhaps from the exhaustion of work, I find myself a little more numb. I don't think it's a good thing. So recently I've been looking at the chart and trying to triangulate where my feelings fall.

Image is in the public domain, from Wikipedia.

PET

Sometimes I see an image like the PET scan above and find beauty even in dry, scientific, clinical studies. Science and art, sometimes considered opposite ends of a spectrum, are actually not so far apart.

Image is in the public domain, from Wikipedia.

Life and Death

Details for both these patients have been changed.

Being in the intensive care unit really reminds me that we care for those patients that straddle the ghostly boundary between life and death. Two patients are transferred to us from outside hospitals. One arrives with a catastrophic retroperitoneal bleed from a fall. She is bleeding into her back, but the surgeons in the other hospital do not feel comfortable operating and have no interventional radiology facilities. She has received a good amount of blood before getting here but requires further transfusions on arrival. I quickly intubate her for respiratory distress, put in an axillary arterial line, and send her to interventional radiology where the active bleeding artery is located and embolized. We all high-five each other, but upon returning to the intensive care unit, we find that the patient's lactic acid levels skyrocket from 2 to 10. Lactic acid is a reflection of ischemic or unoxygenated tissue. We don't know what's going on and decide to take her to the operating room where the trauma surgeons wash out the belly. Although we have a concern for ischemic or dead gut, there are no clinical findings. Nevertheless, upon returning to the intensive care unit, the patient's lactate drops quickly and the blood pH normalizes. We are able to extubate the patient, send her to the floor, and discharge her home in five days. We never find out what exactly went wrong; whether she had some small amount of peritonitis that needed a washout and antibiotics or whether we were just seeing a delayed reflection from the initial retroperitoneal bleeding. But occasionally supportive care without a definite answer is sufficient to get someone through a crisis.

On the other hand, we can know the cause of illness yet be unable to rescue a patient. A woman is transferred from a small community hospital several days post-operative from a gynecologic procedure. The outside hospital physicians initially believe the patient is simply having a slow recovery; bowel function does not return and the kidneys suffer a little, but these are not uncommon from an operation. Several days after the surgery, however, she is transferred to our hospital for consideration of dialysis. Shortly after she arrives, she has a witnessed cardiac arrest. The code blue team is able to revive her, intubate her, get adequate access, and send her to the scanner before getting up to the ICU. On arrival, her pH is 6.9 with a lactate of 20, nearly incompatible with life, and we have the looming job of resuscitation. Her belly is hard as a rock. The diagnosis is abdominal compartment syndrome; something in the belly is causing the pressures to skyrocket. We have to paralyze her, put in a dialysis catheter (my first), start broad-spectrum antibiotics, and normalize her blood chemistries as best we can. After she is stable enough to go to the operating room, the trauma surgeons open up the belly, and this time, they find dead gut. They resect as much of it as they can and leave the abdomen open. We don't know why she has such an intestinal injury or how it is related to her original surgery. However, necrotic bowel can lead to rampant infection, the abdominal compartment syndrome, and the cardiac arrest. Despite doing everything, the patient passes away the next day.

The similarity and proximity of these two cases made me think a lot about the intensive care unit. Two patients with intraabdominal catastrophes leading to a severe lactic acidosis had completely different outcomes. Looking back, we think that the first was salvageable, but the second was too late. ICU care, perhaps, is about finding those cases where a difference can be made.

Philosophy and Responsibility

A friend was recounting a story in which he was driving through a city and saw a stray, abandoned dog running through the streets. Worried that the dog would be hit by oncoming traffic, he called animal control and had the dog picked up. The animal control officer was very kind but also blunt: he said that the city had so many stray and abandoned dogs that the pounds were full of them. The dog would be tested for aggression and if he passed, he would go to one of the pounds, but would be unlikely to ever find a home. If he did not pass, and it seemed as though many don't, he would be euthanized. Seeing the emotion on my friend's face, the officer said, "You did the right thing. He would have been hit by traffic and likely bleed to death in pain. Now he gets a few weeks of shelter and food, and if he had to be euthanized, it would be done in a painless fashion."

The moral dilemma is this: my friend felt that despite saving this dog from certain death, he still condemned him to another kind of death, albeit more peaceful. He felt it a moral transgression to have intervened when the best most likely outcome was still unacceptable to him. What obligation do we owe those we save? What obligation forms or develops where no obligation used to be? If he had simply driven past, he would not have committed any moral error. But in doing what he thought the right thing at the time, he finds himself inevitably bound in some moral gray zone.

Image shown under GNU Free Documentation License, from Wikipedia.