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.
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This is an excellent article! Although it's a sad one. But thank you for posting it because it makes me more aware of the field I hope to match into and more excited about how I can help. I'm just a med student and should hopefully be doing an away rotation in anesthesia later on. As an anesthesiology resident, would you have any advice for med students doing away rotations, such as recommended books to read or what to do (or not do!) to impress people like the PD?
Great to hear from you. For the most part, you aren't expected to know much about anesthesia when you rotate through as a medical student - what we do is so different than the other core rotations. But getting a sense early on of the different common medications we use will help. Mostly, we look for enthusiasm, curiosity, thoughtful assessment, engagement in patient care, and communication/teamwork skills.
Eventually, you'll probably want to do an ICU rotation and that's a good place to shine as a lot of the complexity and issues that arise (especially with hemodynamic, ventilatory, and sedation aspects) overlap with anesthesia.
Sorry I don't mean to jump into the middle of all this, but for the books, someone recommended the NMS Clinical Manual of Anesthesia as a good book. For a textbook I heard Morgan and Mikhail's Clinical Anesthesiology is good too and there's a new edition out. But I'm also a med student so maybe this is bad advice.
I've heard doing an ICU rotation could be bad if you do poorly since it could adversely effect your chances at the residency program. Unless you know you have nothing to lose, why take the risk? It might be safer to do an anesthesia rotation? But maybe I'm over-thinking all this.
You should definitely talk to an advisor, but generally, it is harder for an attending to evaluate a medical student in an anesthesia rotation than in an ICU rotation. ICU rotations have more continuity with an attending and allow medical students to prepare more, give a presentation, come up with an assessment and plan, etc. When you have to start looking at letters of recommendation, ICU attendings may be able to write more personally than anesthesia attendings.
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