Arts and Anesthesia

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Like last year, I've been part of organizing Stanford's Arts and Anesthesia Soiree, happening tomorrow at 5:30pm. The arts and humanities are so important to making us who we are, yet underrecognized in medicine. For this evening, we invited everyone from the anesthesia community here to showcase their hobbies and talents. We have performers singing, dancing, playing piano, reading poetry. We have displays of photography, sketches, drawings, furniture, and knitting. We even have some projects made around anesthesia equipment - vial caps and coban. Our goal is to celebrate the diverse, surprising, and beautiful endeavors of our colleagues and to enjoy an evening appreciating the more human side of anesthesia.

Suicide

Does everyone who attempts (or commits) suicide have a mental illness? This is a controversial and touchy topic, but it's been on my mind ever since medical school. I can tell you what happens. When someone attempts (or threatens) suicide, we put them on a "5150." This is a section of the California Welfare and Institutions Code that allows a 72 hour involuntary psychiatric hold for someone with a mental illness who poses a threat to themselves, a threat to others, or is gravely disabled. Much of the time, the patient has a documented psychiatric illness, but sometimes this is the first presentation to a hospital or old records are unavailable. Nevertheless, a 72 hour hold is placed, and to me, the reason is that the suicide attempt is sufficient evidence of mental illness. Of course, on further psychiatric evaluation, a hold can be lifted if in fact the patient does not meet all the criteria.

Let me put on my philosophy and logic hat. It seems to me now that we follow a pretty strict rule: if someone commits suicide, then they have a mental illness. The contrapositive states that if someone does not have a mental illness, they will not commit suicide. Is this an absolute truth? I'm not sure that it is. One could imagine (as philosophers do) morbid situations in which a perfectly sane person would choose not to live. A Japanese samurai of complete sound mind adheres to a bushido honor code and takes his own life rather than fall in the hands of the enemy. A prisoner in a Nazi concentration camp decides he would rather touch an electrified fence and die than continue to suffer. An elder Eskimo ends his life to leave greater amounts of food to the rest of the community. A 90 year old person who has lived a life of great satisfaction and fulfillment sustains a stroke requiring them to be on life-supporting machines; they choose not to live in that manner, and so pass away peacefully.

Of course, these examples are not the ones who show up to our emergency department. And I agree with placing a person on a 5150 if there is any worry that they are a threat to themselves as a default because the alternative - sending them home and having them complete their suicide - is unthinkable. But I write this post because we do a lot of things in medicine without thinking them through with a philosopher's lens, and we ought to step back and scrutinize what we do. Fleeting suicidal thoughts are normal and don't reflect mental illness. There may be a tiny subset of conditions in which someone may commit suicide rationally. Our laws and regulations are designed to aid this other majority with psychiatric disease, but we should recognize where they may not apply.

Critical Care Medicine

The trend these days is for graduates of anesthesia residency to pursue additional specialized training in the form of a fellowship. This is a new tendency; even five years ago, most residents went out and found a practice to work in. But recently the job market has tightened, especially in the bay area, and it behooves us to have a specific expertise in pediatric anesthesia, regional nerve blocks, cardiovascular anesthesia, pain management, etc.

I probably would have done a fellowship anyway; I've always been the type to stay in training forever. After considering the various subspecialties and the rotations I enjoyed, I ended up choosing the field I always thought I'd end up in: critical care. As an anesthesiologist, I've become proficient in certain aspects of intensive care medicine: the cardiopulmonary system, medications, procedures. But I've missed those things that fascinated me so from medical school and internship: infectious disease, end-of-life care, continuity with a patient. Although the ICU rotations can be grueling, they are also intensely rewarding as we struggle and grapple with the sickest patients, most difficult ethical dilemmas, and hardest situations for a family to cope with. I think as I become a fellow and eventually an attending, I will enjoy engaging the big picture and be a little shielded against the day-to-day exhaustion.

In any case, after I finish my last year of residency in anesthesia, I will stay at Stanford to do my fellowship. I may not be a Bay Area native, but I've definitely made this place my home.

Image Collection

Many physicians collect images from the patients we see. In the same way we accumulate "interesting presentations" or "ethical dilemmas" or "amazing diagnoses," we also like having a case file of "cool images." Whether a gigantic spleen removed from a patient with leukemia or a CT scan of a ventriculoperitoneal catheter that has migrated into the wrong space or a picture of angioedema, these quick images and case studies provide an opportunity to learn and teach others. The most amazing and famous of these collections, I think, is the NEJM image challenge, which I recommend to anyone in medicine. In any case, it is important for us collecting our images to de-identify any patient information and get consent for taking photos. The X-ray shown above was taken to confirm placement of a triple lumen central line placed in the right neck. After reviewing the X-ray, we promptly discontinued the catheter.

PACU

I'm currently doing my two week rotation in the post-anesthesia care unit. Managing the recovery unit is very different than my usual operating room routine. Instead of focusing entirely on one patient undergoing surgery, overseeing the PACU reminds me of running a floor service. The majority of patients wake up fine after anesthesia and need no intervention. Some require minor assessments for pain, nausea, itching, and confusion, while others have epidural or nerve block catheters that require adjustments. But the challenge is to identify and care for those patients who are at risk for dangerous complications. Some injuries may have happened under anesthesia and been unrecognized such as a heart attack or stroke. Other problems arise as patients awake including weakness from residual paralysis, airway obstruction, and arrhythmias. Thus, the PACU teaches me how to look at the intersection of medical comorbidities, dissipating anesthetic, and recent surgery. The other aspect of the PACU is managing the flow of patient care. If all the beds in recovery are full, the bottleneck can really hamper operating room efficiency. I develop a good sense of when patients are stable to go home or to the floor. And I can't complain about the hours, since the first patient arriving in recovery is an hour after the usual operating room start time.

How to Be a Good Patient

Here's the rub. We want patients who are invested, involved, and active in their care and treatment plan. We advocate for patients to take control of their health and make their medical decisions. But many physicians also dread the patient who is too "high maintenance." We seldom enjoy the patient who has printed out reams of paper from websites about their symptoms, disease, or drugs. Patients who shop around multiple physicians for second, third, fourth opinions undermine the trust of the patient-doctor relationship. And occasionally, it can be frustrating to work with a patient who has her mind set on what she wants and will take nothing else. Some of this is historic, echoing the days when medicine was very paternal; some of it relates to our feeling that four years of medical school, three to ten years of residency, and experience drawn from practice gives us an element that cannot be gleaned from the internet.

But it's a difficult balance for patients. Naturally, you will look something up about your surgery, disease, medication, or symptom. You'll begin to accumulate questions. You might convince yourself that one approach, test, or treatment is best. And then you might arrive at your doctor's office expecting it and ready to demand it if it's not offered. Somewhere in this process, you will have switched out your hat from the one being treated to the one treating, and this can be off-putting for physicians. I think doctors need to recognize this human tendency and work with it, affirming the patient's thought process or explaining why it might not be the best course. We should not view these patients as "difficult" because they aren't; they're scared, anxious, motivated, and involved in their own care. All of this is better than the other extreme, the patient who does not take care of her health, takes medications sporadically, doesn't engage her practitioners, and expects everything to be done for her.

Tolerance

We often think of illicit street drugs - heroin, cocaine, methamphetamines, marijuana - as recklessly dangerous, irresponsible, and morally reprehensible, but we are recognizing more and more that prescription drug use can pose a medically similar danger. In fact, prescription drug abuse has skyrocketed among youth and become more of a problem than the traditional bad habit drugs.

A patient with phantom limb pain from an old traumatic amputation presents for an endoscopy under sedation. The case is booked with anesthesiology because of his incredibly high pain tolerance. He has a peripherally inserted central catheter (PICC) line at home through which he receives IV hydromorphone and lorazepam. The doses he gets at home (I didn't ask how he gets the drugs) were mindboggling; he takes 20mg of hydromorphone four times a day and 10mg of lorazepam several times a day. 

The entire situation worried me because the medical treatment of phantom limb pain does not consist of opiates and benzodiazepines. He had become so tolerant to these medications that I couldn't predict how much he would need for the endoscopy. It also shows how amazingly malleable the human body is; a tenth of the dose he takes would be sufficient analgesia for a major surgery in an opiate naive patient, and anyone else taking his dose would become unresponsive. The practitioners who tried to treat his phantom limb pain somehow escalated his doses past any reasonable and defensible amount (in addition to allowing him IV access at home) and now his body has become a black box for anesthesia, analgesia, and side effects. This was a dramatic example for me of the danger of prescription drug abuse and the impact of a chronic pain state on a young man's life.

Allergies

In the operating room, allergies are a really big deal. It makes sense. An anesthetized patient won't be able to stop someone from giving an antibiotic that causes a reaction or using latex gloves or prepping the skin with iodine based solution. And a surgery is where someone will receive the highest number of different drugs in the shortest period of time. So allergies have become a part of my daily routine; I ask about it, the pre-op nurse asks about it, the circulator asks about it, and it's reviewed in the time-out.

But I think we've made allergies into too big of a thing. Most of the allergies I encounter aren't true allergies. Many patients come in with the vague story, "My mother told me I reacted to penicillin," and a big permanent "Allergy: PCN" gets put into the record. But the truth is, of the 5-10% of patients reporting a penicillin allergy, only 10-15% have a positive skin test. The problem is that often surgeons choose different peri-operative antibiotics for "penicillin allergic" patients. And if those patients don't truly have a serious reaction, that's doing them a disservice; clindamycin and vancomycin have a poorer risk-benefit profile than the typical cephalosporin. I encourage surgeons to stick with their routine cephalosporin unless the allergy is a verified serious reaction. (Plus, although this is not good justification, if you were to have an allergic reaction, you might as well have it in the operating room with full monitoring and an anesthesiologist who can administer epinephrine.)

The other thing that bothers me about allergies is that medication side effects are often listed as allergies. I have seen too much of "Allergy: Vicodin causes nausea." All the opiates have the side effect of nausea, but this is not an allergic reaction mediated by immunoglobulins or T-cells. And if used correctly, opiates could be perfectly appropriate for the patient. But once this makes it onto the chart, it is incredibly hard to change. It's of course not the patient's fault, but I hope  the person putting the allergies into the record understands the impact of what they're doing.

The most extreme example of this is a patient I saw who had an allergy to epinephrine - it causes palpitations. As this is one of the direct effects of epinephrine, it's hardly an allergy at all. The danger is that epinephrine is the treatment for a true allergic reaction, anaphylaxis. Such things drive me crazy.

Scientific Journals

Academic journals have come a long way. From the first issue of Nature, published November 4, 1869 to the current multitude of obscure super-specialized publications, there has been a huge growth and evolution of the way we disseminate cutting-edge research. But will this be the way of the future? I currently get a few medical journals: a weekly JAMA, monthly Anesthesiology, and quarterly Anesthesia and Analgesia. Sadly, most of them are collecting dust in a pile, unread. I flip through the table of contents and earmark articles I want to read, and sometimes get around to one or two. But it's easy to get inundated with information, and there is never enough time in a resident's life to stay fully caught up with the relevant literature.

The other big change is the revolution in cloud storage and search. It is infinitely easier to find an article now than it was two decades ago. A quick search on PubMed or Google Scholar and I can find any research article I want. And the Internet is so much easier. As I download papers, I sort and categorize them so I can find them without digging through my bag of old journals. I can highlight and search them. I can send them to colleagues.

Although there is something wonderfully nice about receiving and flipping through a scientific journal and the history behind them in amazing, I think we are starting to find ourselves in an era where digital information becomes the dominant way to spread and share new medical discoveries.

Both images are in the public domain, from Wikipedia.

Construction

Earlier this month, Stanford Hospital broke ground on the site for its new hospital, slated to open in 2018. As I pass through a sky walkway between the main hospital and our ambulatory surgery center, I get a spectacular view of the construction site. It's impressive. Although it seems weird, I don't think I've ever really been to a place where tons and tons of dirt are being moved (when I was little, I never had the obsession with tractors and hard hats). Supposedly, a truck is carrying out dirt every 90 seconds until October. Watching the drills, tractors, and other heavy machinery I can't name, I'm only starting to understand the scope of building a new hospital. I've seen people placed on heart-lung machines, the emergency department flooded with patients from a car accident, a 30 week premature infant in the neonatal intensive care unit. But looking out from that third floor walkway down to the well-choreographed machinery gives me pause. It's a monumental undertaking.

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

Trying New Things

The problem with getting older is that we become more self-conscious, nervous, and worried about new things. Most of us, I imagine, find satisfaction in the routine of our lives. We become sedate, lose courage, stop imagining, cease learning.

This is not a post about medicine, but this happens in medicine all the time. I see attendings who refuse to try new medications and techniques because they came out after the attendings trained. I see surgeons who avoid robotic and laparoscopic surgery because they never got the hang of the innovative technologies. And in myself, I know that immersion in anesthesia means I like talking about perioperative medicine, but not about psychiatric disorders or radiology reads or preventive medicine. Of course there is a reason for this. We want our doctors to stick with tried-and-true methods, to avoid being "creative" in our treatment, to hone one skill and practice it.

But let's not get in a rut. I want to be the kind of doctor that challenges the old, pokes and prods the new, and makes an honest, open, and reasoned assessment about what new things to adopt. I want to be the kind of doctor who takes ownership of my field but does not become confined by it, who seeks to learn about innovation, development, and technology outside of anesthesia.

But more importantly, I want to be the kind of person who tries new things. It is time to strike out, breach that comfort zone, change and improve things. I want to quell that unease in my stomach when I meet new people, to peel myself away from the wallflowers at a dance, to explore cooking a new cuisine, to embark on new life milestones.

Happiness

Perhaps ultimately, it is happiness that matters. Everything we do - well-baby check-ups, appendectomies, blood pressure management, colonoscopies, hip replacements - is measured in the medical community in terms of mortality, function, complications. Even palliative care literature couches outcomes in "quality of life," and for scientific, quantitative, comparative research, such terms might be necessary. But I think what we're truly getting at, what really really matters is happiness.

On that note, I am going to take a week off this blog. I'll be back in a week. I am happy. Are you happy?

Doctor Patient

What is it like for a lawyer to review a contract or an accountant to fill out his taxes or a doctor to be a patient? Perhaps we envy the professions with an intimate knowledge of things that are a black box to us. But the truth is, when doctors get sick, we are just as scared, worried, anxious, and affected as any patient. Whether a broken bone, an accidental needlestick from an HIV+ patient, or a parent whose child has a sky-high fever, going to the doctor is no fun for us either. And knowing too much can be a double-edged sword. We know what to look for, we have resources that we trust, we know people in every field, but we also know the worst-case scenario and we've all seen that patient whose sore throat was really cancer. Even though we see people who are sick every day, being sick feels no better for us than for someone else. And because medicine is so specialized, we don't always have the answers when it comes to a skin rash or an eye problem or a new vaccine. We know just enough to get ourselves in trouble.

Neurosurgical Anesthesia

As I finish my month on anesthesia for brain surgeries, I reflect on how neurosurgical anesthesia differs from what we do for other procedures. Here, I get detailed neurologic exams of the patient pre-operatively so I know what to expect post-operatively. This is in contrast to an acute abdomen or an ankle fracture; I don't necessarily check for rebound tenderness or palpate a joint as part of my pre-anesthetic workup. But anesthesia does not affect those organ systems as much as it affects cognition, information processing, and mental status. As a result, we have to know a patient's baseline neuro exam and select an anesthetic plan and pain medications to minimize interference after the surgery.

Although modulating blood pressure is an important aspect of all anesthetics, it is critical in neurosurgery. Too much pressure and the surgical site bleeds or aneurysms burst. Too little and the patient may stroke. Thus, modulating pressure, especially at the wake-up, requires attentive, careful, and deliberate titrations of highly vasoactive substances.

Similarly, anesthesiologists are able to control the pressure inside the brain. Because the skull is a fixed cavity, increased intracranial pressure - from swelling, too much cerebral spinal fluid, dilated blood vessels - can be lethal. With pharmacologic, respiratory, and mechanical interventions, we can prevent brainstem herniation and give surgeons better operative fields.

Despite these particularities about neurosurgery, the anesthesia is not so different from that for other cases. At the conclusion of this block, I will have rotated through pretty much all the various surgical services and seen most operations in a multispecialty hospital. Hopefully, this has prepared me well for my final year of residency.