Ethics

The further you get into clinical medicine, the fuzzier ethics seems to become. When I looked at theoretical ethical frameworks as a philosophy student, I studied things like deontology or utilitarianism or cultural relativism. At the time, the arguments appeared easy. Physicians should follow these absolute rules: do no harm, respect a patient's autonomy, uphold a patient's dignity, advocate for justice and fairness for all. Healthcare systems should be designed to give the most good for the most people; we should allocate our resources and make decisions based on the utility of those actions. We need to respect differing values of different cultures and elicit the things patients find important.

But as I delve into clinical situations, I find these black-and-white generalizations difficult to parse. Often, multiple prerogatives or imperatives conflict each other. Sometimes, it's not clear whether what we're doing is harming a patient or respecting autonomy or preserving dignity or fair to other people. The system does not know how to allocate resources evenly, and people suffer as a result. We often struggle to understand a patient or family member's perspectives or opinions. And this occurs with well-meaning, well-intentioned physicians. The complexity of a clinical situation is compounded by the social situation, and what results can be an ethical quagmire. Thus, although I always strive to do the right thing, sometimes I struggle to figure out what that is.

Book Review: The Book of Lost Things

I recently read John Connolly's The Book of Lost Things, a fairy tale for adults. A child escapes into a fantasy world, not unlike Narnia, where he goes from adventure to adventure which vaguely mimic fairy tales. But the fairy tales presented are twisted, warped, strange, and grotesque. It is a bildungsroman story of growing up, adapting to family changes, finding self, but it wasn't satisfying to me. I wasn't able to fully grasp the symbolism of each fairy tale, wasn't tracking the main character's growth. I didn't find epiphany or closure at the end. Nevertheless, it was an interesting retelling and revisit to the world of childhood that so many of us have left and forgotten, and I appreciated that reminder of what fairy tales feel like.

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Ortho Trauma

Now I'm back in the general OR pool and assigned to orthopedic trauma for two weeks. Ortho trauma has its own anesthetic concerns. Patients vary from the young, healthy, and foolish who get into a brawl or car accident to the old and medically ill who fall and have a hip fracture. Since cases are urgent, there's little time to get to know the patient and optimize them medically, so the anesthetic course can be a little rocky. For example, I had a young patient with a hip fracture who drank a bottle of whiskey every day and went into active alcohol withdrawal right when we started the case; we had to design a benzodiazepine heavy regimen to smooth the wake-up and prevent seizures. Another man who had been shot multiple times had extremely complex fractures that required many hours to fix. A woman found down and altered could not give a medical history so we went in not knowing much about her. A patient who had just eaten and was actively vomiting needed a washout of an open fracture before it became infected. Unfortunately, these patients are not happy to be in the hospital, and working with them can be challenging. Such is the life of an anesthesiologist at a trauma center.

Image of implants for right radius and ulna fracture is in the public domain, from Wikipedia.

A Truncated Thanksgiving

Holidays feel like a thing from childhood. The feeling is a little wistful, a trace of longing, when four day Thanksgiving weekends were expected; now, having two days is precious and cherished. On days like this, I get a keen appreciation of what it means to be in a world that churns on, 24 hours a day, 7 days a week, 365 days a year. (Barring natural disasters) the hospital never closes. Thankfully, anesthesia is a little more holiday-favorable. There are no elective surgeries so we only cover emergent cases. Then again, holidays bring a lot of accidents. Last night, we had two craniotomies for a bad motor vehicle accident, and that kept me up all night. So when I say this, it is mostly for your benefit but a little for mine: stay safe this holiday season, don't drive recklessly, take care of your family and friends, don't get sick.

Finishing Up the ENT Rotation

As I finish up my ENT anesthesia rotation, I reflect a little on the airway devices I got to learn. The key is to use the advanced techniques over and over so that muscle memory settles in, the steps become intuitive, and troubleshooting becomes natural. I welcomed the days when I would focus on one technique, try it on several patients, read and think about it. This is much more satisfying than the sporadic use of tricky devices on a general rotation. So over the last month, I've become much more proficient at using nontraditional blades like the McCoy blade, introducers like the bougie, the flexible LMA, the intubating LMA, different video laryngoscopes, and the fiberoptic bronchoscope. Although I was learning these techniques, the attendings were careful to ensure patients were not at any risk or danger. Indeed, I feel that patients fared even better than usual with the intense focus we had on perfecting the anesthetic. At the end of the rotation, I feel a lot more comfortable with situations that may involve difficult airways and intubation.

Thanksgiving

There are so many things for which I am thankful, but upon thinking about this blog, I realized most are conventions. I am thankful for the people I love, friends, family, teachers, and mentors; I am thankful for the things that make me happy every day, the challenges, the excitement, the fascination I have with medicine; I am thankful for my passions and hobbies. But it's more interesting and more important on a day like this to ponder those unusual or seldom-acknowledged things we are thankful for. I am thankful for imagination. I feel like I had such an imagination growing up, that I would create worlds and populate them, that I became obsessed with novels. During medical school and internship, some of that drifted away, but now I have rediscovered it. I am thankful for books and libraries, and the return to cultivating imagination which I had left for so many years. I am thankful for the opportunity to write, and for you, readers, who I invite into my thoughts. I am thankful for the bike commute I take to work, the sunlight and wind and calm rustle of leaves. I am thankful for that warm silence that overtakes me right before I fall asleep. When we think of the things for which we are thankful, we realize most of them are not really things. Possessions do not thrill us. People, experiences, values, stories, and the world we live in are the things that are important, the things that lead us to write, on occasion, awfully cheesy posts.

Sux

Many surgeries require some form of muscle relaxation or paralysis. For example, when a surgeon works on a vocal cord, it is imperative that the vocal cord does not move inadvertently, and in many abdominal surgeries, tensing of the abdominal muscles makes the surgery much more difficult. Broadly speaking, muscle relaxants fall under two categories, the fast-acting short-lived succinylcholine (shown above) and the longer acting non-depolarizing agents. We almost exclusively use succinylcholine for intubation only, and one of the long-acting drugs for surgical relaxation. But in some cases where absolute paralysis is required but the surgery is very short (for example, a vocal cord surgery), neither is ideal. Succinylcholine achieves the best conditions but wears off too quickly. Rocuronium or vecuronium lasts too long. Thus, I got to try a fairly arcane technique, the succinylcholine infusion. Continuous succinylcholine drips were popular before the advent of long-acting nondepolarizing agents. Indeed, when I did a literature search, the articles that came up were from the 1980s (a more recent article in 2004 was published in Poultry Science). Nevertheless, the technique, though old, still works quite well in carefully chosen cases, and so I got to employ a seldom-used technique in anesthesia.

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Lasers

I had a case where the surgeons were using a laser to excise a lesion on the vocal cords. This sort of surgery has fairly unique considerations. We use a special endotracheal tube made of stainless steel to prevent damage from the laser. This is particularly important because laser will ignite oxygen; airway fire is a real risk in these surgeries. Thus, we run as little oxygen as possible to reduce the risk of setting something on fire. Endotracheal tubes have cuffs that are usually inflated with air. But these laser tubes are equipped with two cuffs and we inflate the proximal one with a dye, methylene blue. Thus, if the laser goes through the cords and cuts the proximal cuff, the surgeon will see the dye; hopefully the distal cuff will remain intact. Laser surgeries have their own safety requirements. We all have to wear laser goggles to prevent eye damage and laser plume masks that are safer for any aerosolized tissue. It surprised me to learn about all these laser-specific considerations, and I thought it was interesting enough to make a blog post.

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Growing Up

How life changes. In high school and college, I would spend hours on end with my friends; part of the education was the socialization process, the cultivation of relationships, the discovery of self. While I appreciate the education - figuring out my study habits, reading those core biology textbooks, immersing myself in learning - what I take with me is those friendships, those people for whom I'd drop everything to help. I remember the late nights studying, the bonding over personal crises that seem so trivial now, the trying new things together. At the time, I thought this life, this active and exhausting process of going out into the world with my friends, would last forever.

Slowly, it dissipates and we start settling into the life that for so long I associated with adulthood, a quiet private life, one which no longer courts spontaneous witching hour conversations sprawled on the floor, but which instead invites carefully scheduled appointments over coffee. I have noticed this change happening over the last few years. I love my co-residents, but the bond we share is forged over work and challenging anesthesia cases and mutual learning, not heart-to-heart revelations, ponderings about our future, questions of our childhood. I can depend on them, but I don't lean on them. It's a strange realization, the difference between professional relationships and truly personal ones. It's not a bad thing at all, it's a transition in life, a point of maturation, a sign of growing up.

Deep Brain Stimulation

One of the more impressive advances in neurosurgery is placement of deep brain stimulators (DBS). Electrodes are placed in specific parts of the brain and electrical impulses can be sent through a generator. This has been pretty successful in medication-resistant Parkinson's disease, chronic pain, tremor, dystonia, and even depression. While much of neurosurgery deals with anatomic problems, this is a functional approach that seeks to treat disorders by altering brain signals and impulses.

The placement of DBS electrodes is a pretty involved multidisciplinary affair. A 60 year old man with severe Parkinson's disease despite multiple medication trials presents for DBS electrodes placement. I bring him back to the operating room and minimize the medications I give because I don't want to interfere with intraoperative neurologic testing. I administer a low dose propofol drip while the surgeons drill holes into the skull where the electrodes will be placed. Then, after the brain is exposed, we wake the patient up. With enough local anesthetic, the patient tolerates this quite well. Because of the underlying rigidity and tremor from Parkinson's disease, a massage therapist attends to the patient's comfort. As the neurosurgeons place the electrodes, a neurologist does serial exams. As the electrodes get closer to the right location, the tremor diminishes, the joints become more flexible, and the patient's symptoms improve. A PhD and severe technicians are in charge of the electronics. And of course we have a circulating nurse and a scrub nurse as well. Once the electrodes are in the right place, we have the patient go back to sleep as the surgeons close. Other than the local anesthetic, very little pain medication is given. It's a large affair that requires the right patient who can tolerate being awake during a brain surgery.

Image shown under GNU Free Documentation License, from Wikipedia.

The Spine

For me, spine and back surgeries evoke a lot of complex emotions. For some patients, surgery is clearly indicated, as is the case for an unstable fracture. But a lot of people fall into a grey zone for which spine surgery may or may not help. I feel that these patients are between a rock and a hard place. Chronic back pain, shooting pain to the legs, limitation in exercise and movement are real life-altering conditions. When they afflict young active people, they can be devastating. After failing medications, physical therapy, steroid injections, and other interventions, it's no wonder that these patients turn to surgery as a magic bullet. A lot of times, surgery works. But I also see patients for whom back surgery yields little benefit, and occasionally, those patients who need to return to the operating room over and over again. Watching this, I feel like these patients are trapped in a vicious cycle where each surgery begets further surgeries. They no longer live the lives they want. It's one of the hardest things to see. The spine is such a complex structure and the orthopedic and neurosurgical interventions we have are not perfect. It's one of those surgeries for which I really think about the impact of the disease and its treatment on the patient's life.

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Half-Way Point

It's pretty close to the half-way point of my anesthesia training. I'm through with a year and a half of the three years of dedicated anesthesia learning. What is it like? I feel pretty confident with most anesthetic cases. I can be given nearly any kind of surgery and look at a patient's other medical conditions and identify a reasonable anesthetic plan. Although I continue to read about different surgeries and anesthetic techniques, I have a pretty good understanding of the key points in most surgeries. Even rare procedures I haven't done before, I can make pretty educated inferences about. The same applies to various patient conditions and medical problems. While I would find the management of multiorgan system failure tricky, I at least know where to begin, what to avoid, and what goals I have.

After a year and a half of putting in IVs, breathing tubes, arterial lines, central lines, spinals, and epidurals, I feel like I could troubleshoot most procedures. I don't think I can get everything in perfectly, but I know where to begin, where I get hung up on, and how to fix problems that crop up. Even recently, I had a patient I couldn't intubate with a direct laryngoscope. Neither could my attending. We did not panic and simply asked for another tool and intubated the patient smoothly and safely. I think over time I have become much better in responding to changing circumstances, emergencies, problems, deteriorating patients, and complex situations. I may not always know what to do, but I don't panic and I start with the basics and do things step by step.

All of this is quite reassuring. I don't have to be an independent anesthesiologist for another year and a half, but I feel like I could handle the majority of things independently. The rest of residency, then, is to find and work on my weaknesses, refine my technique, and study the material in greater depth so that I feel comfortable with any operation, procedure, or ICU patient.

Construction

I've learned to tolerate hospital construction. Whether it has to do with California laws about earthquake retrofitting or the desire for academic medical centers to continually expand, both UCSF and Stanford are in a constant state of construction. I've gotten used to the sight of scaffolding, the detours, even the hammering (like the Wings of Zock in Samuel Shem's House of God). But the recent changes to Stanford's access has been dramatic as we prepare to build a whole new hospital. Although the grumbling by physicians and staff is tolerable, I worry about the patient experience. Simply parking and getting to the hospital or clinics is now an ordeal. Despite the signage, volunteers, and shuttles, I feel that the construction of the new hospital is really harming the patient's perception of care even before they get to the door. Hospitals ought to treat their patients like businesses treat customers, and I think we could have done a better job here.

Worst Case Scenario

An obese patient with obstructive sleep apnea presents for OSA surgery. He will have much of the soft tissues in his upper airway resected - a tonsillectomy, removal of part of his tongue, and resection of his uvula and soft palate. Hopefully, this will allow him to sleep better without obstructing and snoring as much. The anesthesia for these cases can be tricky though; because patients are often obese, their oxygen desaturates quickly and their pulmonary reserve is poor. Obesity and obstructive sleep apnea can make intubation challenging. Post-operative pain must be managed appropriately because too much sedative can lead to further obstruction and oxygen desaturation.

The case begins smoothly enough; I use a video laryngoscope, see a good view of the cords, and place a small oral tube. The patient's glottis is surprisingly deep and the tube is a little deeper than I would have expected. I secure it, but because the surgeons are working in the mouth, they request a little slack on the tape so they can move the endotracheal tube as needed. We turn the bed 180 degrees so that the head is facing the surgeons and away from the ventilator. The surgeons begin working on the tonsils.

After half an hour, I have an abrupt loss of the ability to ventilate. There is a large air leak around the endotracheal tube, and I have a strong suspicion that the tube has slipped out of the windpipe. I alert the surgeons and go take a look, and see that the tube has come out of place. This is one of the anesthesiologist's worst nightmares; I've lost the airway after the surgeons have started on a fairly bloody procedure, I'm turned away from my ventilator and supplies, and this patient will desaturate quickly and be difficult to intubate. I grab a conventional laryngoscope but can only see blood and uvula. I simply cannot see the vocal cords. I calm myself and remember to start with the basics. I am able to mask ventilate the patient; he never desaturates. Then, I optimize my positioning, give additional anesthetic and muscle relaxant, suction out the blood, and take a look with the technique that worked the first time, a fiberoptic laryngoscope. After reintubating the patient, I make sure I secured the tube tighter. The rest of the case goes just fine.

Trauma

Stanford Hospital does not get a lot of trauma. Fortunately, there are not a lot of gunshot or stab wounds, and we're in close proximity to other major trauma centers. But as a resident, it is important for me to see and experience trauma cases. A drunk woman in her twenties is involved in a motor vehicle accident. She is minimally responsive, intubated, and rushed to the scanner where a CT shows an epidural hematoma as well as multiple facial fractures. Upon seeing this, she is taken straight up to the operating rooms for an emergency craniotomy and evacuation of hematoma, and I'm called to come and anesthetize this case.

Traumas cause a release of epinephrine for me because I don't have the time to investigate, prepare, and plan the anesthesia. By the time I arrived in the room, the patient was being moved over to the operating table. I had to quickly survey the scene, figure out what I needed, and make a quick judgment about the patient's health. Although the patient already had good IV access and an endotracheal tube, I had to pop in an arterial line, begin my anesthetic, and figure out what I needed in terms of drips, blood, and other medications. Because of the patient's young age and lack of other medical problems, the case went smoothly, but it reminded me of the necessity of efficient evaluation and response as well as continuous communication with the surgeons and nurses. It also gave me awareness that trauma patients may have other undiagnosed injuries, some of which (like a pneumothorax) could be fatal if undiagnosed. Vigilance and constant reassessment are absolutely essential.

Image of epidural hematoma shown under Creative Commons Attribution Share-Alike License, from Wikipedia.

Fentanyl

One of the first medications we learn in anesthesia is fentanyl. If you were to ask most physicians, they would describe it as a potent rapid-onset short acting pain medication, ideal for transient discomfort but not for lasting pain because of its limited duration. Most physicians would probably dose it 25 or 50mcg a time and give it every hour or so. For severe persistent pain, most physicians would gravitate toward longer-acting opiates like morphine or hydromorphone. Before this week, this is how I viewed fentanyl.

I was assigned to a 12 hour long plastic surgery case. A woman who had bilateral mastectomies for BRCA positive breast cancer presents for breast reconstruction. These cases are tremendously long, requiring a lot of fine microdissection to ensure good blood supply to the breast flaps. I think a typical way of managing post-operative pain would be fentanyl for the start of the case and titrating hydromorphone to give a good tail coverage of pain as the patient wakes up. However, I was challenged by my attending to use only fentanyl. We modeled the pharmacokinetics of the drug and loaded the patient with quite a bit up front; instead of the usual 100mcg or 150mcg for intubation, we used 500mcg, almost a cardiac induction. We started a constant fentanyl infusion at 500mcg/hr and cut this in half every ninety minutes. Using computer simulation and modeling, we predicted the serum and effect site concentrations of fentanyl. The goal was to saturate the adipose tissue with the drug so that this became a long acting medication rather than a short acting one. Normally, a bolus of fentanyl disappears in effect because the drug goes to the fat tissues. But this time, our goal was to use the fat tissues as a depot for the drug. By the end of the case, we used over 4000mcg of fentanyl - an astonishing amount. Despite this, the patient amazingly woke up right when I said, "Open your eyes," and had absolutely no pain at all. I'd never done anything like this before, and it was a confirmation of the power of pharmacokinetic modeling.

Image of molecular structure of fentanyl is in the public domain, from Wikipedia.

The Socioeconomic Milieu

As the election is coming up, I wanted to write a quick post to say that health care is determined by so many factors beyond which hospital one goes to, the doctors one sees, the drugs one can obtain, the insurance one has. For example, education, profession, and poverty have a remarkable effect on one's health; a study of civil servants in England showed a dramatic difference in mortality based on one's job. We cannot tease out cause and effect, correlation and causation, but it reminds me that our responsibility as physicians extends beyond thinking of just health care delivery, pharmaceutical companies, and questions of insurance but also those other public goods which will, in time, translate to healthier, happier, more active patients.

Patient Participation

Should patients be able to access their charts? Of course, everyone can get their medical records, but doing so is often a big hassle, requiring signatures and time and visits to medical records. But recently, some practices have started opening up their charts to patients through secure internet connections. Indeed, a study of a small primary care office showed that patient satisfaction increased when they could see their providers' notes and that this did not increase burden on providers.

How do I feel about this? Obviously, anesthesia won't be affected much, but in thinking about it more broadly, I am a little apprehensive yet see the world moving towards more open information. If you knew a patient was going to read your progress note, would you be a little more wary with what you write? Would you say "a 50 year old obese woman" or "a 50 year old woman with BMI 32" or omit it completely? Would you mention psychiatric assessments? Would you write down that innocent heart murmur? We worry that patients will go through what we write with a fine-needle comb or take offense or contest our assessments. Would we start getting more phone calls and emails and visits? Small studies have suggested that this isn't the case. And there are so many reasons for patients to know our findings, assessments, and plan. It seems unethical if there were a disconnect between what we tell patients and what our charts say. Though one carries jargon, they ought to say the same thing. Furthermore, one way to solve the problem that electronic medical record systems between hospitals don't communicate is to give that information to patients so that when they show up to a different provider, they know what tests they have had and what their last provider was thinking. In a world where everyone else - politicians, companies, industries - are encouraged to share information openly, there is no reason why physicians should be exempt.

The Nose

The ENT anesthesia rotation gives us a lot of opportunity to do nasal intubations. While perhaps the notion of nasal intubation seems scary - after all, how many of us think we could breathe adequately through only one nostril - it turns out that patients tolerate the tube and breathe easily. We use a nasal endotracheal tube for cases where the surgeons are in the mouth and don't want any obstacles to work around - surgeries for obstructive sleep apnea, jaw surgeries, dental rehabilitation. There are a few ways of putting them in, and they're fun to practice. The simplest way is to carefully introduce the breathing tube into the nose, take a look with a direct laryngoscope in the mouth, and use forceps to advance the tube into the trachea. But I've recently become fond of using a video laryngoscope and watching the tube go through the cords without lifting the jaw too much. Doing so helps me appreciate that these nasal tubes are often positioned to go smoothly into the trachea without much manipulation. In the past, anesthesiologists used to do blind intubations and simply advance the tube, listening for breath sounds. Although this sounds precarious, it seems to work. The last technique we practice for nasal intubations is using a flexible fiberoptic bronchoscope, guiding the tube in over a flexible hand-controlled camera.

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