Holding

"The first time someone shows you who they are, believe them." - Maya Angelou

On the day of surgery, the day the patient has been dreading, sleep-deprived, hungry, and anxious, the patient checks in at the pre-operative front desk. She is unceremoniously given a gown and plopped into a cold, hard hospital gurney. A parade of people come through - a pre-operative nurse, an operating room nurse, surgeons to scribble their initials, anesthesiologists to start the IV. All of these - except perhaps, the surgeon - are strangers. For some patients, this is their first surgery of their otherwise healthy, peaceful, and doctor-free lives. And, occasionally, that first surgery is brain surgery or heart surgery.

The first time someone shows you who they are, believe them. In holding, the veneer comes off. The patient is honest, the fear is palpable, and doing the right thing can be hard. We went into anesthesia rather than psychiatry because we like the sleeping patient, we prefer midazolam to a conversation, our people-skills need tempering. And there is a lot of behind-the-scenes pressure to improve our efficiency, get cases started early, avoid delays. But that moment, when the patient needs reassurance, when sitting down and shaking a hand matters, I have come to enjoy. It is the moment when there is nothing to hide, from our end or from the patient's end, the moment when defenses are lowered, externalities are stripped away, and what's left is an opportunity to form trust and get to know someone.

Awake Crani II

This is a continuation of the last post.

The most important aspect of anesthesia for an awake brain surgery is the psychological preparation. We talked to this patient for over an hour the day before surgery. Along with the routine pre-operative evaluation focusing on heart disease, breathing problems, allergies, and medications, we wanted to build rapport and confidence. We got to know the patient as a person, not only to develop the patient-doctor relationship, but also to get to know details about the patient's life. If, during the surgery, we ask the patient the name of her first husband to test memory and speech fluency, we want to be able to verify her answer. Furthermore, we want a detailed neurologic exam; we test how accurate she can touch her finger to her nose, examine the way she walks, note her muscle strength. Most importantly, however, is the psychological prepation to be under surgery fully awake. We walk her through each step, what to expect, what we'll say, what she will see and hear.

For the beginning of the surgery, we sedate the patient until the brain is open and tumor exposed. The choice of anesthetic has to allow spontaneous breathing and have a quick offset (or be reversible); for this, we chose dexmedetomidine, midazolam, and low dose propofol. The patient comfortably snoring, we place additional IVs, an arterial line, and a subclavian central venous catheter. Then I begin the scalp block. As anyone who has hit their head knows well, the scalp is densely innervated. I inject bupivicaine, catching the nerves as they exit the skull above the eye, around the ear, and near the upper neck. We have to be generous as this is most of the pain control while the patient is awake during the surgery. Meanwhile, the neurologists place electrodes to monitor various nerves. Then, I numb up the pin sites generously. The surgeons place the skull in pins to immobilize it, then position the head to access the tumor. The patient remains sedated as the surgeons dissect through the scalp, drill through bone, and expose the tumor. Then, I run in some IV tylenol but turn all other anesthesia off, and within 10 minutes, the patient wakes up.

Immediately, the patient is oriented so she does not move while her head is in pins. The scalp block seems to work well; she has mild tolerable head discomfort, but complains more of an itch by her eye. The neurologists examine her continuously, asking her to wiggle her fingers and toes, do coordinated motions, answer questions, stick out her tongue, and test her vision (we used an iPhone app). The surgeons debulk the glioblastoma, but when they near the motor strip, they stimulate the tissue prior to resecting it. If the tissue they stimulate is responsible for movement, we will notice twitching or jerking of the arms or legs, and the surgeons know they cannot remove it without consequences. Unfortunately, such stimulation can generalize into a seizure, requiring the surgeons to pour cold saline onto the brain or me to give a touch of propofol. This can be tricky because both a seizure and propofol can cause the patient to stop breathing, and if we were to need a breathing tube, placing one in a draped, pinned patient will not be easy (we had a flexible fiberoptic bronchoscope ready). The procedure went smoothly, and at the end, we even had the patient call her husband from the operating room. The nerve blocks worked so well that the patient didn't need anything during the closure as the surgeons replaced the bone and sutured the skin. She talked all the way through it, telling us about her young adulthood in New York City. When we brought the patient to the intensive care unit for postoperative monitoring, we didn't even need to give her supplemental oxygen. She was wide awake, comfortable, and chatty and the only pain medication she received during the entire thing was local anesthesia and tylenol. I returned to see her the following day to check her neurologic exam and see how she was doing. It was an incredibly satisfying anesthetic.

Awake Crani I

This is why I love anesthesia and the impetus for the post yesterday.

A 50 year old woman who has been healthy her entire life develops nausea and vomiting, then has a seizure. She is brought to the emergency department where an MRI scan shows a brain tumor involving her right hemisphere. A detailed neurologic exam finds that she is weaker on the left arm with poor coordination. A biopsy of the mass shows glioblastoma multiforme. A dreaded diagnosis, glioblastoma has a prognosis measured in months to years. She is evaluated by the neurosurgeons because debulking the tumor, especially if they can get nearly all of it, can improve her quality and length of life.

But the problem is this: the brain cancer infiltrates the motor strip of her cortex; it's starting to affect her movement, sensation, and coordination. The surgeons want to get as much of the tumor as possible without damaging that precious real estate. If they go a centimeter too far, the patient may be paralyzed as a result of the surgery, and since this is a virtually incurable disease, that's not a risk worth taking.

In many of our complex spine and brain surgeries, we do neuromonitoring; while the patient is asleep under anesthesia, our neurologists can stimulate various nerves and parts of the brain to test the crude function of basic pathways. But this technique is hardly perfect and may only catch gross damage to brain and spinal structures. Instead, the best and perhaps only way to guarantee that a patient does not wake up worse off from brain surgery than she started is to have her awake when they're working on the brain. This way, if the surgeons are near a crucial area, the patient can give immediate feedback about any loss of sensation, function, coordination, or other abilities.

Here's the rub. How do you provide anesthesia for a patient whose skull will be pinned (skull pinning is essential in brain surgery because micromovements while the surgeon is operating can be catastrophic) for hours, whose scalp will be dissected and turned back, whose skull will be drilled, and whose brain will be open to a surgeon with a scalpel? All through this, the patient has to be calm, collected, relaxed, awake, and aware enough to remain still, follow instructions, and communicate; this greatly limits how much pain medication and sedation the patient can receive.

What Residency Is Like

Most days, it feels like all you can do to keep your head above water, to keep paddling without sight of the nearest shore or log or respite. When the alarm goes off at 5 in the morning, my brain begins racing as I plan the course of the day. Then, it is task after task, challenge after challenge, patient after patient. The cases blur together. The muscle memory kicks in. The small satisfactions wink by, but the small frustrations stick. Some anesthetics require active management throughout, and I'm on my feet acting and reacting without pause. Others may have that lull, and that's when I catch up, check to see how my other patients are doing, plan the following case, sit for a moment. A hurried breakfast, a rushed lunch, a glance at the following day's surprises, and suddenly, breathless and exhausted, I find myself trekking home. Often as a resident, you can only tend to those human needs: food and rest. I catch up with an old friend on the phone, and that fifteen minute call is a luxury. I cook, I clean, I bathe, I type, I sleep.

Some days, like today, the anesthetic is so incredibly satisfying, it's all worth it.

Book Review: Oryx and Crake

Margaret Atwood's Oryx and Crake is a beautiful intersection of literary writing and science fiction, and is probably one of the best written books I've come across recently. Although the novel's setting and circumstances are science (or speculative) fiction, the novel is, at its heart, a story of a strange menage a trois. As the protagonist stumbles through a bizarre post-apocalyptic world, plagued by guilt, fear, confusion, and responsibility, his flashbacks fascinate us with an almost mythical duo: Oryx and Crake. As the story unfolds, we become entranced by the compelling, pitiful, and brilliant characters and their engrossing, horrific, and beautiful relationships. Atwood's speculations on the worst case scenarios of genetic engineering, cosmetic medicine, and corporate greed are well-researched and believable. Her language and writing is eloquent, tragic, playful, and perfect. The pages of this book turn themselves.

Image shown under Fair Use, from Wikipedia.

Pheo

The pheochromocytoma is a fascinating tumor. Originating in the medulla of the adrenal glands, this cancer secretes catecholamines like adrenaline (epinephrine) and noradrenaline. As a result, patients present with pounding headaches, uncontrollably high blood pressures, racing heart rates, palpitations, anxiety, sweating - all the symptoms you or I have when presenting in front of a large audience. When these patients present for surgical resection, they are at very high risk for perioperative complications, and the anesthesia can be challenging.

The biggest risk is in blood pressure lability; a hypertensive surge can cause a stroke, heart attack, pulmonary edema, kidney damage, and other permanent injuries. Yet blood pressures that are too low risk some of the same consequences. If a patient has had proper diagnosis and management, she will be premedicated with blockers to the catecholamines to ameliorate the effects of big swings in circulating adrenaline. Like cardiac cases, we place an arterial line for close blood pressure monitoring prior to induction. We have the full array of blood pressure medications available to manipulate heart rate and pressure up and down as needed. We cannot expect everything to work normally because the body is so used to high surges of catecholamines and the patients have been taking catecholamine blockers. Once patients are asleep, they need a central line for infusions of these medications and occasionally, a pulmonary artery catheter if their heart has taken a hit from the pheo. When the surgeons get close to the tumor, what they do affects us greatly. If they can take out the entire tumor without disturbing its contents, things go smoothly. But if in manipulating the pheochromocytoma they release its contents, we may have to contend with a catastrophic spike in blood pressure and heart rate. After the mass is out, the circulatory system may collapse if it's used to the tumor's hormones, and we may have to supplement adrenaline-like infusions to smooth out the blood pressure. Fortunately, this surgery went well, but this is an example of how the disease and the surgery impact the anesthesia directly.

Image of gross pathology of pheochromocytoma is in the public domain, from Wikipedia.

Patient Rights

I had an interesting discussion with one of the ICU attendings today about patient rights. As a society, we are incredibly cognizant of civil rights; we abhor racial discrimination, support equality regardless of sexual orientation, champion equal opportunity employment. But we don't think about or know much about patient rights. Now, most physicians complete training on patient privacy, patient safety, how to tell a patient of risks, benefits, and alternatives, and when emergency care must be provided. But patient rights doesn't have the same kind of fervor and advocacy as other social issues, and I think it's necessary.

Unfortunately, patients who don't speak English are more likely to have their rights violated. Often, an interpreter isn't requested because of time pressure, but even with an interpreter, a translation may not convey the same information. How many times have I misunderstood a patient because I didn't have an interpreter? I openly say this because I'm not a perfect adherent to patient rights, and this is an easy example why. But I'm beginning to recognize that this is just as important as the civil liberties I enjoy and the equality campaigns I support. We need to make sure patients know who is treating them. We need to tell them of the risks, benefits, and alternatives of different treatment options. We need to provide care in an emergency. We need to keep private patient information confidential. We need to get an interpreter when a patient doesn't speak English. All these simple things, and more, can be easily overlooked, but that would be a violation of someone's rights.

Cold

Though we manipulate a lot of parameters in surgery, one of the more unique and simultaneously mundane ones is temperature. In medical school, I wondered why temperature was a vital sign; sure, it's important to know if a patient has a fever, but how is it as important as the blood pressure or oxygen saturation? Why the focus on temperature?

At the beginning of anesthesia residency, I also found the fuss over temperature unnecessary. We learn the effects of general anesthesia on body heat homeostasis, the consequences on infection, bleeding, and shivering, and methods of rewarming. But for most short adult cases, temperature changes are inconsequential. In contrast, pediatric anesthesiologists obsess on temperature because children, infants, and neonates lose heat rapidly, and the smallest patients don't have the normal compensatory mechanisms to keep themselves warm.

In neurologic surgery, however, we want our patients to be cold. Though the benefit of mild hypothermia during brain surgery is not clear in randomized clinical trials, the theory makes sense. If the brain is cold, its metabolic demand decreases, and periods of decreased flow, retraction pressure, and surgical manipulation will have less of an effect. Indeed, in cardiac arrest, cooling the patient can lead to better long-term neurologic outcomes. So during some brain surgeries, we actively cool the patient down with a water blanket, and rewarm as the surgeons finish up. The timing is critical; to get a 200lb patient from 37 to 34 is no easy task, and returning him back to a relatively warm state for the end of surgery takes a little planning.

Image of Adolph Northern's Napoleon's Retreat from Moscow is in the public domain, from Wikipedia.

Tragedy

My prayers go out to all those affected by the Boston marathon bombing. It strikes close to home because I have so many friends in Boston. Such a shocking tragedy really rattles the emotions, and also makes me think of how I would feel and act if I witnessed such an event. Anesthesiologists have a unique medical skill set to triage, intervene, care, and palliate. I am sure the trauma rooms at Mass Gen are running all night long.

The Bell Curve

Anesthesiologists overtreat, and it is the right thing to do. If I had known this statement prior to residency, I would have been shocked. In my past blogs, I have written a lot about the problems of doing too much in preventive health screening and the cost of overtreatment. Being too zealous - such as doing unnecessary colonoscopies, prostate cancer screening, or mammograms - can lead to waste, false positives, unnecessary testing, and side effects. I imagine that if I were a primary care practitioner, I'd be prudent in trying to minimize overtreatment.

But anesthesiology is the opposite, and I am only slowly being convinced of it. In anesthesia, we cannot treat to the "average" (mean, median, mode) patient. Say the bell curve above shows the distribution of a patient's response to a muscle relaxant. Often, a patient is paralyzed for the surgeons to work. After a couple hours, the muscle relaxant will have worn off for 95% of patients. The "average" patient will not need reversal of the paralytic. The "average" patient would do fine if we woke them up. But 5% of patients may still have residual paralysis, and waking them up would be unpleasant and dangerous for them. In this situation, I give the reversal agent; I'm not treating the average patient, but rather the tail ends of the normal distribution. In 95% of patients, I have given something unnecessary, overtreated. But I do so to avoid adverse consequences to the last 5% of patients.

I've been struggling with this notion. Why is it that ordering screening mammograms on healthy 40 year olds is inappropriate, that it will lead to unnecessary anxiety, biopsies, cost, and waste? But that giving an antiemetic during anesthesia is acceptable, even though it may be unnecessary for many patients? Is this difference in approach a result of a different culture in each specialty or a different threshold in accepting needless cost or something else? This is one of the facets of clinical decision making that fascinates me.

Image shown under Creative Commons Attribution License.

Reserve

Physicians often talk about young, healthy patients having "lots of reserve," and frail, elderly patients with "little reserve." This is best illustrated by a case I saw recently. A 25 year old is involved in a car accident, found to be confused and hypotensive. In the emergency department, despite 2 liters of fluid, his blood pressures are still 90/30. An ultrasound exam of the abdomen shows free fluid, and he is brought up to the operating room for exploration of the belly. Multiple anesthesiologists work simultaneously to secure the airway, obtain arterial access, place large bore IVs, give antibiotics, maintain blood pressure, deliver anesthetic, send labs, transfuse blood, and chart. When the surgeons open the belly, blood pours out. It's difficult to see where the bleeding is coming from, and methodically, they examine the likely culprits. The spleen is hemorrhaging, and the way to save the patient is to clamp the vessels and take it out.

I don't know how much blood loss there was, but it was impressive. Nevertheless, after initial resuscitation with fluid, some blood, and some plasma, the patient was able to maintain a reasonable blood pressure and heart rate. The 25 year old patient can tolerate this. A similar injury in someone three times his age would have likely been fatal. This reserve, the ability for the body to compensate for disastrous physiologic disturbances, is impressive. It is the reason why the young caveman survived a fight with the saber tooth tiger or a strenous childbirth. Even though we like to think our anesthesia or surgery saved the patient, it is the patient that saves himself.

Call at the Valley

Overnight call at the Valley is quite different than call at Stanford. Santa Clara Valley sees a lot more trauma, and so I expect to be up all night. It's an educational experience providing anesthesia without knowing a patient's past medical history, medications, or substance use and being unable to interview a patient. Now that I'm finishing my second year of anesthesia, the range of cases is less intimidating; whether a craniotomy for a person who fell and crushed their skull or a child who broke her elbow or a combative patient high on methamphetamines with an open fracture, I know what to expect in the anesthetic.

We also cover obstetrics (at Stanford, the dedicated OB anesthesia resident does) and that is a continual deterrent to getting any sleep on call. Every time things seem to slow down, I get paged for a labor epidural. But my last call, I had a pretty adrenaline-stimulating case. I was paged stat to the obstetric operating room for a patient who was admitted for preterm labor but the fetus started having bradycardia. An obstetric emergency, the surgeons were prepping the belly as I got my monitors on. In situations like these, training kicks in; although I haven't seen too many stat C-sections, I could hear my professors' voices sounding in my head: place a bump for uterine displacement, give bicitra if there's time, anticipate a difficult rapid sequence airway. Within a couple minutes, I had the patient asleep, the airway secure, the antibiotics going, and the pitocin prepared. I did learn a lot from that experience, especially in crisis resource management; I had to utilize the nurses in the room so I don't become task saturated, and I had to maintain an awareness of everything else that's going on - not just what I'm doing. Cases like this make Valley an exhaustingly fun place to take call.

Lung Surgery

A 50 year old long time smoker presents with squamous cell cancer of the lungs and is scheduled for a lobectomy. Thoracic surgery offers unique anesthetic concerns for several reasons. Not only do smokers have diseased lungs, but when the surgeons operate on the lung, they prefer not to have a moving target. We have to oxygenate and ventilate the patient with one diseased, poorly functioning lung. Lung isolation poses a problem as well; how do you intubate the patient such that one lung is doing all the work while the other lung remains still? Post-operatively, the pain of the thoracotomy incision is quite intense, which can cause patients to "splint" - that is, take very small, shallow, and ineffective breaths. Without coughing and deep breathing, patients are predisposed to pneumonia, which can be fatal in someone who just had part of the lung resected. So the anesthetic can be challenging, but sometimes that's what makes it fun.

Before going off to sleep, we put a thoracic epidural into the patient. Similar to an epidural for labor, this catheter delivers local anesthetic that numbs up the chest where the surgeons are cutting. This helps with post-operative pain control because the medications are not sedating, allowing patients to work on deep breathing without discomfort. But thoracic epidurals are technically harder than lumbar epidurals to place because of the spinal anatomy. My preference is to do a paramedian approach, aiming for the space from one side at an angle.

After inducing anesthesia, we place a double-lumen endotracheal tube. The tip of the tube goes into one of the lungs, but there is also a passageway that ends proximal (earlier). When the surgeons need lung isolation, we ventilate the bronchial lumen only. When they are ready to go to two-lung ventilation, we ventilate both lumens. These tubes can be difficult to place because they're larger than regular tubes and getting the lumen placement just right requires adjustments with a fiberoptic bronchoscope. During this case, we had a little trouble getting pure lung isolation, but managed to give the surgeons adequate operative conditions. During one lung ventilation, the oxygen drops and carbon dioxide builds up, and as anesthesiologists, we have to manage these physiologic disturbances.

My favorite part of the surgery, though, was at the very end when we extubated the patient and brought him to the ICU. We had given some local anesthetic through the epidural, and when I asked him if he had any pain, he said, "Nope, I'm ready to zumba."

Conference

As part of our education, the residency program encourages us to attend an anesthesia conference. National meetings allow us to see how other institutional practices differ, network with people outside our program, and meet national leaders. Unsurprisingly, medical conferences aren't as rigorous as medical school. At the meeting I attended, lectures occurred in the early morning and late afternoon, allowing us most of the daytime to do other activities. In the evening, we had workshops on nerve anatomy, regional blocks, and advanced airway devices. The experience was good for several reasons. Much of what was presented as "cutting edge" anesthesia and critical care was stuff I knew well, consistent with practice at Stanford. There was also a good amount that was different than what I knew, but these were reasonable alternatives, hypotheses, and suggestions from ongoing investigation. I came away with an awareness of where things were going as well as confirmation that I was doing the right thing for my patients. It also made me realize that being out of training can make someone rusty fast; many of the attendees were taking copious notes. National meetings and conferences are an important component of ongoing learning for full-fledged physicians, especially in the setting of rapidly changing medical science, technology, guidelines, and studies.

Administration

As one of the senior residents at Valley, I had the fortune to attend to the organizational aspects of the rotation. It reminded me how difficult and frustrating administration can be. With only six residents on the rotation, it would seem like the schedule would be straightforward to make, but three iterations took far more hours than I would have guessed. Trying to accommodate everyone's requests, skill sets, lectures, conferences, and vacations became a Sudoku puzzle where a solution wasn't certain. I also coordinate with the attendings so that everyone gets a good mix of cases appropriate to their level of training. I sympatheize for our chief residents who make the master schedule for 80 residents and the monthtly Stanford operating room schedule.

Oh, the Places You'll Go

It astounds me that in going 40 minutes south from Stanford Hospital down to Santa Clara Valley Medical Center, the patient population changes drastically. When looking at medical schools and residency, I always felt that "patient diversity" was important, but every time I'm reminded of it, it surprises me. I've cancelled three cases for methamphetamine use, the drug of choice in some of the communities served by the county hospital. I've had to use my medical Spanish on a daily basis and call interpreters for half a dozen different languages. A smaller percentage of patients want an epidural. A larger percentage of patients say, "Just do what you think is right, doc." Fewer challenge us, fewer have a really engaging discussion of risks and alternatives of anesthesia. While the patients at Stanford seem to have rarer diseases, the patients at Valley have more complications of common diseases. The patients at Valley are very grateful for medical care. I am more cost conscious when I'm down there. We see a lot more trauma patients.

I wouldn't judge that one hospital or patient population or experience were better than another, but I really appreciate the opportunity to broaden my encounters and see more of the spectrum of medical care.

Working with Surgeons III

Have I ever found it challenging to work with certain surgeons? Of course. But luckily, at the environment I'm in, this is a rarity. Culture and environment vary from institution to institution, modulated by the department's leadership, existing physicians, and newcomers. We all play a part in cultivating a teamwork-oriented, blame-free, respectful group that focuses on what's right for the patient.

What I've found is that obvious things are important: you should know the name of the others on the team. When the surgeon doesn't know who I am, it makes our relationship a little more tenuous. Ego is destructive. Surgeons and anesthesiologists need to be confident of their skills, but if ego takes over, disagreements and conflicts can escalate without attending to what's best for the patient. And while it's hard to train attributes like patience, we have to remind each other what's right when tempers flare and emotions heighten.

To work on all this, the residency program incorporates simulation, discussion, feedback, teaching, and rolemodeling. In a recent simulation exercise, the scenario involved a disagreement in management between the mock surgeon and the anesthesiologist. During the debriefing, we examined different ways of approaching the conflict, making ourselves heard, compromising, and de-escalating. Education, especially in residency, is paramount to shaping our future interactions with our colleagues. All that being said, I'm close friends with a lot of surgeons, and I really respect what they do.