Another Orbit Around the Sun

I love this picture of sea foam on Ocean Beach in San Francisco. There is some sort of symmetry in the Earth's Sisyphus-like wandering and the rhythm of the tide. Here we are again. To 2013, a year where we do those things we meant to do in 2012, and more!

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

The Humanities and Medicine

No matter how much physicians try to resist the notion, a lot of medicine has an algorithmic, cookbook, or heuristic nature. I am one of the people that really dislikes this notion. We wish to think the art of medicine magical, that our years of training, nights poring over books, experiences seeing thousands of patients, and Socratic method teaching imparts on us some wisdom that allows us to lay hands on a patient and diagnose. But the truth is, rapidly improving technologies, faster computational algorithms, advances in machine learning, and the complexity of human wellness and disease mean that computers have begun to challenge even the most experienced and well-respected physicians. Physicians dislike patients who come to appointments carrying printouts from Google searches of their symptoms, but we cannot deny that often, our clinical expertise can be matched by technology.

That being said, I still believe the art of medicine is an art that challenges the humanity within us. It's probably evident from this blog, but I strongly feel that the humanities are integral to medicine. Emotions, stories, artwork, reflection, discussion, and debate challenge us to hone those skills of taking care of a person. A computer may make the diagnosis, but a physician broaches the delivery of that diagnosis, cultivates that relationship of trust necessary for compassionate care. We don't respect that skill set enough. It is not easy to go to work every day and care for people who hurt themselves, are going to die, cry on your shoulder, feel terrified, or distrust the health care system. The humanities, with respect to medicine, are about understanding how humans experience illness and disease and placing that within a context of diagnosis, treatment, and care.

Full Circle

I started my anesthesia residency at the VA, and a year and a half later, I'm back. Seeing the attendings who first taught me everything, who guided my hands and made me think out loud reminded me how far I've come. The small group of nurses, surgeons, and technicians also watched me at my fledgling stages, and I remember them and feel honored to work with them again. The veteran patient population feels the same, a group that has weathered so much, that is always appreciative of the care we give. These are some elements of the VA that make it feel like home.

The thing that struck me most is the difference in culture. The VA operates at a much slower pace than Stanford does. While at Stanford, there is a flurry of activity to get rooms turned over, patients in the room, and cases started, at the VA, I'm always ready before everyone else is. There is no pressure from the surgeons to move things along. Things take their own pace. It's good for trainees as we can really take the time to prepare ourselves, do things correctly, and learn and reflect, but the pace can also drive me a little crazy. There are days when our caseload could be finished a lot quicker, but we end up taking all day. But that's the VA.

Happy Holidays

The holidays are a time to reflect. We encounter a new planet, an untread world. We reconfirm a president but face a potential fiscal disaster. We confront the behemoth of health care. We live in a world marred with civil war, shootings, tragedy. A hurricane reminds us of the strength and power of nature. We celebrate the Olympics. We have a great deal to be thankful for, and a great deal more to do to make the world a safer, more beautiful, more loving place.

Image of Christmas tree display at the Galeries Lafayette, Boulevard Haussmann in the 9th arrondissement of Paris shown under Creative Commons Attribution Share-Alike License, from Wikipedia.

Unravelling Bolero

Seeley et. al published a fascinating paper entitled "Unravelling Bolero: progressive aphasia, transmodal creativity and the right posterior neocortex" in Brain, 2008. I don't discuss a lot of papers as I think they're dry and not everyone can get access, but I came across this one and found it curious. One way of approaching neurologic injury is to localize a disease process ("where's the lesion?") and then see what deficits result. For example, a stroke in the motor strip of the brain will lead to contralateral weakness, and so it can be inferred that the affected anatomy has something to do with motor function. But the authors discuss an interesting idea: some lesions in the brain can stimulate new artistic or musical talents. Maurice Ravel was a French composer best known for his orchestral work "Bolero." Near the end of his career, he developed a progressive language and motor disorder. There are hypotheses that as his speech declined, his musical prowess heightened. The authors of this paper present a case study of a patient with frontal-insular primary progressive aphasia who paints. They follow her art from her preclinical phase through her progressive dementia and study her brain imaging. I love the paper because its figures are artwork, from a representation of the number pi to a visual image of Ravel's Bolero. You can see how this patient's paintings change over time, presumably due to her neurologic illness. As her language and speech function disappears, her expression through artwork becomes more and more beautiful. It reminds me how little we know of the brain and how this story can give insight into something as strange as the development of a new talent.

Clasp

This time of year gets quite busy for me as I try to scrub rust off those interests, passions, relationships, and goals I haven't cultivated for a while. I've been procrastinating on figuring out what I want to do after residency, a little slow in sending holiday cards and emails to those I haven't talked to in a while, and neglecting my reading as the in-training exam begins to loom nearer. I have some writing projects to work on, a lot of cleaning to do, and a big to-do list to catch up on. So I'm going to take a break from this blog for a week. Thank you for following along; I've run into a few people who've known about this blog, and it's always fun to hear that other people do actually read this. See you next week. - Craig.

Image of rust-laden links of a sea-sprayed chain of Golden Gate Bridge shown under Creative Commons Attribution Share-Alike License, from Wikipedia.

Pre-Op Clinic

Now that I'm back in pre-operative clinic, I think of how it's evolved for me over time. I started as an intern, prior to doing actual anesthesia. Although this may seem strange, pre-anesthesia evaluations are more medicine than anything else. I had a lot of questions for my preceptor and I did really thorough medicine evaluations. I remember examining for lower extremity edema and JVP, trying to palpate the liver and spleen, and discussing exercise and behavior changes with most patients.

Now well into residency, I have a much firmer sense of what's directly relevant to anesthesia. I still try to be a good citizen and physician, encouraging patients to stop smoking, discussing side effects of medications, and probing psychiatric overlay. But I can see a patient so much faster because I know the types of medical problems that worry anesthesiologists, the tests I would want to see for a particular surgery, and the common questions that come up about going under. I know specific surgeon preferences and I often give heads-up pages to anesthesiologists to prepare them for cases. I understand the ins-and-outs of the system, and as a result, pre-op clinic is smoother and more straightforward now than a few years ago.

Poem: In Memoriam

I heard about it right after I finished my ECTs, when I went to the physician lounge for a bagel. Strange how we sense something isn't right; I can't identify exactly when I knew, but I knew before I parsed the words from the television. My heart aches for all those involved. My prayers go with the victims and victim's families. I am a little numb with shock, and struggle to understand my thoughts (and to avoid Claudius' folly in Hamlet: "My words go up, my thoughts remain below. / Words without thoughts never to heaven go."). Everyone has their way of coping, whether posting on social media, petitioning a senator, mourning, or gritting teeth and plowing on. I write. First drafts are never clean, but I hope that my words and thoughts are married and carry my deepest sympathies.

-
In Memoriam

lip of wax tumbles headlong
melting a rosary bead wake
chill caresses fingers
ache entombs brain
steady flame quenched
acrid stink, disfigured
candlelight darkens

i danced with a blind woman
held a cancer patient's hand
peeled an orange
listened to latin chants
and heard of the twenty
who will never have

twenty christmas trees
long of child, twenty
siblings find no counsel
twenty priests turn away
twenty politicians arise
twenty insomniac families
twenty candles to light

a child is who we wished
we could be, who we wished
for, who we wished could
see do hear taste play love
and to say we love a child
is to use the best word
for why our heart squeezes
so damn hard
but the word still falls
so so short.

ECTs

This week, I have been doing anesthesia for electroconvulsive therapy. I have written a blog on this in the past so I'll leave out the technical details, much of which is the same. But ECTs are interesting because we work with a particular patient population, those with refractory depression or bipolar disorder. Interacting with these patients reminds me of my psychiatry rotation; their behavior, affect, speech, and interaction all give clues about their underlying diagnosis and the efficacy of their treatment. It can also make consent issues challenging, though it is helpful that psychiatrists are experts in determining a patient's capacity to consent. The other aspect of providing anesthesia is that we have to be cognizant of the patient's nonpsychiatric issues, especially since these can be overlooked by their mental health professionals. Depression, bipolar disease, schizophrenia, eating disorders, and other psychiatric illnesses are accompanied by physical changes and symptoms. Patients may overeat and become obese. They may neglect their health and develop diabetes, hypertension, hyperlipidemia. They may overdose on medications, leading to kidney or liver insufficiency. Suicide attempts may result in severe trauma. So these cases are not medically benign. Although the anesthesia for ECTs is more or less cookbook - we use a standard cocktail of drugs to help induce a seizure, provide adequate anesthesia and amnesia, and facilitate a quick wake-up - patients still respond very differently and can have severe cardiovascular changes during the ECT. It is a good reminder that even for quick cases that generally go smoothly, we have to be cognizant, vigilant, and aware of what we're doing to the patient and how to rescue them in the event of an emergency.

Canceling a Case

An older gentleman who has multiple medical problems including insulin-dependent diabetes, amputations of both legs, dependence on a caretaker, and spinal stenosis presents for spinal surgery. In past anesthetic records, it's noted that he is a difficult intubation and has required multiple attempts and rescue techniques. When I meet him in the pre-operative area, however, I find out that he ate solid food for breakfast.

The reason why we have patients "NPO" (nil per os or nothing by mouth) before surgery is to reduce the risk of aspiration. If induction of anesthesia causes vomiting, a full stomach can go down the lungs, and that can be lethal. In cases where we cannot wait for a patient to be NPO, like an emergency trauma, we induce anesthesia and intubate as rapidly as possible. For this case, we were stuck against a rock and a hard place. The clear defensible obviously-correct answer is to delay the case until the requisite time is met. The risk of aspiration is unacceptable in someone who just ate solid food and is undergoing an elective surgery. We even considered doing the case with a rapid sequence induction, as if it were a trauma, but the history of difficult intubation makes that hardly ideal. We toyed around with the idea of an awake intubation, but that puts the patient through more discomfort than necessary.

The problem with delaying, however, is that the complexity of the case and the hardware needed makes daytime the best time to do the case. It was scheduled to be an incredibly long procedure and would need consultation with biomedical reps to get the appropriate equipment. Starting the case in the afternoon might mean the surgeons wouldn't have access to what they needed in the evening. They did not want to start the case that late, and so we had to cancel.

We do not cancel cases lightly. We fully recognized that this patient cannot leave his home independently, depends on his caretaker, and needs specialized transportation. Furthermore, adjustments to his medications on the day of surgery, especially insulin, makes his sugar and blood pressure management difficult in the case of a canceled operation. But after discussing all of this with the surgeon, the patient, and the caretaker, we decided to do what was right despite the inconvenience and disappointment to all involved.

Purple

There are really quite many amazing and beautiful places in the Bay Area. This is Pfeiffer Beach in Big Sur, and for reasons I have still to investigate, the sand has a gorgeous purple sheen. We don't get a lot of free time as residents, but when we do, we have to take advantage of it.

Interview Season

Already, we find ourselves halfway through the interview season for potential residents. For those who've stumbled upon this blog looking for anesthesia or Stanford's program, welcome and good luck! I really enjoy meeting all the prospective residents; they have amazing stories, interests, and backgrounds. I know it's the time of year when applicants feel pretty worn out and residents realize they have seasonal affective disorder, but I really do feel strongly about putting an honest, open, and supportive face to our program. I remember the red-eyes, the hotels, the wrinkled suits, and I try to welcome all our potential applicants warmly. It's a really tough time, and also a really eye-opening experience. If anyone comes across this blog and has a question about our specific program, I'm happy to answer comments to this post.

Running an Operating Room

We had a grand rounds on operations management, and the discussion helped me realize how complex it is to "run the board" - that is, schedule and manage the surgical flow of 21 operating rooms. Even simple decisions become convoluted. When should the day end? Should there be an end time? Having an expected end-time simplifies staffing; shifts can end at 6pm except for a skeleton crew to accommodate emergencies. Setting and meeting expectations helps well-being, allows planning, and keeps operations organized. But this must be balanced against the increased revenue that can be obtained by letting surgeons book as many cases as they want. The more cases a hospital does, the more money the hospital makes. And if a surgeon is willing to operate, why restrict him to 6pm? Yet if there is no set end-time, how do you manage staffing of anesthesiologists, nurses, and technicians far in advanced? How can we plan our lives if surgeons can add on a non-emergent case, and we have to be available to do it?

Then there are problems at a more micromanagement level. Say you have one room that has 4 cases scheduled: one very long, two short, and one of variable duration. Do you schedule the longest case first? This would allow the other cases to be shuffled to different rooms if other rooms finished earlier. It would also mean that if a case had to be canceled because the room ran over, it would be a short case and not the long one. But there are risks; what if the long case is canceled, and none of the other cases are ready to go because they expected to be in the afternoon? How do you fill the gap?

Lastly, there are a lot of problems specific to medicine. As opposed to a production line or a senator's schedule or the fast food rush, surgeries can be incredibly variable in length of time. The same operation can take much longer or much shorter than expected, and it's hard to accommodate for this. The most extreme example is pancreatic cancer surgery. Despite a comprehensive workup, a surgeon can open up the belly expecting to take out the cancer and find that it is much more widespread than he thought. In this case, the best decision for the patient is to close the abdomen without doing the surgery because surgery will not help. But from an operations standpoint, this changes a 6 hour case to 30 minutes. How do you deal with that?

Intuitively, I favor a computer algorithm or calculation that can look at past cases, take into account all these rules and preferences, and spit out an answer. But after listening to the ground rounds, understanding the pros and cons of different approaches, and seeing the practical result of our daily case scheduling, I'm not sure it's that easy.

Book Review: The Song of Achilles

Madeline Miller's ambitious novel, The Song of Achilles, was ten years in the writing. I loved it. Set in Ancient Greece, it traces the lives of Achilles and Patrocles: their childhood friendship, education and training, intimate relationship, and role in the Trojan War. She creates a wonderfully magical world; I was enchanted by the interaction, interpretation, and co-existence of mortals, half-gods, and deities. We are swept into the culture, lifestyle, values, and people of this beautifully-depicted time. The writing is amazing: smooth, sweeping, vivid, and lyrical. The integration of events and characters we knew from childhood with the imagined hinges of the plot is seamless. It made me realize how much I miss and love myths, history, classical literature, and storytelling. I could not put this book down, so I encourage you to carve away a bit of time before picking it up.

Image shown under Fair Use, from Wikipedia.

Measurements

Isn't it interesting how we can use things daily but not know all that much about them? For example, I routinely use orogastric tubes and large bore central lines that are measured in "French" without knowing exactly what a "French" is. This may seem strange, but how many of us worry about the number of megabytes an attachment is or the miles per gallon we get on our car? It's easy to use something practically without focusing too much on extraneous details.

But out of curiosity, I looked into it. A French sized catheter is three times the diameter in millimeters, a system invented by Joseph-Frédéric-Benoît Charrière, a 19th century French surgical instrument maker. In thinking about this, I realized I didn't know where needle gauges came from. Apparently, needle sizes are derived from the Birmingham Wire Gauge system (also called the Stubs Iron Wire Gauge system) that specifies the thickness or diameter of metal wire, strip, and tube products. According to Wikipedia, it is the only wire gauge system recognized in the United States by an Act of Congress. Strange how history plays out and becomes ingrained in something we use every day without recognizing its odd nomenclature and past. Good thing I don't have to learn about sutures.

In Defense of the Humanities

I recently read an article about the declining interest in the humanities in higher education. In the last decade, graduates seem to be majoring more and more in the fields of science and engineering and less and less in those perennial mainstays, English and history. Even fewer are doing the smaller disciplines like classics, philosophy, or art history. With the tech boom, the entrepreneurial bravado, the start-ups, and the worry over finding a job, fields like computer science, mechanical engineering, economics, and biology seem more practical. After all, understanding Shakespeare is nowhere as marketable as understanding business.

I was a humanities child, and I am writing in defense of the fuzzy fields. In true humanities fashion, I don't have data or numbers or evidence, but instead a story. In college at Stanford University, my most influential, memorable, mindboggling, and inspirational teachers were all in the humanities. I loved it; I drank it up; I wanted to emulate them. Lectures about morality, discussions about a short story's narrative decisions, and essays on free will - these were epiphanies, they made sense of the word philosopher, lover of wisdom. The humanities broadened my perspective, engaged me in debate and conversation, guided me into the depths of human emotion, passion, reason, and motivation, and challenged me to ponder and articulate my own thoughts and interpretations.

On the other hand, science was, at least at the introductory level, the memorization and mastery of a new language, codex, book of rules, set of equations, and facts. It tested other equally important skills, the consumption and comprehension of a vast body of knowledge, the logical progression of proofs, the application of the known world to the unknown. The struggle was working through a problem for which we knew there was an answer; we just needed to get there. In the humanities (at least philosophy and creative writing, which I did), an answer was never guaranteed.

Here I am. I was always good at the science, and I knew I wanted to become a physician. But the humanities, which I was not good at, defined me. I struggled all through college with essays, short stories, reading large texts, parsing arguments. I knew I was not going to pursue it as a career. But as education? I would never have given it up.

So I tell those who would be doctors - or economists or businessmen or accountants or scientists or journalists or engineers or pretty much anything - that the humanities in college offers a new skill set, a new world of exploration, a new body of literature that may not offer a high salary career but will offer a depth and meat of living, a different way of thinking, and a new appreciation for the human life and context that is invaluable.

Image of Plato by Silanion is in the public domain, from Wikipedia.