Happy New Year!

Cheers to a happy, happy new year! I'm on call tonight so drive safely, don't get sick, and watch your drinking! Actually, though I may jinx myself, things are quiet in the operating room right now so I'm going to sleep when I can and hopefully the New Year rings in during an uninterrupted REM cycle.

Justice

I think human nature inherently believes in or wants to believe in a sense of justice. Even though we know things aren't fair, we really want them to be fair. We want to take a world of entropy and cage it in rules, make it predictable and known. And though I know this is irrational, I can't help but feel this way about our recent burglary. When our house was broken into, I was probably anesthetizing a two year old child who had a dogbite. My fiancee was telling a woman with glioblastoma multiforme that her cancer was worse and she had to tell her children she was likely to die in less than a year. On the one hand, our lives are charmed and idyllic when compared to the crises of these patients (and parents and children). We have nothing to complain about; we ought to feel grateful for our good health and fortune. Yet on the other hand - the side of me that is a little ashamed - I think of how unfair it is that right before Christmas, we were working late in the hospital caring for others, when some stranger took our laptops and jewelry. We never did anything to deserve this, I think. I realized that this must also be how patients sometimes feel, the feelings they never share with their doctors. Our child never did anything to deserve a dog bite to the face, thinks the parents of my patient; I never did anything to deserve brain cancer, thinks my fiancee's patient. Oh, in the end, we know that fairness has little to do with it. But this incident has taught me a little more about how human nature reacts and perhaps how my patients feel.

Victims

I've seen a lot of victims in the hospital. We see victims of gang rivalries who go to the operating room for a stab wound, victims of domestic violence during pregnancy (a time with increased domestic violence) who have preterm contractions, victims of child neglect. Every time I see someone who is a victim of crime or violence, my heart reaches out to them. My voice softens, my gestures are more measured, I slow down the rush of things. I apologize for their loss or what they are going through, and I make an earnest effort to make their anesthetic or hospital course a little more pleasant.

But I never really knew what it was to be a victim until now. That feeling of violation, the idea that someone has battered down the door, trespassed into your home, and torn everything apart - it wreaks psychological havoc. It disrupts sleep, blunts appetite, dulls the senses, wells the emotions. I alternate between being incredibly rational and goal-directed - talking to the police, filing insurance claims, cleaning the house, cataloging losses - to aimless thought wanderlust. This transition from general to specific is a terrifying, eye-opening thing - to go from the disbelief that such things happen in this world to someone robbed my house - exemplifies for me the idea that you can know something without being intimate with it. And being intimate with crime - even nonviolent property crime - is an awful, wrenching feeling. When this is mixed in with our nonstop schedules, the holiday whirlwind, the new interactions with insurance and law enforcement, it's hard to pin down what I'm feeling. I wall off my emotions and reflections to get through the day. Somehow, sometime, I will need to sit and process everything I'm feeling. For now, I will persevere, remain strong, check off those boxes to get my life on track and safe. 

I will also have a little better understanding of what it means to be a victim. When I see my next patient who is a victim of violent crime, iatrogenic harm, loss of medical insurance, an accident - anything - my heart will call out to theirs. We heal in many ways.

Happy Christmas

This has been one of more surreal holidays I've had, and that's counting holidays spent entirely on call in the hospital. I'm still reeling from the burglary of our house, but I am so grateful for everyone who's responded with kindness, sympathy, support, and care. I am sure the shock will abate, but the aftermath of this mess - cleaning the house, replacing stolen items, rebuilding music and picture libraries, working with our insurance company - have caused our to-do list to overflow.

Burglary notwithstanding, we had a warm, comforting Christmas with family, and that helped cushion the feeling of helplessness. I also think the things I see in the hospital help give me perspective. The loss of a few laptops, jewelry, and Christmas presents are nothing compared to the things I see on a daily basis. Health and safety are indispensable. Things can be replaced.

I hope your holidays are filled with joy, celebration, relationships, and magic. I also hope they are a time for reflection and a reprieve from the trials and tribulations of everyday life.

Burglary

Our house was burglarized yesterday. I'm still in shock. After a busy pre-Christmas call anesthetizing seven cases, I returned home to find our house in ruins, the door frame shattered, everything astray, valuables missing. The time to process all of this will come. Right now my mind is still reeling that such things happen. What an awful feeling, to be a victim of a crime. And all the things lost that are irreplaceable, memories, sentimentality, security, the feeling of home. To feel ones privacy, sanctuary, safety invaded, rifled, discarded, and missing. More on this later, but I sincerely wish you and yours a safe, happy Christmas.

The Problem with C-sections

I'm not an obstetrician and the decision-making around calling a C-section is complex, but as an anesthesiologist watching from the sidelines, I've developed a lot of notions and opinions. Since the modern C-section was first performed in the 1880s, it has quickly become one of the most common surgeries in the United States with an incidence around 1/3 of all pregnancies. This statistic just amazes me; how can it be that birth happened for centuries and centuries (albeit with a higher maternal and infant mortality rate) without problem but now, a third of all pregnancies end in surgery?

One problem is that surgery begets surgery. Once a woman has a C-section, she's much more likely to have subsequent sections; trial of labor after Cesarian continues to be uncommon. Fetal monitoring has lead to increased rates of C-section, though fetal monitoring has never been scrutinized through well-conducted prospective randomized controlled studies. And in the back of medical economist heads, the question of medical malpractice lingers. A woman who has surgery but a healthy baby is unlikely to sue for unnecessary surgery whereas a woman who did not receive surgery but has infant morbidity or mortality is much more litigious. It's safer for obstetricians to err on the side of going to surgery.

Ideally, we would have informed, in-depth discussions with our patients about the rationale for a C-section, the risks, the benefits, and the alternatives. But with a laboring woman in pain, a fetal strip showing late decelerations, and the commotion of labor and delivery, I've rarely seen the balanced conversation. However, it's important to remember that surgeries and C-sections should not be taken lightly. Though our anesthetic and surgical techniques make it generally safe, complications happen and they can be catastrophic if they do.

Image shown under Free Art License, from Wikipedia.

Obstetric Anesthesia Again

I also had my second month of obstetric anesthesia. The second time around, the rotation was noticeably smoother. Human experience is interesting in that we rarely notice ourselves change or improve. But when rotations are set a year apart, the difference between the two experiences is quite striking. I remember being apprehensive about obstetric norms, diseases, and expectations during the first rotation. Even though it's been a year since then, a year since thinking about pre-eclampsia, magnesium, terbutaline, and ruptured membranes, I've somehow retained that information and navigate it a lot easier. During my first month, epidurals still remained in a little black box; I understood enough but not everything. This time, I better appreciated the anatomy, understood how to troubleshoot, and became more comfortable with "difficult" epidurals. My success rate with patients with scoliosis, morbid obesity, and inability to sit still was much higher this time around. To myself, I was noticeably faster, efficient, and precise. My manual dexterity also got better in ways I don't understand. You don't really think that your ability to "feel" changes, but mine did. The epidural is a very tactile procedure; I got better at feeling spinous processes, determining the different ligamentous layers by their density, and moving the needle with controlled, precise intention.

Although we don't necessarily like to think about it this way, residency and medicine is a practice of refined learning. I am better now than I was a year ago. Did I provide substandard care a year ago? I don't think so. But I certainly provide better care now. The process of learning, improving, and training is necessary. We have to try, do, stumble, repeat before we can feel entirely comfortable and confident. Balancing this with appropriate patient care is hard, but luckily I think I have made it through the tunnel to the other side.

Clinical Volume and the Holidays

Blogs have been somewhat sporadic because the operating rooms have been extremely busy. In trying to understand why, I learned that patients are squeezing in elective surgeries before the end of the year to use their flexible health spending accounts and maximizing their insurance policies. As a result, we've been booking a lot of cases trying to get everything done. Finances are a big driver in patient decision-making. Rather than "waste" flexible health spending accounts, patients will choose to get elective surgeries that perhaps they would have waited on. On the one hand, perhaps we are doing some unnecessary procedures since to some extent money is driving decisions rather than medical necessity. But on the other hand, we begin to understand how economic incentives influence consumer decision-making. Can financial carrots encourage patients to take better care of themselves, exercise, eat healthier, get preventive medicine, take their medications? How do we take advantage of patient motivators to improve health care delivery and outcomes? Important questions to ponder when work gets less busy.

Holiday Party

We had our department holiday party tonight, an incredibly fun and quite swanky affair. The most fascinating thing about it for me, though, is that I don't know the majority of the people there. The administrative staff, research faculty, emeritus professors, lab staff, nurse practitioners, and fellows dwarf the residents and attendings. It's amazing how big the department is and how many people are involved in its daily operation. I begin to realize that perhaps only a small subset of people are at the patient's bedside and in the operating room, but they are supported by a remarkable machine that helps further our mission of patient care, research, and teaching.

The General and the Specific

As medicine becomes more and more subspecialized, the generalists lose skills they used to have. Decades ago, all anesthesiologists did cardiac, thoracic, obstetrics, pediatrics; because there wasn't further specialization, we were expected to do it all. Of course over time, medicine becomes more complex; the surgeries we do today involve much more technology, equipment, skill, and expectation than those in the past. We are doing harder surgeries on sicker patients, a phenomenon that leads to more specialization, more training, and more differentiation.

But after a month of cardiac anesthesia at the VA doing run-of-the-mill community-level cases, I think that there's something lost when generalists no longer do specialized cases. It would be inappropriate for a general anesthesiologist to do an aortic root replacement or brain surgery for a neonate. But it's not out of the question to expect him to manage a simple three vessel bypass or inguinal hernia repair on a child. The problem with subspecialists is that we now expect a cardiac anesthesiologist to do all heart cases and a pediatric anesthesiologist to do all the kids. But with a limited supply of subspecialists and a growing number of surgeries, this becomes untenable. Furthermore, if the generalist lets his skills atrophy, then cases that used to be appropriate no longer remain so, a sad reflection that we no longer practice to the fullest extent of our training.

I understand the nature of increasing complexity and increasing subspecialization. But this does not mean that the generalist's sphere of practice needs to change.

Book Review: Jonathan Strange and Mr. Norrell

Susanna Clarke's Jonathan Strange and Mr. Norrell was my first foray into alternate history fantasy fiction. I'm pretty mixed about the genre, but I really enjoyed this epic book. Over 700 pages long, the book offered many opportunities for me to give up and return it to the library, but I simply could not stop. Set in an alternate fantastical history, it explores a 19th century England in which magic is returning. But the book delves into fascinating themes of what it means to be English, the nature of friendship, and the gray zone between reason and madness. It incorporates history, postulating the use of magic in the Napoleonic wars. It even creates its own history of magic compiled in a wealth of footnotes scattered through the book.

Jonathan Strange and Mr. Norrell captivated me most, though, with the way its written. With almost a tongue-in-cheek playful approach, it tries to be Jane Austen and Charles Dickens and a comedy of manners and a Gothic tale and a Byronic hero all at once. The writing is gorgeous, a little flowery, and proud of it. It really captures the diction, tone, and style of the 19th century. It is a huge tome, though, so only pick it up if you're willing to tackle a 700 hundred page novel.

Image shown under Fair Use, from Wikipedia.

Thoracic, Revisited

As the cardiac resident at the VA, I also do most of the thoracic anesthesia. Like cardiac, it's fun revisiting these anesthetic techniques in the VA environment. It helps me see how much I've really learned as the second time around, these cases are much smoother. After learning something intensely, the mind and body needs a period of time to assimilate and integrate the new information and skill set. Then when I return to those clinical situations, things feel much more instinct and habit than novelty. The thoracic epidurals, double lumen intubations, troubleshooting, and flow and expectations of surgery become a lot easier. We had a wide variety of cases, from simple wedge resections to a full-on Ivor-Lewis esophagectomy. It makes me much more confident in my skills and decision making as an anesthesiologist.

Where Care is Given

The way we deliver medicine changes in strange ways. There are more and more places that deliver care; new hospitals, clinics, ambulatory surgery centers, and procedure centers are being built year after year. We are caring for patients at more diverse and more numerous places than ever before. Several decades ago, the idea of a freestanding outpatient surgery center would have seemed crazy; now, they are a profitable business model. The same thing applies to clinics found in pharmacies, flu shots being given at grocery stores, and independent laboratory and radiology facilities.

At the same time, though, specialized care is being concentrated more and more at certain hospitals. For example, bariatric surgery outcomes are better at places that do a lot of weight-reduction surgeries; as a result, these centers of excellence concentrate all the bariatric surgery volume. Parents may take a child with complex congenital heart disease hundreds of miles to a subspecialist who is an expert in that condition. Some patients fly across the country to see the nation's best rheumatologist, geneticist, or hand surgeon.

To me, this is a weird result of unregulated medical expansion. We want to do the best for our patients, and we want to have a successful business doing so. So all the routine stuff spreads out for patient convenience; why go all the way to an academic medical center for routine prenatal care if the local obstetrician can open a clinic where you are. But all the rare stuff coalesces at discrete centers to ensure that experts remain experts and patients get the best care. With rare diseases, patients are willing to go farther and wait longer to see the best oncologist in the area. 

At a top academic medical center, I really enjoy seeing the high concentration of complex diseases. But as I look at jobs and think of the future, I realize most physicians out there work with run-of-the-mill bread-and-butter most of the time.

CoreValve

Medicine is moving towards minimally invasive surgery, and cardiac surgery is no exception. The VA participates in a national trial evaluating a percutaneous aortic valve replacement with the CoreValve system. Along with the Sapien valve, these two devices are aortic valve replacements deployed through the femoral artery, or less commonly, through the aorta. Patients qualify for these procedures if they are too high risk for standard open-heart aortic valve replacement with cardiopulmonary bypass. The trials with these devices, however, are quite impressive. Although there is a significant risk of stroke, outcomes with these valves are not bad, especially considering how sick the patients who receive them are.

We coordinate the case with cardiac surgery, cardiology, and the cardiac catheterization lab. After placing an IV and an arterial line, we induce anesthesia. Because these patients all have severe or critical aortic stenosis, this is an extremely high risk moment. Unlike our standard cases where we use high doses of fentanyl and midazolam, our goal is to wake the patient and extubate immediately after the procedure so we have to rely on etomidate (and rarely propofol) based inductions. I mention this moment blog after blog because I think it's underrecognized how dangerous general anesthesia can be for these patients with such advanced cardiac disease and even our physician colleagues rarely realize that we employ all our knowledge of cardiac physiology, disease states, pharmacology, pharmacokinetics, and technical ability in these five minutes around intubation. After securing the airway, we place a central line for vasoactive medications and a trans.

During the entire procedure, the perfusionist is on standby in case we need to crash onto cardiopulmonary bypass; luckily, this is a very rare event. The surgeons do a cut-down to the femoral vessels in the leg; if the femoral artery is too small to accommodate the device, they have to do a mini-thoracotomy in the chest and cannulate the aorta (in this case, we have to isolate the lung with a double-lumen endotracheal tube). The cardiologists put a femoral arterial line and temporary pacemaker into the heart. Then, they guide the replacement aortic valve through a large-bore sheath retrograde into the heart. They position the valve with both fluoroscopy and echocardiography. First, the cardiologists do a valvuloplasty to open up the diseased valve, followed by deploying the artificial valve. In order to do this, they pace the heart incredibly rapidly. They don't want the heart squeezing when the valve is deployed because this can dislodge the valve. By pacing at around 200 beats per minute, the ejection fraction is minimal; though this is transient, the changes in blood pressure are quite alarming. After the new artificial valve is placed - in a way blindly since it is only guided by fluoroscopy and echocardiography - we look on echo to look for perivalvular leak. If the valve looks like it's seated well, they surgeons close up the femoral incisions and we prepare to wake up and extubate the patient. Surprisingly, they rarely need high doses of vasoactive drips. Occasionally we have to place a temporary pacemaker because the CoreValve can cause heart block. The whole procedure takes a couple hours and patients can be awake, talking, and ready to eat several hours afterwards. Its quite impressive as recovery seems so much easier with the percutaneous approach rather than the open approach.

Recipes, Innovation, and Convention

Cardiac surgery and anesthesia at the VA follow a very protocolized treatment regimen. The lines, the drips, the surgical approach, and the post-operative management are standardized almost to recipes. And we don't manage patients the same way as they are managed elsewhere. We keep our patients deeply sedated the first night in the ICU where other institutions may aggressively wean sedation and try to extubate. We use extremely high doses of benzodiazepines and opiates, even up to 20mg of midazolam and 4mg of fentanyl. Why do we do this and does it make sense?

It's easy to criticize this management as old and outdated. After all, this is how cardiac anesthesia was described a decade ago. Only more recently have other hospitals pressed to extubate early, decrease ICU stay, and shorten length of time. But the VA has stuck with what's worked for it. Many reasons can be offered; perhaps our vets have a high prevalence of PTSD and trying to wake up and extubate at night leads to delirium or perhaps the VA is less cost-conscious without economic pressures to get patients out of the ICU as fast as possible. But I think the most important reason is culture. Our surgeons, nurses, and anesthesiologists have come to expect cardiac surgery courses to follow a certain arc and barring reason to change it, keeping the status quo is working with the tried and true. Compared to other things in medicine, cardiac surgery is an enterprise that benefits from standardization. While diagnostic mysteries or chronic care have uncertainties, there should be minimal uncertainty in an elective surgery. Cardiac surgery and anesthesia can be performed in many different ways, but the key is for everyone to agree on one standard process and optimizing it as best as possible.

Thanksgiving

I am thankful this year for my health and the health of my family and friends. It's easy to take our health for granted; this is why health insurance is such a complicated issue. We think ourselves invincible, unlimited, unfettered, at least until we aren't. Perhaps I gain more of an awareness of the tenuous nature of health by working in the hospital and seeing the college student with appendicitis, the pregnant woman with placenta accreta that needs a massive transfusion, the high-powered businessman whose stress and anxiety never let him relax. Reflecting on this post-call holiday, I am most grateful that I am healthy. I am tired, I am weathered, I have minor aches and pains, but overall, I am healthy. And my gratitude extends to all those I love who are also more-or-less healthy. Take care, be safe, and be well this holiday season.

VA Hearts

One of more popular rotations among anesthesia residents is VA hearts. Most of us do our required two months of cardiac anesthesia at the beginning of our second year of anesthesia. This rotation allows us to return to cardiovascular anesthesia as senior residents with a little more experience. The procedures at the VA are standard bread-and-butter heart surgeries: bypass surgeries and aortic valve replacements. The surgeons are phenomenal and bypass times are short, reflecting private practice circumstances. The patients are well-screened and optimized. Unlike Stanford, we rarely see exceptionally complex cases like Marfan's syndrome or pulmonary hypertension. Because most cases are standard, the anesthetic is somewhat standard and protocolized, and residents can get a lot more independence and confidence in cardiac anesthesia.

On a typical day, I arrive at 6AM to set up the room. The anesthesia technicians at the VA are incredibly helpful so most things are prepared in advance; I only have to mix up the drips and draw up medications. I meet the patient early, place an IV and an arterial line, and then roll back the OR, usually before all the regular non-cardiac cases. After a gentle induction, we intubate the patient. When I did my initial cardiac rotation, I focused heavily on the intubation because that's where I was in my training. Now, though, the intubation is easy, and I focus on learning how to induce anesthesia in someone with critical aortic stenosis or three vessel coronary artery disease. Although we induce general anesthesia regularly without much planning, a wrong decision in someone with life-threatening heart disease can mean death. After intubation, we place a large introducer with a pulmonary artery catheter. At the VA, cardiac surgeries are protocolized to all use a Swan-Ganz catheter, something we place rarely these days, so this was a great opportunity to familiarize myself with the procedure. We then place a transesophageal echocardiogram probe and get initial views. This had the steepest learning curve for me, but after a few weeks, I could quickly find all the valves and assess the squeeze of the heart.

The surgery itself was fairly predictable in nature. As the surgeons enter the chest, we drop the lungs to avoid laceration. They dissect out vein grafts at the same time as chest opening. After exposure, we heparinize, and the surgeons place cannula in the aorta, inferior vena cava, and those to deliver cardioplegia. We then go onto bypass, sending blood returning to the heart instead to the machine and pumping blood from the machine into the aorta. After aortic cross-clamp, the surgeons get to work and the perfusionist cools the body. Our bypass times were usually around an hour and a half, and as we come off bypass, we warm the body, get the heart beating again, and start vasoactive drips as needed. After reversing the heparin, we assess whether the patient may need product, and given our short pump runs, this was pretty uncommon. We keep the patient intubated to the ICU, and at the VA, they stay deeply sedated overnight. The cases are immensely satisfying, especially as we get the routine of things. There are usually one to two cases several days each week.

Frailty

As a society, we don't understand frailty very well. Even the medical community - other than gerontologists - has a difficult time grasping the concept of frailty. Frailty is this process of getting older, and though we do not want to think of it, closer to death. Frailty is a loss of physiologic reserve, a decrease in the backup life force than someone has. I feel funny using such fuzzy words, but it's because we don't think of it enough and consequently don't have the right words to describe it. Frailty is not a disease or illness; rather, it's a state of being, an inevitability. As someone ages, even if she is perfectly healthy, she will become frail. Although heart disease, cancer, smoking, and chronic disability can lead to frailty, frailty will happen regardless. It is like death; there is no avoiding it or pushing it back or staving it off.

And our society needs to understand that. Even if we cure our grandparents' heart disease with stents, put their cancer in remission, convince them to quit smoking, replace their joints, stave off their dementia, vaccinate against the flu, they will still be frail. They will still someday pass away. They won't be able to walk as far as they used to, live as independently, weather respiratory tracts as quickly. They will, by virtue of age, have a change in their quality of life. Doctors cannot fix that. We have to accept aging as a process that finds every single person. At some point, we have to start talking about quality of life, about whether it makes sense to start chemotherapy or let that cancer smolder, about whether that surgery will provide enough benefit long term to justify the short-term risks. We have to think about whether someone would prefer comfort, function, meaningfulness, and living at home to chasing every disease trying to achieve immortality. We need to hear these patients' stories, their lives, their wishes, their fears, and their hopes. Perhaps not all their dreams will revolve around living forever. How do we live with frailty? How do we die with dignity? Aging, disability, and death are taboo topics in our society, but it is time to put them out in the open and talk about them.

Vaccines and Outbreaks

The story of vaccination is a fascinating one. Vaccines are often hailed as a true game-changing medical breakthrough. I've never met someone with polio who was born after 1950. The eradication of smallpox is something medical students today never appreciate. The idea that the immune system can be primed with killed or attenuated virus is a beautiful one that has borne out in practice. Yet in the last decade or so, the gains made by vaccinations have slowly withered away. With increasing unfounded fear over side effects such as autism, public stances made by celebrities, and the prevalence of unproven information on the internet, parents are starting to choose not to vaccinate their children. This blog isn't meant to be a soapbox and I don't want to give medical advice, but this trend is disturbing to me. My interpretation of the information out there is that vaccines do not cause autism or have detrimental long-term side effects. They do, however, protect children from diseases. Furthermore, vaccines have a property called herd immunity, the idea that a large population of vaccinated individuals will protect those who are not vaccinated.

This change in our society and culture to decline vaccination is scary because of outbreaks that occur in communities with a high prevalence of unvaccinated children. In 2010, there were 9000 cases of pertussis with 10 deaths in California and these cases clustered in communities with high rates of vaccine declination (measured by exemptions for kids to attend kindergarten without proper vaccines). The outbreaks and the unvaccinated children also clustered in communities with high socioeconomic status. As the outbreaks show, when fewer people are vaccinated, herd immunity is lost, and diseases that are entirely preventable can even cause death.

The Culture of the VA

After rotating through different hospital settings, I've noticed that each place has a specific culture to it. Some places, focused on revenue and caring for many well-insured patients emphasize throughput, productivity, and efficiency. Other places that serve uninsured or underinsured patients concentrate on saving money and rationing resources. The VA, on the other hand, is its own sanctuary. Doctors at the VA are salaried; they don't make more money by doing more procedures. The benefit is that there is no incentive to do unnecessary surgeries; however, it also means that indicated surgeries may be delayed. I like it because we make clinical decisions based on what's right for the patient, not whether it may generate more revenue. And while no physician would do unnecessary surgery for profit, it may unconsciously influence us without our awareness. But since the VA doesn't make more money by doing more surgeries, its pace is a lot slower. We take much longer for our surgeries than equivalent private practices. Part of that is the teaching environment of the VA and part of it might be the fact that it's government. But I find that there's less time pressure to get things done, and it reassures me that I can take longer to do something right. Because cost is usually not an issue, VA patients get fairly extensive pre-operative testing. VA patients are less likely to be litigious. They are more accepting of case delays and even cancellations. Eventually, I will have to think about the culture and work environment of my future job, and it's good for me to get a sense of the diversity now.

Consolidation in Health Care

In the last decade, we have seen a move to consolidation of health care entities. Instead of individual doctor's offices, pharmacies, insurance companies, and hospitals, we've started to see large integrated systems of care. I am particularly aware of this as I talk to my co-residents who are looking for their first jobs after graduation. Whereas in the past, physicians would open solo practices or join small private groups, now it is becoming more and more popular to latch onto a large entity. While solo and small group practices have more potential to be lucrative, large entities offer job security, a focus on medicine over business, flexible schedules, and better benefits. But this shift from small businesses to large ones and to integrate care is more prevalent than where physicians are working. Hospitals, insurance companies, pharmacies, and other health care entities are all melding together and getting bigger. Is this better for patients? This remains to be seen. The advantage of large groups includes purchasing power, spreading risk over a larger area, negotiation of better prices, lowering overhead, and the ability to buy costly improvements like capital equipment or electronic medical records. But this does not always funnel down to patients. In the same way that large systems of care negotiate better rates from drug companies, device manufacturers, and insurers, they can make money by setting high costs for patients. With fewer systems of care in the marketplace, competition decreases. I'm not sure whether consolidation is ultimately better for patients, but it is certainly the way the health care market has gone.

Dreams, the Unconscious Mind, and the Subconscious

When I awoke today, draped in the remnants of sleep, I thought of the strange nature and process of dreams. There is so much we have yet to learn about the mind. What is the purpose of dreams, and what does it teach us about our subconscious? I've always been curious to see if a phone number from a dream is actually a real phone number or whether recurring symbols, themes, or feelings reflect my responses to events in real life. We know so little about the unconscious mind, despite spending a third of our life in a dream state. And, in the same vein, I know little about the experience of a brain under anesthesia. We look at the EEG, understand the kinetics of our drugs crossing the blood-brain barrier, and see the outward manifestation of how patients act. But I wish we knew more about what we were doing to the subjective experience of the mind when we give propofol or sevoflurane. The mind, to me, is beautiful in spite of and because of how little we understand of it. The heart, the kidneys, the lungs, the liver - they carry little mystery for me and little intrigue. I've always been enraptured by the fact that we manipulate the brain so much under anesthesia yet only have a rudimentary knowledge of what we do.

Jet Ventilation II

This is a continuation of the last blog. When we got a chest X-ray, we found that the operative side was whited out and the non-operative side was hyperinflated. When the patient's cancer invaded the bronchus, it destroyed the muscular layer that normally keeps the bronchus open. After the pulmonologist cored out the tumor to open it up, the airway was open but easily collapsible. When we ventilated with positive pressure - that is, when the ventilator (or a hand-squeezed-mask) delivered pressurized air to the lung, the pressure would hold that bronchus open. But when the patient was breathing on his own, utilizing negative pressure ventilation, it would collapse. When you or I take a breath in, our diaphragm drops down, the lungs open up, and the negative pressure in our chest draws air from the environment in. But for this patient, the negative pressure caused the flimsy walls of the tumor-riddled bronchus to collapse. That lung didn't aerate, and because we kept asking the patient to take deep breaths, all that air went into his good lung. Hence the X-ray, a whited-out affected side and a hyperinflated contralateral side.

We had to re-anesthetize the patient. After I intubated him, the pulmonologist went in with a bronchoscope and placed a stent - a wire frame that would keep the affected bronchus open. After deploying the stent and cleaning out the lungs, we woke the patient up once again, and this time, his breathing was unlabored, his oxygenation much improved. He was discharged to home the following day.

Jet Ventilation I

A 60 year old long-time smoker with metastatic lung cancer presents for a palliative bronchoscopic procedure. His lung cancer, which has unfortunately spread to his bones and throughout his body, has invaded into one of his bronchi, one of the branches of his windpipe. As it compressed the airway, the patient developed worsening shortness of breath. He was effectively breathing only with one lung. And although his disease was incurable, his pulmonologist wanted to improve his quality of life by opening up that compressed airway, relieving his shortness of breath.

When I met the patient, he was cachectic, thin and wasted as a result of his cancer and chemotherapy. His oxygen saturation was 92% on room air and I could not hear much air movement on his affected lung side. We placed an arterial line for blood pressure management because of cardiac comorbidities prior to inducing anesthesia. After we induced anesthesia, the pulmonologist placed a rigid bronchoscope, a large metal rod, through the mouth, past the vocal cords, and down into the lungs. We used the rigid bronchoscope to initiate jet ventilation, blasting high pressure oxygen into the lungs and allowing passive exhalation. Working closely with the proceduralist, we stopped oxygenating temporarily as he used laser to remove cancer from the inside of the bronchus. When he initially went in, the bronchus was 90% obstructed, and after removing the cancer and debris, it was almost completely open. Through this time, the patient's oxygen saturation, hemodynamics, and level of anesthesia were very stable.

After the pulmonologist finished, he took out the bronchoscope and we placed a laryngeal mask airway to maintain oxygenation and ventilation until the patient woke up. All his vitals looked great, we stopped the propofol and remifentanil, and he was breathing well on pressure support ventilation. The patient would start taking a breath and the machine would assist slightly to make sure he was taking in enough volume. The patient became fully awake and we took out the laryngeal mask airway and put him on a facemask. Over the next ten to fifteen minutes though, his work of breathing increased and his oxygenation decreased. He dropped from 100% saturation down to 85%. He was fully awake, following commands, taking deep breaths with good breath sounds, but his oxygenation simply would not improve. An arterial blood gas confirmed that something was wrong. Even though we placed him on a non-rebreather oxygen mask, he did not improve. He was shunting blood; that is, blood from the venous circulation was bypassing alveolar exchange units and going to the arterial side. No matter how much oxygen we gave, we could not improve his oxygen uptake. The rest of the case in tomorrow's blog.

VA

I had a couple weeks of general OR anesthesia at the VA. Coming back year after year is a really interesting experience. Since I started my residency at the VA, it has a special nostalgia. I remember coming in so early each morning to set things up, poring over patient charts, calculating doses before each anesthetic. But now as a senior resident at the VA, it's such a different experience. It's fun to have a wide case diversity; in a week, I will do orthopedic, ophthalmic, plastic, ENT, urology, and general surgery cases. It used to scare me as a new resident as I was learning a new thing each day, but now I take it in stride. I used to work to keep up with the pace, but after seeing other environments, I realize the VA is quite laid-back and I often have lots of free time between cases. The faculty are outstanding and I can see the change from close supervision to distant observation. The anesthesia techs, surgeons, and staff there are a true pleasure to work with. As I wrote yesterday, I love the patients, though medically, they can be complicated. Our veterans smoke, drink, have tried drugs, have hypertension, hyperlipidemia, diabetes, coronary disease, suffer from dementia, peripheral vascular disease, COPD, struggle with reflux, BPH, and cancer. Few patients are truly healthy, a challenge to providing safe anesthesia. But vets are hardy folk, and every day the medical challenges are manageable and even fun. Although some aspects of the VA OR drive me crazy, I also enjoy it as a relaxed environment with all the bread-and-butter cases in sick patients.

Veterans

I've been at the Veterans Administration the past few months and wanted to set aside a blog to honor the veterans who have served our country. Every time I rotate through the VA, I am genuinely touched by the veterans I see. They have so much courage, fortitude, and stoicism, and whether it is due to the experiences and adversity they've had, veterans about to undergo anesthesia and surgery are so much calmer than other patients. Although I don't want to generalize, the veterans I've met have been kind, open, generous, trusting, and respectful. Each day at the VA, I am reminded why I went into medicine, and so today, I honor those who have served our country.

Image is in the public domain.

Ergonomics in the Operating Room

I find it a little ironic that in the operating room, we pay painstaking attention to positioning the patient to prevent nerve injuries yet I think I am developing a minor nerve palsy from poor ergonomic attention to myself. While a patient is anesthetized, they cannot protect their pressure points, so we pad their elbows, make sure the shoulder is not overly abducted, protect the radial and ulnar nerves. Yet I constantly find myself typing into the electronic record at an awkward angle, bending down to difficult-to-access drawers, and lifting heavy equipment. Now that I'm starting to get right shoulder pain and some carpal tunnel syndromes, I wish I was better aware of my occupational health hazards. We cannot care for patients if we do not care for ourselves.

Volunteering

It's hard to volunteer much as a resident. So much of our time is occupied by medicine that we hoard the free time we have. Even more than that, our schedules are so variable and irregular that we cannot commit to a regularly scheduled extracurricular activity. Perhaps we try to make up for it by donating to those causes we support. But overall, it is a segment of our lives where, understandably, we have little time to volunteer. Yet my fear is that once our lives open up, once we have more freedom and flexibility in our schedules, we will forget the importance of volunteering. In the same way that we are active participants in the medical community, we play a role in cultivating our local communities as well. As I reflect on how I parcel my time now, I wish I had more things I did out of the hospital. I love my work and I enjoy residency, but oh, what it's like to talk to friends who don't just have medical stories. What it's like to nurture a passion in the arts. What it's like to help someone out who is not a patient. What it's like to see more of the world.

Leaders in Medicine

We spend so many years in school learning how to be a physician, studying the biology and physiology, apprenticing on the wards, developing a framework to go from symptom to diagnosis, memorizing diagnostic tests and treatments. But as I near the end of my residency, I begin to appreciate that our education has not taught us how to become leaders. And as I've begun to appreciate the ebbs and flows of policy, health care reform, business management, hospital systems, and "bigger picture" issues, I've realized this is a big deficiency. We need good doctors, good physicians. But doctors are trained in a framework, a system, and in many respects, this system is not sustainable. It is the leaders who will innovate, change, create.

But compared to other fields, medicine doesn't engender leadership. Our classrooms in medical school - at least in the past - revolve around passive learning. We spend all our time trying to absorb a massive corpus of knowledge. When we first learn things, we memorize and regurgitate. Even as we progress in our medical education, the information is merely applied or data interpreted. We aren't trained to imagine, question, and create, at least not to a great extent. In residency, we are structured into hierarchical teams; we don't learn to challenge the way things are or question authority. This is the way medicine is learned for many reasons, and innovative education systems are starting to change things. But I compare this to the environments my friends in business, law, PhD, or design school experience. They are given problems without discrete answers and work in teams to design solutions. They think outside the box, try things, fail, make changes, and persist.

I've been in the operating room for three years, and I haven't come up with a single invention. I know the inefficiencies, the problems, the things I wish I could do. But I haven't been equipped with the skill set or toolbox to create something de novo.

But identifying the problem is the first step. We need leaders in medicine. Changes in health care, the way people are insured, the way physicians are paid, the relationships with industry, the way it is delivered need to be spearheaded by physicians. I feel like I have a long way to go to accomplish this. But if I am really to engage in medicine, I need to do a little more than write blogs and give patients naps.

The American Resident Project

I am one of the writers contributing to The American Resident Project, a platform for medical students, residents, and young physicians to share, explore, connect, and discuss the transformations in medicine today. From health care reform to the shortage of primary care physicians to the role of technology, changes in medicine are dramatically changing our role as physicians. Sponsored by ThinkWellPoint, this forum is a dialogue between young doctors, thought leaders, and the public about how to improve health care delivery, navigate the growing complexity of medicine, empower patients, and change things. As one of eight blogging fellows, I aim to write about an article a month, challenge current paradigms, engage the community, and probe possible solutions for the future of health care. Please join us at The American Resident Project; share your views, tell others about the site, and read the articles written by the other blogging fellows.

Happy Halloween!

After spending so much time in medicine, whenever I see a skeleton around Halloween, I can't help by check the accuracy of the anatomy.

Image is Study of Skeletons by Leonardo da Vinci, c. 1510, in the public domain, from Wikipedia.

International Medicine

I loved every moment of the medical mission. Most of it, though, was a little bit self-serving. There is a question in philosophy whether an act can be truly altruistic. An act that may seem altruistic - donating to a non-profit, for example - gives the donor a sense of satisfaction or pleasure, and hence is not a purely altruistic act. In any case, instead of spending the week anesthetizing patients at the VA, I had the true privilege and opportunity to help kids in Guatemala who needed it. We made a difference in the lives of our 30-some patients. I loved it; it was so satisfying and fulfilling. We do a lot of volunteering and public service as high school students, medical students, undergraduates. But since residency, I haven't had the time or energy for something like this, and I missed it. It feels good, satiates some internal desire to give to someone who needs it. And now, I realize, I have a knowledge base and skill set that's truly useful, necessary, and uncommon.

But did we make a dramatic difference in the community? No, not at all. Communities need infrastructure, resources, physicians who will stay for the long haul. An international group that comes in for a week and then returns to our charmed lives changes things for individuals, but not communities. The people I admire most are those with the vision, resolve, and self-sacrifice to try to make the real lasting changes. One mentor I've worked with helped build a hospital in Rwanda; other anesthesiologists in the department have taught and trained anesthesiologists in other countries. Those are the foundations of real international medicine. What I did - no matter how great it was - was dabbling.

Nevertheless, I learned a lot and I grew a lot. In terms of medical knowledge, I broadened my experience of pediatric anesthesia, especially seeing pathology that would normally be treated much earlier on. I learned how to cope with older equipment, limited medications, a different environment. I began to learn about systems-issues when infrastructure, nursing, floor care, and pain management are limited. My Spanish improved. I cared for patients with medico-psycho-social problems, became aware of how culture affects care, gained an appreciation for the nonmedical issues - education, physical therapy, support systems, ethics - at play. My abilities, techniques, comfort, and confidence improved over the four days we operated. Our operating room teams worked smoother and more coherently with each case.

I am so grateful for this opportunity and would not hesitate to go on future medical missions if I am able. Although I wish I were the kind of mover and shaker that could really elicit change in a setting that needed it, I am content with being one of the players who changes lives of individuals, one at a time.

A Little Bit of Fun

We also had a few days of rest and relaxation on our mission trip. The whole group went to Antigua, a beautiful church-laden cobblestone town. We hiked up a volcano, stayed in a beautiful resort, and explored the old capital of Guatemala. Over the week, I got to know the medical team incredibly well. Everyone was so dedicated, motivated, and wonderful to work with. We worked long hours but no one complained. We improvised and made do with the resources we had; we played with the kids; we came together as a seamless team. It truly was a work hard play hard type of trip. In the end, I didn't feel like it was a vacation per se, but it was more fun than a regular week of work ever was. There is something magical about bonding in a different country with a group of people you wouldn't normally hang out with but a group of people brought together by a single unifying desire to care for children in need. I had such a great time and definitely want to incorporate international medicine in my future career if I can.

Culture and Language

Although I experience different patient populations working at different hospitals, the difference between patients at home and patient I saw in Guatemala was very striking. The children we treated in Guatemala seemed to me more independent, stoic, and hardy than those I remember from home. Part of it was an increase in the authority dynamic of medicine. I think the families, parents, and children in Guatemala viewed us in a particular light because we were physicians donating our time to an international medical mission. Families were passive; there was no argument or objection to our medical decision making. For example, if I felt that a 40kg 10 year old needed an IV start rather than an inhaled mask anesthetic, no one complained. None of our patients got any midazolam syrup, a common anti-anxiety premedication we give here, but very few of our patients had irreconcilable separation anxiety. Almost all the children we took to surgery were calm, understood what was going on, and acted a little older than their age. Even after surgery, the patients in Guatemala were stoic and hardy with regard to their pain. There was an understanding, an expectation that surgery would hurt, and they didn't need excessive coddling, treatment, or attention. When our physical therapist pushed the patients to do their exercises, the children did even though it hurt, something we don't always see in American kids.

I also got to practice my Spanish. Over the last several years, I've built up my medical vocabulary, but there are still gaping holes. Immersing myself in the local environment really gave me the opportunity to work on my communication, gain confidence, and learn. Our interpreters were so helpful, encouraging us to speak the language and build relationships with our patients. We also worked with physicians from Guatemala, and that dialogue was not only an opportunity for them to practice English, but also an enlightening experience in understanding medical delivery in a different country.

Scoliosis

Our biggest surgery on the medical mission was a 10 level spinal fusion from T4-L1 in a young teenage girl with adolescent idiopathic scoliosis. She had worn a brace for years with little improvement and was incredibly motivated to get the surgery. However, we had to be sure we could do it. Even small things we take for granted here in the states aren't readily available in Guatemala. For example, our operating bed was not designed for prone cases, that is cases where patients are positioned on their stomach. Working with our nurses and techs, we fashioned a prone operating table that would relieve pressure on her vital organs during this long 8 hour surgery. We did not have invasive arterial blood pressure monitoring. We had to confirm our access to a blood bank and ability to get blood for transfusion. We inquired about access to blood tests and the turnaround time; we ended up sending our blood draws by taxi to the nearest lab. We hammered out a plan for post-operative pain because a surgery this large was going to hurt. And in the end, we decided to proceed.

With all our preparation, the surgery went incredibly smoothly. Although it was a grueling 7-8 hours, we worked together as an amazing team. The surgeons worked incredibly efficiently, the nurses coordinated smoothly, and the Guatemalan physicians and staff assisted us with getting blood and sending our CBC tests. The result was so incredibly lifting for me. We tided the patient through her post-operative pain, and by the end of the week, she was walking down the hallway. All of us were so inspired to see the change we made in her life.

Image shown under GNU Free Documentation License, from Wikipedia.

Pediatric Nerve Blocks

One of the neat things we brought to Guatemala was an ultrasound machine and equipment for performing nerve blocks. Regional anesthetics or selective nerve blocks have a real advantage, especially in resource-poor environments. Our opiate availability was limited and once the patients went to the floor, the nursing ratio was not as high as we'd like. As our nerve blocks can last many hours, that would help our patients get rest that first night and begin physical therapy earlier. Since nearly all our surgeries were on the extremities, for many cases we would induce anesthesia, intubate the patient, and then do the nerve block. We mostly did popliteal, saphenous, femoral, and infraclavicular blocks as single shots (we could not manage catheters) and the results were excellent. For young children, we also did caudal blocks which are similar to single shot epidurals, allowing four hours of pain relief. The surgeons were wonderfully patient in letting us do these blocks.

We had to be careful though because we didn't have our normal emergency resources. If a patient had toxicity from too much local anesthetic, we didn't have the antidote, lipid emulsion. If we punctured the lung in an infraclavicular block, we would not have X-ray or chest tubes to diagnose or treat pneumothorax. In the same way, general anesthetics carry the risk of malignant hyperthermia and we did not have dantrolene for reversal. We carried a small supply of emergency drugs and had a defibrillator, but I was concerned about these rare emergencies. On our first day, we came up with plans for most emergencies, and luckily we did not have to use them.

Surgery

During the four surgical days on our medical mission, the entire group would have breakfast at the hotel together at 6:30 and then take shuttles to the hospital. The surgeons then made rounds on their post-operative patients while the anesthesiologists and nurses set up the operating rooms. When we were ready, we would meet the patient and parent in the pre-operative area. We adhered to standards at home; we made sure the surgeon initialed the operative site, double checked the procedure and consent, reviewed the plan with the parent. Unlike operations at home, we didn't pre-medicate the children with midazolam because we didn't have any. But surprisingly, the children tolerated the new and scary experience quite well. For the older and larger kids, we would start a pre-operative IV. For the others, we brought them back and induced inhaled anesthesia by mask. Common procedures included Achilles tenotomies, psoas muscle release, excision of extra digits, leg lengthening or shortening, osteotomies, and revision of prior surgeries. We used fentanyl and morphine as our opiates; we brought some ketorolac, acetaminophen, and ketamine as well. We were limited in our antiemetics so we only used them for older children and when necessary. Though the monitors and ventilators were old, we were able to do most of the things we needed with them. Unlike surgery at home, we didn't have good ways of warming the patient under anesthesia so the rooms were on the sweltering side. In fact, for one of the surgeries, the surgeons had rubbing alcohol poured down their back and clipped icepacks inside their gowns because it was so warm.

The post-anesthesia recovery unit was immediately outside the ORs, so close that we could stick our head outside the OR and check on our patients. We had 3 beds awaiting our patients. The PACU nurses took blood pressures manually and had a pulse ox but no EKG. Once the patient was awake, drank some jugo, and was comfortable, they were brought upstairs by orderlies to the pediatric ward.

We had anywhere from three to six cases in each room each day and operated until around 7pm. Even after the last surgery was finished, we hung around to do post-operative rounds and make sure that the last patients were discharged from PACU safely. Because everyone had to take the shuttles together back to the hotel, everyone worked together and waited around until the day's work was done. During the day, we'd have a delicious lunch provided by the hospital, and at the end of the day, we had dinner as a large group in the hotel before retiring for bed.

Clinic Day

The Sunday after arriving to Guatemala was our clinic day. Imagine a waiting room the size of a tennis court filled with over a hundred people. Children hunch over coloring books we brought, some having others color for them because their congenital hand deformity won't allow them to grip a crayon. They are here to see the surgeon about that club hand. The parents socialize, forming an ad hoc community, lamenting how hard it is for their bowlegged son to go to school or how expensive it is to buy a wheelchair. The doors to the smog-filled street are open and fans are going full blast because there is no air conditioning. Volunteers check patients in and call them up to see the surgeons in a makeshift examination room. Screens are set up to give some semblance of privacy as surgeons test range of motion, check gait, hold X-rays up to the fluorescent lights. An interpreter and scribe are assigned to each attending surgeon and the process moves quickly. The surgeons determine whether we can feasible intervene; sometimes, we don't have adequate equipment, facilities, or follow-up. But if the child is a candidate for surgery, they will either send them to get further X-rays or see us in our anesthesia closet. On their way to see us, nurses take their height, weight, and vital signs. Then in a quick 10-minute visit, I go through the medical, surgical, and birth histories, medications, allergies, anesthetic plan, preparations, and expectations. I carefully record the patient's information and file the chart - the surgical evaluation, my pre-op assessment, a photograph of the child, X-rays, and a contact information sheet - away carefully.

After we have seen about fifty children, we convene to discuss the cases. We are operating for four days and we want to fill the slots with the most high-impact cases. We have to decline some children - the surgery is too involved, the anesthetic is too risky, there are undiagnosed medical illnesses, or the child is running a sky-high temperature. But for most of the children, we slot into each day, trying to create a balanced schedule. After making the week's operative list, we go back down to the waiting room to all the eager faces.

Travel

The entire medical mission group flew together to Guatemala. We brought over 30 bags of equipment, almost 50lbs each, filled with surgical instruments, crutches, splints, a wheelchair, medical supplies, and anesthetic equipment. Although we got our controlled substances at the hospital we were volunteering at, we brought along all our other pharmaceuticals - from sevoflurane to emergency drugs to antiemetics to antibiotics. Getting these through customs always takes a little time; indeed, we arrived at the airport 3 hours before the flight and spent a while waiting when we arrived in La Aurora Airport in Guatemala City.

Although it felt a little silly bringing so much stuff, when I arrived at the hospital in Guatemala, I knew why. We were working at a small but adorable hospital only used for mission trips. Although it had large equipment like beds, operating tables, Mayo stands, cabinets, an autoclave, and ventilators, it didn't have too much more. We even brought disposable things like gloves, gowns, hats, and masks because we didn't want to use up local resources.

Each day, we climbed up four floors through the tiny, narrow, adorable hospital. There were three small operating rooms, and according to other group members who'd been on multiple missions, this place was luxurious. We quickly settled in, hanging shoe-racks on the walls to hold our supplies, testing the monitors and ventilator, hooking up the suction and electrocautery. Each ventilator was different, donated from American hospitals once they were obsolete. When I started residency, we had a few similar models so I wasn't completely lost, though over the last few years, Stanford has phased all these old-school Drager machines out.  I got to work, rummaging through our equipment, jerry-rigging and cobbling things together until I was satisfied. Although there was a small culture shock when I first walked in, when I got down to it, we had everything to deliver a smooth, safe, and stable anesthetic.

Images taken by me on the Operation Rainbow medical mission.

Operation Rainbow

I just returned from a medical mission to Guatemala with an organization called Operation Rainbow. It was an incredibly eye-opening and deeply moving experience. I was initially approached by our chief residents as the group was looking for an anesthesia resident to accompany them. The brigade of 26 volunteers included 4 surgeons, 3 anesthesiologists, 9 surgical staff (including circulators, scrub nurses, and sterile processing technicians), a physician assistant, orthopedic technicians, a physical therapist, a bioengineer, interpreters, and a medical student. We were going down to Guatemala City to work with a local pediatric foundation to provide orthopedic surgery to kids with a variety of deformities, from rickets to scoliosis to club hands to traumatic nonunions. I was thrilled to do it. One of the great things about anesthesiology is that even in residency, there is flexibility in the scheduling. I signed up hardly knowing what I was getting into.

Logo shown under Fair Use, from operationrainbow.org.

If I Had More Time...

Perhaps it is inherent to this time in life or stage in my career or my generation, but I never seem to have enough time. I have so many topics I want to blog about yet I struggle to find time to proofread the posts I publish. There are aspects of anesthesia I want to read more about but each evening, bedtime comes before I can pull up PubMed (it doesn't help that the government shutdown's tentacles have ensnared PubMed either). If I had more time, I'd reimmerse myself in philosophy, visit the library more often, write more poetry. I recently came across articles discussing the German Tank Problem and the Doomsday Argument, fascinating queries involving philosophy of science and mathematics, and it reminded me of a course I took on philosophy of physics. There was a time when I had the luxury of time to ponder on such thought experiments, and it feels a little sad now that my life has pared itself down to simplicity. I reassure myself that such is the reality of residency or perhaps this is the nature of most people at my stage in life. Each night, as I fall asleep, I resolve to make more time, more time to write, dance, read, learn, discuss, play, exercise, and work.

Liver

You can probably tell from the last few posts, and I promise this will be the final one about liver anesthesia, but I had a great time on the rotation. I only had two transplants, but they were rewarding and exhausting. The goals of anesthesia vary from case to case, and being a satisfied anesthesiologist is finding the cases whose goals resonate. In an outpatient surgery center, the goal is to expedite quick wake-ups, discharge, and turn-overs. In neurologic surgery, the goal is to select anesthetics that protect the brain and allow a quick neurologic exam at the end of the case. In liver transplants, the goal is to keep the patient alive. Those anesthesiologists who balk at real risk, who gravitate towards happy and healthy patients need not apply. But for me, the type of person who loves "big" cases, complex medical decision making, facility with procedures and their interpretation, the liver room is the place to be. I had a fabulous time with the challenge, and it gave me my moments of anxiety. But at the end of the rotation, I think I am a better anesthesiologist as a result. Hopefully, when I finally go out to find a job, I can incorporate cases like this because the challenge is thrilling.

Liver Transplant IV

The liver synthesizes most of the proteins involved in coagulation or blood clotting. While we think of most cirrhotic patients as coagulopathic - unable to form clot - they are also paradoxically hypercoagulable. The liver also synthesizes proteins that break down clots so sometimes the balance tips towards formation of thrombi and emboli. We further perturb the system during surgery with local inflammatory mediators triggered by trauma, the transplant of a liver which has been synthesizing pro- and anti-coagulant proteins, transfusions of plasma to help reduce surgical bleeding.

This was most prominent in one of my liver transplants where after reperfusion of the new liver, clots were noted by transesophageal echocardiogram in the heart. There was a period of time when the heart was stunned during reperfusion, and I wonder if these low flow states in combination with procoagulants released from the liver lead to clot formation. Furthermore, the focus of the clot seemed to start from a central line tip sitting in the atria. However, when we checked coagulation tests, the patient's INR was 8 and PTT was over 300, both suggestive that the patient's blood was too thin.

This is the paradox of coagulation in liver disease. The patient was bleeding and clotting at the same time; somehow, the normal system of checks and balances had failed. This is disseminated intravascular coagulation, and in the middle of surgery, this is life-threatening. Even though it doesn't make much physiologic sense, we gave a small bolus of heparin to dissolve the clot while transfusing products to decrease the bleeding. Over the course of the surgery, the clot melted away. We didn't see any changes in our pulmonary artery pressures or oxygenation so we didn't think the clot emobolized from the heart to the lungs. Such situations show me the complexity of managing coagulopathy especially in the setting of a major surgery with vascular components in a cirrhotic patient.

Liver Transplant III

A gentleman with hepatitis C cirrhosis is scheduled for an orthotopic liver transplant. Though he has no other major medical conditions, his liver disease is fairly severe; his MELD score, a measure initially used to estimate 3 month mortality and now used to determine liver transplant priority, is 36, suggesting over 50% mortality in the next 90 days. He has significant ascites, leg swelling, esophageal varices, coagulopathy, portal hypertension, and hepatic encephalopathy. He needed a new liver.

We waited to induce anesthesia until the donor organ arrived. Until the transplant surgeon examines the organ fully, there is always the possibility that the surgeon may cancel the procedure. Though this was highly unlikely, we also did not want to put the patient at risk unnecessarily. Once we got the green light, we induced anesthesia, struggling with hypotension as liver disease severely impairs normal cardiovascular responses. We placed multiple lines including single lumen central line placeholders that could be converted to bypass cannulae if necessary. The transesophageal echocardiogram showed a hyperdynamic heart, commonly seen in patients with liver disease. We began reversing the patient's coagulopathy as his INR was five times normal. We began the patient on octreotide and some vasopressin, and the surgeons began.

To expose all the abdominal organs, major vessels, and the cirrhotic liver, the surgeons make a large "Chevron" incision below the ribcage about two feet long. He also makes an incision from the bottom of the breastbone down to the bellybutton. When he does so, several liters of ascites, fluid that accumulates in the abdomen as a result of liver dysfunction, spilled out. The dissection is meticulous, especially since the patient had gallbladder surgery in the past and had some scarring and adhesions. Through this time, we struggled with the blood pressure; cirrhotics are in a chronically vasodilated state, and general anesthesia doesn't help. This was a rare surgery in which we ran a very light anesthetic with heavy paralysis. With the level of liver dysfunction, the patient was confused and disoriented to start and would not be able to metabolize anesthetics easily. Thus, we expected our midazolam to linger longer than normal and provide adequate amnesia.

As the surgeons prepared to remove the old liver and connect the new one, they placed vascular clamps along the inferior vena cava. The clamp time was less than half an hour, but during this time, the normal blood return from the intestines and lower legs was impaired and portal venous pressures began to increase. The old liver came out, scarred, battle-ridden, even with the remnant of a TIPS catheter. The surgeons worked furiously to reconnect the inferior vena cava "cuff" of the new liver to the severed vena cava of the patient. Similarly, they reconnected the hepatic artery and portal vein. Meanwhile, we began optimizing the patient to the tenuous moment that the cross-clamps would be removed. We replaced electrolytes, warmed the patient, and decreased the anesthetic to almost nothing. Since the patient is anhepatic - liverless - the circulating medications were not being metabolized.

With the removal of the vascular clamp, blood flow began circulating through the new liver. However, this meant that all the toxins that built up while the donor liver was out of the body and being prepared are now released into the body. Cold potassium, preservation solution, cytokines, inflammatory mediators, and cellular debris floods into the heart. This is then followed by the venous blood draining from the intestines and lower extremities that could not be cleared during the cross-clamp. This blood is no better for the heart. To prepare for this hit, we gave calcium, glucose, insulin, and bicarbonate. Nevertheless, the patient's heart rate plummeted to 30 and the blood pressure halved, then halved again.The surgeons could not palpate the carotid or femoral pulses. This is the rollercoaster of the liver transplant. Fortunately, we anticipated this. I bolused atropine, escalating doses of epinephrine, and additional calcium chloride with appropriate responses. We shot a cardiac output with our pulmonary artery catheter and it showed a markedly stunned heart and a completely vasoplegic vascular system.

The anesthesia is challenging. We sent off blood gases every 20 minutes, adjusted our drips, fixed electrolytes, and gave blood products. The patient bled and bled and bled, and we found ourselves spiking bag after bag of blood, plasma, platelets, and cryoprecipitate. Eventually, we were able to achieve hemostasis and as the new liver began to work, we weaned the patient completely off drips. The heart began to squeeze vigorously, and we knew we had weathered the patient through.

Liver Transplant II

Our set-up for a liver transplant is pretty involved and can take me up to an hour. Although we use one of the large cardiac rooms, with all the equipment, it feels pretty crowded. We even have a floor plan to detail where everything goes. After we induce anesthesia and intubate the patient, we still have at least half an hour's worth of preparation. We place multiple lines including a femoral arterial line (believing that especially in cirrhosis, central pressures are more accurate than peripheral pressures). Sometimes, we'll also place a radial arterial line just for blood draws as we can be sending off a lot of blood gases, blood counts, and coagulation samples during the procedure. We then place two large 9 French introducers into the left internal jugular vein. We place a pulmonary artery catheter through one of these introducers. We hook them up to a Level 1 rapid transfuser and a Belmont rapid transfuser. We also have a backup Level 1 in the room in case one of the transfusers fails. Then depending on the surgeon, we may place additional 16 gauge central lines in the femoral and right internal jugular veins which allow the surgeons to rewire into a bypass cannula. We hook up our drips; routinely, I make phenylephrine, epinephrine, vasopressin, and octreotide. Lastly, we place a transesophageal echocardiogram probe. This can be a little tricky as patients often have esophageal varices that can hemorrhage, but the TEE allows us to visualize the cardiac contractility and volume status. By the time all this is done, I'm pretty spent, and we haven't even made incision.

Liver Transplant I

Liver Transplants are complicated for many reasons. Not only is the liver an incredibly vascular organ, but it also filters blood returning from the abdominal organs through the splanchnic circulation. In patients with end-stage cirrhosis, the pressures in the splanchnic circulation is very high as the blood cannot be drained through the scarred liver. This portal hypertension greatly increases the bleeding risk. So how do you replace a liver when you have to detach all the vessels, which are under high pressure, and reattach them to a new liver? During this whole process, the surgeons have to clamp the vessels to work on them. Where do they clamp and how does that affect the body under anesthesia?

In the most standard version, the surgeons will clamp the inferior vena cava, which receives all the blood draining from the liver. However, doing so means that venous drainage from the lower extremities and abdomen ceases since the blood cannot get back to the heart. The patient may tolerate this temporarily, but as time goes on, that venous pooling starts accumulating evil humors, and when the clamps are released, the accumulated toxins flood the body. To ameliorate this, surgeons often do liver transplants with veno-veno bypass. They bypass blood from the femoral and hepatic vessels to the jugular or axillary vein where it can return to the heart by the superior vena cava. This tends to smooth the clinical course when the inferior vena cava clamps come off, but comes with its attendant risks.

When the surgery is this tricky, the anesthesia has to be delicate and careful. The liver transplant is a great example of how complex surgery affects what we do on the other side of the curtain. We have to plan for potential large bleeding if those portal vessels are injured, aid in the preparation for and management of veno-veno bypass, and prepare for arrhythmias, hypotension, hypothermia, and cardiovascular collapse when that all-important inferior vena cava clamp comes off.

Book Review: Snow Crash

I read Neal Stephenson's Snow Crash right after Lexicon and there are some remarkable similarities. It, too, has an undercurrent of neurolinguistics, the idea that words can affect the brain. Set in a very different world, Snow Crash takes place in an amazingly constructed dystopic future that was so much fun to read. Like Ready Player One, characters interact in both a real and virtual world. The characters of this plot driven thriller are captivating, from a teenage heroine who skateboards highways by harpooning trucks to a ninja hacker who researches ancient civilizations to a mafia boss who guarantees 30 minute pizza deliveries. It was one great vacation read.

Image shown under Fair Use, from Wikipedia.

Book Review: Lexicon

Max Barry's Lexicon reminds me of Lev Grossman's The Magicians. Set in more-or-less the modern day in the modern world, it is about a secret fantastical group of people with semi-magical powers involving words. If the idea that words could have real power and influence is interesting, this is the book to read. Action-packed and fast paced, it moves quickly. The writing is easy, not too sophisticated, but appropriate to the novel. I loved the structure of the book which lends itself to liking two very polar characters and puzzling out the intrigue. It's a great light science fiction read which I managed surprisingly between my thoracic and liver calls.

Image shown under Fair Use, from maxbarry.com.

Liver Resection

A man with cholangiocarcinoma - cancer of the gallbladder - presents for a large resection of the liver. The liver is divided into eight segments based on its anatomy and our goal was to remove two-thirds of it. This was going to be a large, potentially bloody surgery because the tumor was fairly close to the inferior vena cava. We planned accordingly, placing an introducer sheath into one of the large neck veins and setting up a rapid transfuser. The surgeons worked carefully; I could see the concentration in their movements as they delicately dissected the cancer from the largest vein in the body. We watched closely, as any errant move could cause massive blood loss requiring clamping of the inferior vena cava. But our surgeons' precise movements allowed them to peel the cancer away, an amazing technical feat of precision. The tension relaxed as the rest of the liver segments were resected, the hepatic vessels clipped, the bile duct system reconstructed, and the lymph nodes sampled. The patient never had problems with low blood pressure or excessive bleeding, we were quite satisfied as we finished the ten hour procedure, removed the breathing tube, and brought him to the recovery unit.

I began another anesthetic when the resident in the recovery unit called me. "I wanted to make sure he was never hypotensive," she said, "because he's dropping him blood pressure right now. The surgeons think he's dry and we're giving him some albumin and fluids." This was an appropriate initial response; we keep patients dehydrated for liver resections because liver congestion can cause a lot of problems, and most patients require rehydration after the operation. But when I checked in again, he was even more hypotensive, requiring pushes of vasopressors to keep his blood pressure in the normal range. His oxygen requirement went up and he was becoming more confused again.

I knew something was very wrong. When I got to the bedside, I called for blood and told the surgeons we needed to go back. There was unresolved bleeding somewhere, even though the drains were empty and the belly was soft. When I drew a blood gas, the blood didn't look like blood; it was too dilute. The only way to find and stop the source of bleeding was to go back in and find the bleeder. We crashed the patient back into the operating room, four anesthesiologists, working seemlessly as a team. We re-induced anesthesia, a tricky but necessary affair for a patient in hemorrhagic shock. We got a rapid transfuser set up and called a massive transfusion protocol, giving a total of eight units of blood, seven units of FFP, and some platelets. Such a resuscitation requires a lot of work, and we were occupied the entire time. But we managed to titrate the pressors off, improve the acidosis, replenish electrolytes, and stabilize the patient. The surgeons found a bleeding arterial vessel whose clip had been dislodged. If we had waited much longer, the patient would have had a cardiac arrest. But we managed to get him to the ICU in stable condition. The problem is that his liver, which has already suffered a large resection, had further injury during the period of low blood pressure. It will be slow to clear the acidosis, make clotting factors, clear waste products, and function again. But we hope that we can tide him through this critical period.

This case taught me that even if a field looks bloodless, an unexpected post-operative course must include unseen and unexpected hemorrhage. Sometimes a re-operation is necessary and sometimes the anesthesiologist who knows the patient's physiology best and identifies that something is direly wrong needs to speak up and make it happen. Access was central here, and the fact that we had an introducer to give blood as fast as a unit a minute saved this patient's life. The case taught me to prioritize and manage a rapidly changing clinical situation. This is what physician anesthesiologists train to do.

Liver Rotation

On a two week liver anesthesia rotation, we get assigned to some of the more complex liver surgeries and take call for all liver transplants that come in. It's a busy two weeks as the weekday surgeries tend to be busy, involved cases and liver transplants are some of the biggest cases we do, requiring a great deal of set-up time and lasting from eight to twelve hours. Patients with liver disease have important relevant medical issues, as well. As the liver produces all the clotting factors, these patients can bleed a lot if they have liver dysfunction or undergo a large resection; this can limit our ability to put in epidural catheters for post-operative pain. Liver disease can cause altered mental status with hepatic encephalopathy, involve the lungs with hepatopulmonary syndrome, and precipitate kidney failure with hepatorenal syndrome. While the heart is usually uninvolved, if patients develop liver disease because of alcohol or drugs, we have to rule out cardiac consequences. We depend a lot on the skill of our surgeons as well since the liver is next to important structures and receives a large blood supply. Bleeding can be brisk and catastrophic, and these cases are one of the few that I request a rapid transfuser such as a Level-1 or Belmont. Nevertheless, at this stage of my training, such cases are exciting, challenging, and educational, and I look forward to it.

1800

This is the 1800th post! Perhaps I've done close to that number of anesthetics, which is a little mindboggling. Reflecting on this reminds of the real privilege of being a physician and an anesthesiologist. Even though things feel a little more routine and straightforward in my third year of anesthesia, I've also developed a real respect for what we do. General anesthesia has become so safe in the last few decades that it is easy to underestimate what it involves. Although we often use the metaphor of "sleep," it's really not a state of sleep. When we induce anesthesia, we render someone unconscious, devoid of their normal physiologic protective reflexes. In doing so, we take responsibility for their body, confident that we can weather them through a surgeon taking a scalpel and traumatizing the patient. With each anesthetic, there is the risk that we cause irreparable, irreversible harm. And each time I induce that state - a state dramatically affecting the patient's neurologic, cardiovascular, and pulmonary systems, I know that I am risking a patient's health with the confidence that my knowledge, skills, and medicine will be enough.

Thoracic

I thoroughly enjoyed my month on thoracic anesthesia. I found the cases challenging and diverse, really pushing my technical skills with lung isolation and thoracic epidural catheters and engaging my medical knowledge with complex and ill patients. I've always enjoyed longer tougher cases than many short simple ones. And in thoracic, there isn't much downtime; the surgery itself affects the anesthetic management intimately and so we are always anticipating and responding. Thoracic anesthesia cases are tiring but very satisfying at the end of the day. In practice, there isn't a huge volume of thoracic surgery so anesthesiologists can choose to eschew it from their practice if they choose. And unfortunately, these skills get rusty if they aren't continually honed. I definitely want to keep thoracic anesthesia in my armamentarium as I start looking into what kind of practice I'd like to eventually join.

Variations in Practice

Talking to one of my surgeon friends in the last post reminded me that there's a wide variation in practice. Some surgeries that are routinely done in an open fashion here are done laparoscopically or robotically elsewhere. We are experts in certain procedures that aren't performed at outside hospitals. From a pre-operative standpoint, we don't routinely check pregnancy tests for women in their childbearing years before surgery whereas it is always performed at other places. Our anesthetics differ as well; in Europe, anesthesiologists use laryngeal mask airways for cases that we would normally intubate. There is a wide variation in how to maintain anesthesia, what post-operative pain management entails, which antiemetics are routine. Even in other specialties, there are many approaches to the same clinical scenario, and much of it is institution, culture, or training based.

This is not to say that one practice is better than another. There are certainly standards and guidelines, but most variation in clinical medicine falls within perfectly acceptable norms. This, then, becomes the art of medicine. We tailor our practice to the strengths of our physicians, the expectations of our patients, the review of complex and often conflicting research data and evidence. We make conscious choices in creating the culture and norm at our institution, then tailor specific decision-making to each individual patient. As a result, patients may get different diagnostic tests or treatments at different places, and we understand this can be distressing, especially if patients think there's one right answer or approach. Unfortunately, such variation in practice comes with the uncertainty, complexity, unknowns, and challenges of clinical medicine.

Ivor-Lewis

One of the bigger cases we have is the Ivor-Lewis esophagectomy for cancers of the lower esophagus. We begin by placing a thoracic epidural for post-operative pain control because the incision is quite large. Then after inducing anesthesia, we place a single lumen endotracheal tube and additional lines and monitors; we always have arterial access, and sometimes opt for central venous access as well. The general surgeons start with an upper endoscopy to look at the esophageal cancer and then perform a large abdominal laparotomy to mobilize the stomach and nearby structures. After they are done, we switch out the single lumen endotracheal tube to a double lumen tube. The thoracic surgeons then cut open the chest cavity. After resecting the cancer, they have to take the stomach, freed from its moorings, and pull it up into the chest to reform the gastrointestinal tract. Because all of this happens deep within the chest, we have to deflate a lung to give the surgeons space to work. They are quite close to critical vascular and nerve structures, making it a high risk surgery. The challenges for the anesthestic management include balancing fluid goals. An open abdomen and chest causes an enormous loss of insensible evaporation, but we try to keep patients dry in thoracic surgery because wet lungs can be hard to manage. Post-operative pain control is tricky because the incision extends all the way from the ribcage down to the bellybutton; a well-placed epidural will catch the area, but a poorly placed one will be patchy. Nevertheless, for some patients, this surgery is worth it if it means that the cancer is cured.

Watching the Surgery

One of the fun and unique privileges of being an anesthesiologist is being able to watch the surgery. Because we work with many surgeons in different fields, we get to see everything, from lithotripsy of a kidney stone to a hip replacement to delivery of a baby by C-section to biopsy of a brain tumor. In some procedures, I can't really follow what the surgeons are doing; despite watching multiple sinus surgeries, I'm never sure where we are. But many times it is imperative that we follow what the surgeons are doing. In my thoracic rotation, for example, I follow the manipulation of the lung carefully. Not only is it fascinating to see an organ so central to anesthesia practice, but what they are doing matters. When the surgeons are close to large blood vessels, I make sure they don't injure any of them, and if they do, I am ready to respond to a rapid massive blood loss. When the surgeons enter the thoracic cavity, I watch to make sure the lung is isolated and deflated so they don't accidentally injure it. When they are finishing the lung surgery, I watch as I inflate the lung to make sure that everything inflates appropriately. The same principles applied when I was on my cardiac anesthesia rotation where manipulation of the heart and great vessels had many direct anesthetic implications.

LD50

The LD50 is a pharmacokinetic term that describes the lethal dose of a drug for 50% of the study population. We talk about similar concepts all the time in anesthesia (for example, the dose of a drug for 50% of patients to fall asleep) so I loved this comic.

Image is from xkcd, drawn by Randall Munroe, shown under Creative Commons Attribution License.

Why I Put IVs in the Hands

This great observation shown under Fair Use, from http://thisisindexed.com/. I've learned over the years not to catch too much arm-hair when putting the tourniquet on and to go for hairless real-estate when taping IVs in place.