Voice

What is it like to lose your voice? An elderly gentleman with a cancer of the vocal cords presents for removal of the larynx or voice box. There is a lot about this case that is interesting from an anesthetic standpoint - securing an airway is challenging because of the mass, decreased range of motion of the neck, and a history of radiation therapy. But I wanted to write about this case because of the notion of voice and identity. After the surgery, the patient cannot talk, though with long-term speech therapy, he will be able to communicate through an artificial valve. This struck me profoundly; I was the last person to talk to him. As we rolled back to the operating room, I asked him about his time in the military, about the job he had for thirty years, about his family. At the time, I was just chatting; a conversation quells the nerves right before surgery. But now I cherish that moment. For so many of us, voice defines. In those five minutes, I learned who this man really was, and I think how brave he must have been to walk into a surgery where his voice would be stripped away.

Image of the larynx shown under Creative Commons Attribution Share-Alike License.

Current Events

A lot has been going on in the world, and some of it has penetrated that insulation of residency. To everyone affected by Hurricane Sandy, I hope you and your loved ones stay safe. For the San Francisco Giants fans out there, congratulations and thank you for the lulls during games and the storm of emergency cases right afterward. And lastly, it is amazing to me how the internet has transformed this election with rapid widespread dissemination of information as well as the viral spread of parodies and commentaries.

Image of Hurricane Sandy is in the public domain.

ENT Anesthesia

Finally, I'm back in the general operating room pool on a rotation specifically for ENT anesthesia. It's actually been 6 months since I last did general adult anesthesia; I've had two months of cardiac, two months of ICU, and two months of pediatrics, and it's a weird feeling stepping back into the main ORs where I spent the bulk of my first year. Fortunately, it's been a smooth transition; so much of anesthesia has become muscle memory that although some things are initially rusty, it comes back quickly. This month I'm on a rotation to learn techniques for the difficult airway. ENT surgeries have some unique characteristics including sharing the airway with the surgeons, using highly-potent opioid infusions, managing difficult intubations, and facilitating a smooth extubation and rapid recovery. It's been great being introduced to advanced airway techniques and medications I usually don't pick up, and I think I'll learn a lot in the next four weeks.

Medicine

If I didn't choose anesthesiology, I'd be an internal medicine doctor. Although there are many things about the field I didn't like - and I ultimately chose not to go into it - I do miss some aspects, especially differential diagnosis. My last admission to the ICU was a fascinating medical conundrum. He was an elderly gentleman found with altered mental status. No one knew his medical history, medications, or anything about him. He was confused and oriented only to his name and age. He couldn't tell us where he was or what year it was. He kept on perseverating on odd subjects like his high school or his brother. On admission, his vital signs were completely normal - no fever, heart rate 95, blood pressure 120/60, normal oxygen saturation on room air.

But he was ultimately admitted to the ICU for several odd reasons. His blood counts showed a white blood cell count of 1,000, a hemoglobin and hematocrit of 4/11, and platelets of 60,000 - all of these were extremely low. His kidney function was poor with a creatinine of 1.7 (with an unknown baseline). His INR - a measure of coagulopathy - was elevated. A CT scan showed that most of his intestines were up in his chest in what was called a Morgagni hernia. What was going on? No one really knew. The decision to admit to the ICU was pretty soft, but I took him.

Trying to tease everything out was very fun. This is what internal medicine physicians live for. Was this a problem with bone marrow? Did he have a primary malignancy somewhere? Could this be occult liver disease? Or a state like TTP-HUS? Did severe nutritional deficiencies or hormone imbalances present like this? Or some strange atypical infection? What drugs and medications could be playing a role? Was his confusion due to the other things going on in his body? How did this weird hernia fit into the picture? In the end, I sent a panel of tests that ranged from a blood smear to copper and zinc levels to protein eletrophoresis of the urine to thyroid function studies. I hope that the hematologists and probably a bone marrow biopsy will give us the answer.

Electronic Anesthesia Records

Electronic medical records are an incredibly pragmatic and exceedingly boring topic to think about, but currently, the main operating rooms at Stanford are switching from paper charting to electronic charting, and that's got me thinking. Although the activation barrier is high (there are a dozen training classes to get every anesthesiologist at Stanford plugged in), it's likely to increase overall efficiency, accuracy, legibility, and effectiveness of documentation. I write this blog because it always seems to me that the design team of electronic medical records (EMRs) don't employ a resident, and that's who they need. Residents do the grunt work from the physician side of the hospital. We navigate the chart, put in orders, follow-up tests, look at radiology scans. But the current system is horribly inefficient; I have to sift through completely useless notes ("Please see dictated note"), load up EKGs, and search through reams of PDFs (from consent forms to insurance requisitions to outside records) to find old anesthetic charts. When I admit patients, the general order set does not include things like IV acetaminophen or insulin or electrolyte replacement scales. There's the ability to customize things, but it's not the easiest to navigate, and so I wish the design team got input from a resident to start.

Old

You may notice that my posts about the ICU often carry a theme of how to approach the end of life. We see so many patients here who face that question and have given it very little thought. When the circumstance is sprung upon them, they are adrift. Consequently, as I wade through their troubled ICU course, I ruminate on it, and meandering thoughts find their way here. The other day, we had a patient who was a hundred years old come in with septic shock as a full code. He wanted everything done for him if necessary - chest compressions, mechanical ventilation, long term artificial nutrition, shocks. Of course, that is his right. But it got me thinking about age. I'd like to think I don't discriminate on age, that I don't look at a hundred year old patient any differently than a third year old. But the truth is that elderly patients are frail, they have little reserve, and they cannot weather the strain of the ICU as well as they could years ago. That colors the way I look at code decisions. The survival odds are clear; a young person is much more likely to make it if their heart stops than a little old lady. But words like this run afoul of being condemned a "death panel." I'm not out to kill any grandmothers. But I feel that it is a disillusion and disservice to pretend that an octogenarian has a good chance surviving cardiac arrest. I'm struggling with this right now, and maybe I'm wrong, but at least I'm thinking about the issue.

Sleep in the Hospital

We underestimate how much discomfort we put patients through simply by admitting them to the hospital. Imagine being woken multiple times at night for someone to poke and prod, shine lights in your eyes, take a blood pressure. Imagine, even worse, in the ICU when machines begin beeping every five minutes, when you cannot get more than an hour of uninterrupted rest, when you cannot eat, when you cannot count how many lines and tubes are coming out of your body. When I think about how cranky I can be when I am awoken by a page, I can't imagine what it must be like to be in the ICU. Furthermore, patients with a breathing tube often cannot communicate, and that must compound that feeling of being trapped so much more.

One condition we see quite often in the unit is ICU delirium, a state of confusion seen in elderly, sick patients where their mental status waxes and wanes. No wonder they cannot think straight. We subject them to so many discomforts, and I worry that some of these are against their will. So many family members want "everything possible done" for their loved ones, but everything has its risks and benefits. I have come to appreciate the consequences of simply being admitted to the hospital.

Stages of Life

It always impresses me when I talk to a resident who has children and a family. I think it's incredibly difficult to achieve any balance in trying to manage a home life when one is working 80 hours a week. I can barely juggle work, studying, errands, and fun, and I don't know how those residents in our program who have multiple young kids do it. It also reminds me that we're all at different stages of life; back in college and even med school, everyone more or less progresses together. But by residency, the group has become so diverse that we're all in a different part of growing up. Although the camaraderie feels different, it's also enlightening to see how everyone settles into his or her stage of life.

No Rest for the Wicked

Usually, I can get pockets of sleep on a call night in the ICU. Once things settle down, I go from room to room and check to make sure the patients are stable and the nurses don't need anything. Hopefully by warding off nonurgent calls, I can get a little bit of rest. But occasionally, a call night comes when the work just does not abate. On one of my recent calls, a patient with acute myeloblastic leukemia develops a heart attack, a patient with a recent duodenal ulcer starts bleeding profusely, a new admission from the emergency department has overwhelming sepsis, a patient whose brain is herniating needs a central line for hypertonic saline rescue, and a patient with ongoing seizures needs intubation to protect her airway. Times like this are thrilling and terrifying, and the adrenaline keeps me awake. I have to prioritize effectively with the fellow to get everything done as efficiently as possible. Sometimes, it means relying heavily on my consultants (I called the cardiologist and said, "I'm intubating someone right now, but I just found out this patient's troponin is sky high - I don't have time to give you much more information, but I'd really appreciate it if you could see the patient and help"). But I made it through the night, and more importantly, so did all my patients.

The Multidisciplinary Approach

One of the great advantages of the tertiary academic center is that you can get a lot of specialists. Patients who undergo complex neurosurgery and come to the ICU are overseen by their surgeons, a team with expertise in neurocritical care, and us - the medical intensivists. By having multiple people look at all the data from different viewpoints, we hope to harness different expertises and skill sets. The neurosurgeon manages the extraventricular drain, the neurologists adjust the antiepilpetics, and we take care of the antibiotics. And if an unclear clinical problem arises, we put our heads together to try to solve it. Or at least, we're supposed to. The problem with having multiple teams is akin to too many cooks in the kitchen. Occasionally, we don't see eye-to-eye on all the active issues or we find that the primary decision makers have different priorities than we do. It reminds me how crucial communication is for all the teams to come to a consensus about what's best for the patient.

Pedigree

Many years ago, when I was an undergraduate, I worked in a lab that studied adrenergic receptors, G-protein coupled receptors that bind catecholamines in the body. Recently, the Nobel Prize in Chemistry was awarded to two of the founding fathers who first began to understand adrenergic receptors: Brian Kobilka and Robert Lefkowitz. Strangely enough, they are almost research grandfathers to me. My principal investigator for my undergraduate research did his PhD in Dr. Kobilka's lab. When I interviewed at Duke for the MD/PhD program, I had an interview with Dr. Lefkowitz and chatted to him about his research. It's funny how small the research world is, and I'm thrilled that the Nobel prize was awarded to these two amazing pioneers who have not only elucidated receptor chemistry but also touched my life as well.

Image is in the public domain, from Wikipedia

Choosing When to Die

A woman in her 60s who has fought a battle with breast cancer presents with odd symptoms of an ascending paralysis. An unclear neurologic illness has slowly picked off her cranial nerves one by one to the point that she cannot even swallow, cough, or gag and has to be intubated to protect her from choking. A PET scan shows a concerning mass on the same side of her body as her original breast cancer, and after multiple tests, we determine that her cancer is causing this odd paraneoplastic paralysis. She is, however, still able to communicate by writing on a notepad.

The oncologists and neurologists sit down with the patient and her family to discuss options. They believe that with aggressive chemotherapy and radiation, they could suppress the cancer and would expect slow return of the patient's neurologic function. The patient, however, does not want this. She communicates completely clearly to us that she would not want to undergo chemoradiation, and in fact, wants palliative care. She has decided it is her time to pass on. She chooses to do it with dignity, without the uncertainty, fear, hair loss, pain, nausea, discomfort, and risk of chemotherapy. She says her goodbyes - hour-long heartfelt tearful farewells - and asks to be extubated. Although we did not think she would pass so quickly, she died in the next few hours. It was as if she had chosen to die.

We choose how we live, how we act, what matters, why we do things. Why should we not choose how we die? This woman surprised me because so many other patients want absolutely everything done to live. But she resolutely and stoutly chose not to try chemotherapy, even though it offered a chance at recovery. Her passing, and the way and timing of it, was entirely of her choosing.

Teaching

One of the best parts of the intensive care unit rotation is the privilege and opportunity to teach medical students. I have always loved teaching and feel that my passion for medicine was very much fostered by the mentors and role-models I had in medical school. Unfortunately, in anesthesiology, there's not as much of an opportunity to teach students. Few students rotate through, and rotations aren't long enough for a medical student to pick up more than the basics. But in the intensive care unit, there's so much opportunity to cultivate enthusiasm and curiosity. I love walking medical students through simple procedures, talking to them about landmark trials, and examining patients with them, especially when the story is still evolving and uncertain. There's something to learn for everyone - from antibiotics and EKGs for the medicine-bound to chest tubes and line placement for the surgery students to treatment of delirium for psychiatry students to evaluation of airway for those interested in emergency medicine or anesthesia. I also try to encourage students to step out of their comfort zones and learn about aspects of ICU medicine that frighten them: pressors and ventilators, end of life conversations, nutrition, lines and tubes. I learn things every day, and I try to make it a priority to teach something every day as well.

Moribund

It may be creepy to say, but sometimes just by seeing a patient, I know they won't make it. After being in the unit long enough, I've seen enough people to get a sense of the ones who, despite everything we do, will die. I met Ms. A in the emergency department a week ago. She had end stage cancer and looked like a stiff wind might knock her over. At first, I thought her frailty encompassed mind and body alike, but then I saw her bat away a nurse trying to place an IV and argue loudly to get a dinner. As her physical strength waned from a battle with chronic disease, her spunk had increased such that she was always ordering her caregivers around. I managed to get her out of the intensive care unit pretty quickly to a medicine floor team but I never quite forgot about her.

When I met her again, she looked completely different. The medicine team called because her blood pressures were sagging, she had a rampant infection, and her mental status was getting worse and worse. When I saw her, I knew. She no longer fought with the nurses. She no longer argued with me. That part of her which was so strong on admission - her will and mental stamina - had given out. I knew she wasn't going to make it. An hour later, she had a cardiac arrest with asystole. Although we regained spontaneous circulation, we soon made her comfort care afterwards.

Occasionally, I see a patient like Ms. A, and even without looking at labs or imaging or the chart, I know what will happen. It is a strange intuition to pick up in medicine, a sort of insight that seems to skirt past scientific explanation, a feeling that settles in the back of the mind and aches until I pay attention to it. I always hope I'm wrong, but most of the time, it happens to be true.

Being a Doctor

On call yesterday night, I admitted an elderly patient with sepsis to the intensive care unit. He needed an arterial line for close measurement of blood pressure and frequent labs. It was one of those non-stop whirlwind call nights, running from one emergency to another, and by the time I brought the arterial line box into the room, it was 3AM.

One thing I have learned about placing arterial lines and IVs is to sit down if you can. It's much better for the back than stooping, it optimizes positioning, and at 3 in the morning, a chair is a welcome reprieve. When I felt the patient's pulse, I knew there would be no problem placing the line; he had a clearly demarcated radial artery. But instead of rushing through the procedure, I took my time and asked him to tell me about his life. While I positioned his hand and prepped his wrist, I learned about how he met his wife, what his children were doing. When I placed the lidocaine, he told me about a daughter he adopted and how proud he was of her despite developmental delay. In the next few minutes while I entered the radial artery, I began to learn of his grandchildren. As I sewed the catheter down, I learned of his job. The entire thing took ten minutes, and by the end, I felt like a primary care doctor, holding a patient's hand, sitting at the bedside, cherishing what it means to be a physician.

Anesthesia's Political Landscape

I don't want to make this blog a forum for anesthesiology's political agenda, but I feel that I should advocate for my specialty. As a resident, I think it is important for me to learn about and understand issues facing the field, and one of these is the role of certified registered nurse anesthetists or CRNAs. CRNAs are a valuable and vital component to the anesthesia team. Nurses who undergo additional training can be licensed to provide general anesthesia, and they work at many places, from community hospitals to academic centers. They are generally supervised by an MD anesthesiologist unless a state opts out of that requirement. California has done so, so in this state, CRNAs can practice independently. The state society of anesthesiologists has objected to this "opt-out" but it seems that it is here to stay. What should you (the public) know about CRNAs? For the most part, they provide anesthesia for low acuity cases; some studies have shown that much of the Medicare billing by CRNAs are for colonoscopies and cataracts. For most anesthetics, CRNAs are a perfectly appropriate provider. However, their training is different than that of anesthesiologists; a nurse's skill set, approach to clinical problems, and background is very different than a physician's. The California Society of Anesthesiologists feels that this is significant enough to warrant physician oversight of CRNAs. I personally cannot comment on it as I haven't worked all that much with CRNAs. Many hospitals, despite the "opt-out," still have physician supervision of CRNAs. There are also other issues with CRNAs, especially in performing pain procedures, and again, anesthesiologists as a whole are reluctant to allow them to practice independently. In any case, all patients should know who their providers are and be aware whether a CRNA is practicing with an anesthesiologist or independently.

Book Review: The Gone-Away World

Although I ought to be studying anesthesia, lately I've been hankering for some immersing nonfiction, and a friend recommended Nick Harkaway's The Gone-Away World. His first novel, it attempts to be and succeeds as an epic all-encompassing science fiction stream of consciousness that dallies in mysticism, philosophy, the industrial complex, physics, ninjas and mimes, identity, and love. It reminds me of Kurt Vonnegut's Cat's Cradle in creating a world teetering on the edge of collapse and following it through. The writing is witty, crisp, hilarious, and tongue-in-cheek, almost Douglas Adams in nature. It does have some of the hallmarks of a writer's first foray, however, and is quite long and occasionally loses itself in tangents and diatribes. But it's been one of the most fun new reads I've had this year and figured I'd mention it on this blog.

Image shown under Fair Use, from www.nickharkaway.com.

A 14 Gauge Needle and Strong Arm

In Samuel Shem's satiric novel, House of God, there is a housestaff rule: "6. There is no body cavity that cannot be reached with a #14G needle and a good strong arm." Though quite blunt, this is not a completely ridiculous adage. Over the last two and a half years of training, I have become much more comfortable placing a needle into someone who needs it. During intern year, I'd done a number of paracenteses: the drainage of fluid from the abdomen. Patients with liver disease often accumulate a lot of fluid in the belly and occasionally, it should be checked for infection or drained for symptoms. I hadn't done a paracentesis for over a year, but when a patient came into the ICU with end stage cirrhosis and severe ascites, I felt comfortable doing the procedure. I begin to see things in the way I imagine surgeons see them. Using a few basic principles, it's not too hard to access a vessel or body cavity with a needle. The skills of using ultrasound, the Seldinger technique, careful intentional movements, and manual dexterity apply to central line placement, arterial line placement, epidurals, spinals, thoracenteses, paracenteses, and other procedures. With a 14 gauge needle and a strong arm, any body cavity can be reached.

Emergent

As part of the intensive care team, I have to be ready to respond to emergencies and rapidly changing clinical situations in the hospital. The anesthesia residents carry the airway pager and respond to code blues. But even in the intensive care unit, our patients are so tenuous that emergencies arise daily. One patient who was recovering from a severe neurologic illness was becoming close to transferring out of the intensive care unit. He had been in the ICU for 2 weeks, most of that time on a ventilator. Because of a progressive disease that took out cranial nerves, he didn't have much of a gag reflex or a strong cough. Unfortunately, that put him at high risk for aspiration - choking on secetions. When we were called to bedside, he was hypoxic and minimally responsive. After mask-ventilating him to bring his oxygen up, we used a flexible fiberoptic bronchoscope to take a look and saw a lot of junk down one of the lungs. We decided to reintubate him and put him back on a mechanical ventilator. I then took a look with a bronchoscope to suction out the airways and do a bronchoalveolar lavage, testing for infectious organisms. Despite the hope of having the patient leave the unit, one small event set him back two weeks of recovery. This reminds me that even patients who seem to be doing well can easily have setbacks, whether from new infections, a blood clot from not moving, or deconditioning from prolonged illness. Although we hope for a smooth trajectory of recovery, patients often have a much more day-by-day progress-and-obstacle circuitous route to leaving the unit.

tPA

Tissue plasminogen activator or tPA may actually live up to its name as a miracle drug. It dissolves clots and is primarily used to treat acute ischemic stroke. An older gentleman with no significant past medical history has a witnessed change in mental status. He is eating with his daughter when he suddenly stops talking, "acts oddly," then falls to the ground. At that point, the daughter realizes he cannot move his left arm or leg. He is emergently brought into the emergency department. There, a head CT is negative for bleeding, and tPA is given. When I first meet the patient, the tPA has not yet had effect; the patient can only say his name and cannot move the left side of his body at all. He has a prominent facial droop and it is difficult to understand his speech.

Several hours later, after the clot is dissolved, I go see him. He tells me his name, the city, and gets the date right within a week. He wants "cerveza" and chocolate. Although his left side is still weaker than his right, he can grasp my hand and push his toes down reasonably hard. His left facial droop is nearly gone. Two days later, he goes home and soon will be back to tending his garden. After seeing the remarkable and dramatic neurologic improvement, I really gained a new awe for tPA.

Image of molecule shown under Creative Commons Attribution Share-Alike License.