Baby Robot

I like this picture of the Da Vinci robotic surgical system because it captures the attending surgeon in the console as well as the plastic-draped robot hovering over the patient. While I've provided anesthesia for several adult robotic cases, I did my first pediatric robot surgery in a child the other day. From a purely medical standpoint, the case wasn't too remarkable; it was a healthy child undergoing kidney surgery and the anesthetic was standard for a laparoscopic intervention. But I thought it was pretty impressive that the robot, which towers over me (I admit, I'm not incredibly tall) could be used to make delicate and precise movements in the belly of a child not even 2 years old. Watching the surgeons manipulate the tissue on the monitor, I find that in such a small child with such tiny organs, perhaps robotic-assisted surgeries are better than traditional approaches because the robot can translate our gross movements into much finer, graceful maneuvers.

Image is in the public domain, from the National Cancer Institute.

Children and Trauma

One of the most common causes of childhood injury and mortality is accidents, and unfortunately, we see these kids as frequent flyers to the operating room. The stories devastate me; when I hear about a previously healthy kid who gets hit by a car, has a fall, or gets into an accident, I feel awful about the situation. The most severe of these injuries may necessitate a prolonged stay in the intensive care unit, multiple orthopedic procedures, skin grafting for wounds, even a tracheostomy or gastric tube for breathing and feeding support. The patients and parents fight an uphill battle, trying to quell infections, maintain nutrition, control pain and emotional tumult, keep all the organs functioning. One particular kid, all the anesthesiologists and staff know because he's come to the operating room over and over again. We do our very best to take care of these children, but for these types of injuries, prevention is the best medicine.

Book Review: The Curious Incident of the Dog in the Night-Time

Although it was written in 2003, I had not heard of Mark Haddon's The Curious Incident of the Dog in the Night-time until recently. I was simply enchanted by it. The winner of multiple awards, this short novel is written from the perspective of a 15 year old boy with something on the autism spectrum. The author does an absolutely superb job delving into the mind, personality, thought process, desires, and motivations of the narrator. As the mystery novel unfolds, we become more engrossed in understanding what it's like to be different, to perceive the world differently than others, and to be perceived differently by the outside world. A short 200 page piece written in sections, its target audience is the nebulous "young adult," though I think anyone would appreciate and learn a lot from this novel.

In reading this book, I realized that I and many people I know have some traits of this "abnormal" boy narrating the book. We see how he adapts to his condition, how he gains insight to the way he is, and how he struggles and succeeds to function in the world. Many of his obsessions and compulsions reflect things I remember from my childhood: how certain arbitrary things would make a day a "good day," how I became obsessed with a very small niche of knowledge (like dinosaurs or planets), how I made lists and schedules. As we grow older, we conform into the people society needs us to be and lose some of those quirks that once defined us. The Curious Incident of the Dog in the Night-time returns us to that era in life when we valued our individuality, saw the world through a novel lens, and cared very little about how others were bothered by our oddities and awkwardness.

Image of the cover shown under Fair Use, from Wikipedia.

Pediatric Pain Service

When we are on call, we cover the pediatric pain service. We also receive some lectures by the pain attendings, and many of them work in the operating room as well. At first, I was surprised there was such a thing as the pediatric pain service. How many kids have chronic pain? What kinds of cases did they manage?  But I soon saw that the mix was not so different than the adult pain service. A subset of patients have epidural or peripheral nerve catheters coming out of the operating room. Whether a TAP block for an abdominal surgery or a thoracic epidural for a lung resection, these patients needed management of the catheters postoperatively. A few patients had chronic pain from ongoing diseases. Many inflammatory bowel diseases hit teenagers and those who have had multiple surgeries develop a high pain tolerance and constant discomfort. The hardest cases for me to deal with were unfortunate children with metastatic cancer. Although rare, Stanford's pediatric oncologists see a high proportion of patients because of their expertise. Rarely, patients have true pain syndromes like complex regional pain syndrome. The most unusual cases, I think, are cases of opiate weaning for newborns whose mothers used chronic opiates or heroin. With a pretty good mix of cases, I learned quite a bit and reinforced my understanding of pain pathways and multimodal intervention techniques.

Bad Outcome II

This is a continuation of the prior post. Once the medical questions shake out, the weightier issues come to bear. How does one emotionally deal with an unexpected death of a pediatric patient? It's absolutely devastating. Immediately, all I could feel was shock. It was difficult to think, difficult to process anything. And still, I was on call; I was finishing other cases, returning phone calls for the pediatric pain service. I felt very removed, doing things by rote, aware but not engaged. During the first few days, many people came to talk to me about the experience, and sometimes I wanted to discuss it, and sometimes I didn't. It very much became a Thing, and I wasn't sure I wanted it to be a Thing. It dragged on me. Work was no longer fun; my motivation was gone. I even thought about taking time off, which some attendings felt perfectly reasonable. It took weeks for my heart to stop racing, for things to settle down, for me to realize death is an extremely rare occurrence, for my emotions to heal. Even now, I think about the case from time to time, and I'm not sure how long it will take to fully achieve closure.

What I feel pales in comparison to the grief of the parents. They had brought in their most precious possession, their healthy child, and entrusted care to us, and we caused an irreparable injury. I cannot imagine how they feel now, how much they regret bringing her to the hospital, how it aches when they come home to an empty room, how they tell their other children, family, friends, school, church what happened. I am sorry this happened. Nothing we do can make it right again.

Bad Outcome I

Sometimes no matter what we do, a situation cannot be salvaged. Despite all the preparation in the world, anticipation of difficulties, immediate diagnosis and treatment, and timely intervention, there are surgical misadventures for which we cannot compensate. In any endeavor, there is the possibility of mistake, failure, unforeseen obstacles, and we hope that in some realms - nuclear power plants, airplane control towers, pediatric surgery - these never happen. But they do.

I was involved in a situation where a healthy child had an elective surgery. The operative plan changed mid-course due to unexpected anatomic abnormalities. In fact, the surgeon talked to the family and consented for additional procedures that had not been planned. Things progressed well for a few hours until the surgeon suddenly encountered a brisk arterial bleed. The surgical field welled up with blood, and the lesion was so deep they could not get surgical hemostasis. I managed it as anesthesiologists do: obtaining large IV access, arterial access, calling for blood, resuscitating aggressively. The vital signs were always stable. Since the bleeding would not stop, we rushed the patient down to interventional radiology to see if the vessel could be embolized. That in itself was a learning experience; I had to quickly pack up my emergency airway equipment and drugs, all while resuscitating this actively bleeding patient. Unfortunately, the cath showed a devastating lesion that extended into the brain. Neurology was consulted and placed EEG leads while the neurosurgeons embolized the lesion, but the damage had been done. Even without anesthetics on board, the patient had little brain activity. Imaging was consistent. The patient never woke up.

Anesthesiologists like to banter that our job is to protect the patient from the surgeon. Lamentably, we don't always succeed. There is so much that goes through my mind and heart after experiencing a case like this. Everyone focuses first on the medical points. Was this purely a surgical mistake? Could it have been avoided? Should we have aborted the procedure when we came across the first obstacle, ordered more tests, asked for another consult, decided to plan things for another day? It's easy in retrospect to say so, but it's not uncommon for surgeries to run into minor hiccups, and how do you decide when something is minor or major? Could there have been anything else we could have done to stop the bleeding, or could we have gotten to the cath lab faster? Was there anything more we could have done for the anesthetic and resuscitation? As I ponder this case, I feel that there wasn't much more I could have done from my perspective, and that this injury was simply non-survivable to start.

Fiberoptic Nasal Intubation

On call in pediatrics today, we had an emergency case of a patient with a critical airway. A four year old had an extremely swollen tongue, so bad he couldn't eat, drink, or even breathe through his mouth. His voice was severely distorted. Looking into his mouth, all I could see was tongue. How do we secure the airway for the ENT surgeons to excise the lesion?

Luckily, the four year old had an IV and in fact was incredibly cooperative through the entire procedure. We used dexmedetomidine and ketamine for the child to fall asleep, a carefully selected combination of anesthetics to keep the patient spontaneously ventilating. Then after a lot of oxymetazoline, I inserted a tiny pediatric fiberoptic endoscope into the nose, following it back into the pharynx. I navigated around the massively enlarged tongue until I could see the vocal cords. I had to time my movements to the patient's breathing; as inhalation opened the airway, I had to quickly duck through the cords into the reassuring tracheal rings. We then slid the endotracheal tube over the scope and ventilated the lungs. It was a lot of fun, a little nerve-wracking, and pretty satisfying in the end.

Image shown under Fair Use, from faculty.washington.edu.

Neonate

The smallest child I've anesthetized so far was a three week old premature infant who was about three kilos (6.6 lbs). Prematurity, unfortunately, is associated with a lot of medical problems, and this infant in the neonatal intensive care unit needed an abdominal surgery. She was tiny. It was amazing and a little terrifying to hold this baby and carry her onto our warmed bed. She seemed so incredibly fragile, and our EKG leads looked enormous on her chest. In another time and place, I might have found our neonatal equipment - the breathing tube, the blood pressure cuff, the oral airway - cute because they were so small, but now I found the task daunting. All my medications were double diluted or drawn in TB syringes because the doses were so small.

Suddenly things that were irrelevant for larger children or adults became important. I had to debubble my IV tubing. I turned up the room temperature. I learned the appropriate rate and squeeze to mask ventilate the infant. After inducing anesthesia, I had to intubate quickly and realized the airway anatomy was tiny; there was barely a millimeter of space where I could lift up the epiglottis and see the vocal cords. If my hand shook the smallest amount, the epiglottis flopped down and I lost my view. Luckily, everything went quite smoothly, and I managed to keep my youngest child alive during one of the first surgeries of her life.

Image of a healthy newborn about the size as the baby described above shown under GNU Free Documentation License, from Wikipedia.

Anesthesia for Minor Procedures

Unlike adults, children often don't tolerate even minor procedures. You can't explain to a toddler that she has to be still during an MRI despite the loud noises it makes. You can't even get close to a teenager with a scalpel to do a procedure that an adult would tolerate with local anesthesia. So anesthesiologists are often involved in cases where perhaps the anesthetic is as big as the procedure itself. I've done a couple general anesthetics for chest tube placement, bone marrow biopsies, CT and MRI scans. The craziest request we've gotten, however, was a general anesthetic for IV placement in a child who refused to have an IV. There, the risks of a mask anesthetic were probably higher than that of the IV placement.

Poem: An Old Gossip

In the last writing workshop, one prompt was to write about "an old gossip." This is the poem I jotted down.

 -
An Old Gossip

It was an old gossip he found
a shamed part of him
unreal until he saw it in writing
ancient enough no one would care
not even his wife, of whom it concerned.
He found the smudge drawing
while opening boxes in the attic, the kind
sealed with layers of tape, labeled “other.”

He took that old gossip
ancient enough no one would care
and tucked it into the breast pocket
of his shirt. He kissed his wife before going out
and in the moment of embrace
felt that folded corner
and its dozen fingerprints grow hot,
hot as his face.

After he entombed it, he went drinking with friends.
A lot of shots went round. In the morning
after he sobered up, he bought two bouquets
daffodils aflutter. One, he lay on the now-quiet
mound of earth. The other, he gave to his wife.

Parents

I wrote a post some time ago about the variable demeanors of dads in the labor and delivery suite, and a similar comment can be made about parents. How do parents act when their child is about to go into surgery? Most are pretty appropriate: concerned, anxious, but reassurable. But there are some who go to extremes. One mother sobbed uncontrollably, and her toddler, who up until then had been perfectly content, realized something was wrong and began crying inconsolably as well. This didn't make things better; anxiety feeds on itself. I've had aloof parents whose questions encompassed where the nearest cafeteria was. I've had simply exhausted parents kept awake by their child's discomfort. I've had parents who come with pages of questions. All this is the spectrum of normal, I suppose, and it's very interesting to see and learn to deal with the diversity of behaviors, which are completely understandable when one has to let go of her dearest possession - her child - into the hands of strangers.

Chekhov

Most people think of Anton Chekhov as one of the greatest short story writers but few remember that he is also a physician. I ran across this quote in a letter he wrote and really liked it:

"Medicine is my lawful wedded wife, and literature is my mistress. When I've had enough of one, I can go and spend the night with the other. You may well call this disorderly conduct, but at least it stops me getting bored, and in any event I am sure that neither of them is the loser from my infidelity. If it were not for medicine I would not be devoting my leisure moments and my private thoughts to literature; I haven't the discipline to do so."

Image of Chekhov's signature is in the public domain, from Wikipedia.

What Surgeries Do Children Get?

Most children don't need surgery, and even for someone in medicine, it's hard for me to name all that many pediatric conditions that require surgical intervention. But since starting pediatric anesthesia, I've found my days quite busy with many short cases. In the ENT room, we do a lot of tonsils and adenoids as well as laryngoscopies to evaluate hoarseness, recurrent croup, and sleep apnea. The urologists perform many circumcisions and kidney surgeries for vesiculoureteral reflux. Plastic surgeons excise lesions, reconstruct ears, and fix congenital deformities. In the general surgery room, many of the procedures are similar as on adults: bowel resections for necrotizing enterocolitis, resection of choledochal cysts, thyroidectomies, and lymph node biopsies. Since my experience in pediatrics is limited, and much of it comprised well child visits, a lot of these surgeries and diseases are new to me. I have a lot to learn these two months.

Distraction

To kids, going to the hospital is right up there with going to the dentist. When they arrive in our pre-operative area, they are scared, anxious, crying, inconsolable. How do we as anesthesiologists convince them to come with us to a terrifying, cold operating room, allow us to put a mask on them, or get close to them with a needle? Part of pediatric anesthesia is learning the developmental stages of children, their coping mechanisms, and how to negotiate with them. They are certainly not "little adults." Calm rationality works only with a minority of children and teenagers. For the rest, we cajole, trick, distract, and amuse.

For some, we create stories. The mask becomes an astronaut mask, the bed a space shuttle, the surgical lamps satellites. For others, we challenge. The blood pressure cuff measures muscles, the balloon on the breathing circuit tests a swimmer's lung capacity. I like bantering with the kids; asking them about when school starts or their next birthday party or their siblings takes their attention from the frightening machines that line the hallways. We flavor the masks with watermelon, strawberry, caramel, or wintergreen scents (no one has asked for the last one yet, but one can hope). We give them masks for their dolls, stickers for their stuffed animals. Children span a huge emotional range; some have been through this many times and know exactly what to expect; some shed their apprehension when we bring in our toys; some refuse to trust us no matter what we do. It's playing and it's fun, but we are also keenly aware that we have to balance the child's well-being, the parent's anxieties, the surgeon's desire to get started, and the efficiency of the operating room day. Overall, though, it's a pretty fun job.

Laser Treatments for Port Wine Stains

I had one day of quite unusual cases; we provided anesthesia for pulsed dye laser treatments for port wine stains like the one shown above. Performed by dermatologists, the treatments themselves take just five minutes, but many pediatric patients don't tolerate it, especially if they have extensive skin lesions. So it was a quick turnover day where I would meet my patient and her parents, induce anesthesia by mask, start an IV, give propofol, dexmedetomidine, tylenol, and toradol, and prepare for the next patient while the dermatologist treated the rash. The laser was pretty remarkable; with a flash and a little smoke, it would create small bruises or welts in the skin. It looked quite painful, though I've been told it's like having a rubber band snap on your skin. Apparently it works wonders as some parents whose children had been through multiple treatments reassured me that the port wine stains had improved dramatically with each session.

Image from UpToDate, shown under Fair Use.

Cost

Curiously, all the anesthesia equipment in Lucille Packard Children's Hospital is labeled with costs, from alcohol swabs ($0.01) and bandaids ($0.03) to pediatric bougies ($78). It really gives me a different financial perspective. Oddly, 10cc syringes are cheaper than 3cc syringes (by one cent, so it doesn't really change which I use). Oral airways of all sizes are the same price. I have mixed feelings about these labels. On the one hand, it is very important to be aware of cost. If I am highly unlikely to use something and it seems relatively expensive, I may not open it, but rather keep it available and packaged. But in the same light, it is a deterrent; I feel myself more reluctant to break open things I may not use, even if I know that I would otherwise. Am I less likely to use an expensive device if I know its actual cost? Do these numbers translate to altered patient care, and is that a problem? Is it absurd to be using things  without any sense of the cost to the hospital? I hadn't entertained these questions until I came to this new operating room setting.

IV

It's so easy to take the simple intravenous catheter for granted. All through my intern year, I can't really remember an instance where I couldn't give someone an IV medication. And all through the last year of anesthesia, I could manage an IV in most patients. But children are different. I can no longer take an IV for granted. Sometimes, older children and teenagers will allow us to place a lidocaine patch to numb the skin and then make one attempt. But most of our small children require some oral midazolam syrup prior to going to the operating room where they get a mask induction. After going to sleep by gas, we sometimes struggle to place an IV. Surprisingly, veins in babies are deeper than expected; they wriggle through a layer of subcutaneous fat. Unlike adults whose veins pop out with a tourniquet, toddler's veins are often just a shadow under the skin, barely discernible. I've never been so frustrated as trying to get an IV in pediatrics. It also means that we occasionally do simple cases without IV access, relying instead on intramuscular injections for emergency medications and rectal acetaminophen for analgesia.

Kanban Cards

The operating rooms at Lucille Packard Children's Hospital are trying to phase in a Kanban card system. Based on the Toyota production system, it is a way of managing inventory. Anesthesiologists use a lot of supplies; we go through IV equipment, airway equipment, monitoring devices, and small things - tape, syringes, needles - quickly. But it's hard to estimate for each case how much we'll use, and since cases are dynamic, we may go through unexpected supplies. How does the anesthesia tech know how much to restock between cases, especially if turnover is less than fifteen minutes?

At the VA, the anesthesia techs change out entire supply carts; they prepare new carts and swap them with the old one, using the time during the case to restock the old ones. However, this can be labor-intensive. At Stanford, anesthesia techs go through the carts at the end of a case, make a list, and restock what they think is missing; it actually works pretty well, but there are occasions when they miss a specific item that we need. Stanford carts are also quite overstocked so there is leeway if one device or equipment isn't replaced.

The Kanban card system is used by Toyota to create a lean just-in-time method of equipment management. It's pretty simple, actually. The supply is determined by the demand. When I use up a stock of syringes, for example, I place a specific card in a box that is checked intraoperatively. This signals early to the tech to bring those supplies during the turnover. This obviates the need for me to remember what I used, for the tech to rummage through drawers during a case, or for the tech to tabulate items during the turnover. Inventories are smaller because there is a greater guarantee that everything that needs to be restocked will be restocked. I imagine that this may be electronic in the future.

I'm all for efficiency, cost-reduction, and improved turnover, but I'm still getting used to adjusting to the new system. Many of us anesthesiologists are used to having huge inventories of everything and not needing to worry about the process of restocking, but we're starting to realize that the behind-the-scenes supplies management is much less efficient when every operating room has an oversupply of everything. So hopefully this new system ensures we have what we need and not too much excess.

Image shown under Creative Commons Attribution Share-Alike License.

Pediatrics

How appropriate that my rotation following obstetrics is pediatric anesthesia. We provide anesthesia for a wide variety of cases, from healthy kids getting their tonsils out to emergency appendectomies to complicated patients with congenital syndromes requiring multiple procedures. For the most part, second year residents don't cover neonates, neurologic surgeries, and cardiac surgeries. Despite that, It's been really busy with a high volume; most of my noncall days are 14 hours long and exhausting. Nevertheless, it's been pretty fun working with children again since the last time I saw kids in a clinical setting was my third year medical student rotation on pediatrics. The attendings are outstanding, but because of the volume, most of the learning is on-the-fly.