Marriage Equality

I am personally thrilled about the recent Supreme Court ruling against the Defense of Marriage Act. Although this issue is so closely tied to our personal beliefs, values, upbringing, culture, and religion, for me, there has always been a clear right decision. But even setting aside those factors, I've learned a lot about love in the hospital. When a patient faces the hardest thing - unexpected illness, a terrible diagnosis, a difficult treatment, surgery, intensive care, palliation - it makes no difference the gender or sexual orientation of their spouse (or family member or friends). Sure, this is California, and I went to school in San Francisco, but when I am wheeling a patient back to surgery and his boyfriend or her girlfriend gives the patient a kiss, cries, writes down all the instructions, commits to changing the colostomy (or foley or wound) bag, bites nails in the waiting area, and so on, I see the same love. When a patient passes away and his husband or her wife holds the patient's hand, I see the same love. I've had veterans tell me how their same-sex union has not been recognized and how it changes their benefits. I've had same-sex parents of children undergoing surgery who show more concern than traditional parents. I've had friends and co-residents who have faced discrimination, disbelief, and insensitive and unaware remarks about who they are. I would never presume what kind of love qualifies for marriage, and I am glad that with the recent Supreme Court ruling we are making small changes not only to civil rights and equality but also, indirectly, to the care of patients.

The Wake-Up

One attending once told me, "You'll learn how to put someone to sleep in the first month of residency, but you'll spend the rest of the time learning how to wake someone up." Not to worry; waking a patient up is not hard, but perfecting the art is an immensely satisfying challenge. As I near the end of the case, I account for a dozen interacting factors: how quick the surgeons are to close, how much anesthetic the patient has received, how they are breathing; whether they will be in pain or feel nausea. And I've started getting the hang of that perfect wake-up: when the drapes come down, I whisper the patient's name, and she wakes up. The breathing tube comes out without any coughing, and within a minute, she's able to say she feels comfortable. Achieving that in a morbidly obese patient, a chronic pain patient, a long complicated surgery with blood loss, or a highly nauseating surgery can be very satisfying. In trying to reach this goal, I've come to respect multimodal pain and nausea management by using medications that act on several different receptors. I've also come to appreciate the difficulty of predicting how each patient will respond to an anesthetic. Nevertheless, with time, I've had fewer premature or prolonged wakeups, more comfortable and awake patients, less confusion and delirium, and more satisfying days.

Employment and Health Care

One of my friends, a surgical resident, told me about a case in which a patient who recently lost her job went to the emergency department. The surgical team recommended admission and observation overnight. However, along with losing her job, she lost her health insurance, and as a result, she was concerned that she could not afford the emergency department bill, let alone a hospital stay. She left the hospital against medical advice despite my friend having a long conversation about her well-being and recommending that she stay.

Stories like this stun me. The loss of a job and health insurance can tip a patient with medical problems over the edge; the patient may no longer be able to see her physicians or pay for medications, may experience stress and anxiety, may be unable to exercise or eat well, may start drinking. And all of a sudden, her well-managed medical problems spiral out of control. Although a patient may know that she has to find health coverage, that's hardly a priority if she's worried about making the rent or mortgage, affording food, caring for children, finding other employment. Now she's in the ED, and she makes the perfectly rational decision not to bankrupt her family. But what if that health concern becomes something much more serious, and after going home, she sustains permanent or irreversible injury, requires an ambulance, or lets a potentially treatable disease become too widespread?

Why do we tie our health care to employment? Why do we link something that everyone ought to have to employment if 7-8% of the population is unemployed? Should a decision about someone's job dictate whether they can afford their diabetes medications, prenatal care, or cancer screening? Although the push for universal health care is starting to divorce the two, the union is so prevalent and deeply ingrained that I don't think much will change. I understand the idea that employers and employees put their money in a pot and that businesses use their purchasing power with insurers, but adherence to these principles will lead to tragic cases like the one above.

100 Years

The Journal of the American Medical Association contains a short section entitled "JAMA 100 Years Ago," and glancing over it is always enlightening. It amazes me that modern medicine as we know it is young. A hundred years ago, medical practice was shockingly different. A century ago, blood types had just been discovered. X-rays and EKGs were coming into use. It wasn't until after the First World War that the first antibiotics were developed. Epidemiology had its heyday with the 1918 influenza pandemic and the focus on public health measures. Only fifty years ago did vaccines begin to control infectious diseases we rarely see today. Smoking and tobacco were widespread for much of the last century. Hormonal contraceptives were introduced within the last fifty years. When I think about this and realize that many of my patients lived through an era with ether anesthetics, racial inequality, travesties of medical ethics, few antibiotics, polio, and other "historical diseases," I begin to appreciate how modern "modern medicine" really is. What will happen in the next one hundred years, I wonder?

Alternate Plans

Although one can learn a lot from textbooks, anesthesia is a specialty learned through practice. For example, in the abstract, all anesthesiologists know that there should be backup or alternate plans for the airway should the primary plan fail. But putting this in action is difficult.

A patient with a fixed cervical spine, morbid obesity, full beard, and large neck presents for surgery. All of these characteristics put him at higher risk for being a difficult mask ventilation and intubation, though he had gone through anesthetics in the past without reported difficulties. In talking with my attending, we came up with a well-articulated airway plan and backup. After adequate pre-oxygenation, we induced anesthesia. He was indeed difficult to ventilate; with two hands and an oral airway, I could get minimal air exchange. But we planned for that and attempted to place a large laryngeal mask airway, intending on using that as a conduit for intubation. However, I could not get the LMA to seat well. After attempting to place it several times, I kept getting a leak. Although the vital signs were stable, I knew that I was running out of time. My attending then indicated we should switch over to our alternate plan. After the best mask ventilation we could do, we gave succinylcholine and used a video laryngoscope to intubate the patient.

A dozen anesthesiologists would come up with a dozen different plans and criticisms of what we did. Some might have started with the video laryngoscope. Others may have balked at giving succinylcholine when our ventilation was so tenuous. Yet others may have tried a different sized LMA or a second generation LMA (supreme, proseal, or fastrach). And the most conservative would have kept the patient awake until intubation. My attending and I had discussed all those approaches and arguments. But what I learned most from this experience was when to pull the trigger and say that the primary plan simply wasn't working and to switch to the alternative. And perhaps, the importance of having even a Plan C if A and B failed.

Quality and Quantity

I had a conversation with one of my attendings about physicians doing research. He argues that thirty years ago, physician scientists did much better research. Those who were interested in it were much better at basic science; they understood core biologic, chemical, and physical principles better than we do. It's evident in the textbooks from the day where the author of a chapter on cardiac output measured cardiac output in dogs and knew every detail and nuance. Now, authors are respected physicians who assimilate information from lots of sources but infrequently involve themselves in the nitty-gritty gathering of data. The researchers of yore had no institutional pressures; they didn't have to deal with the current "publish or perish" attitude of academic medicine. They studied science because they enjoyed it, and their research was better. Now, there is such a high volume of studies published that little is relevant, and very little is truly well done. It's a problem because as consumers of the literature, we have to sift through a lot to find the rare brilliant, innovative, or insightful study. And fewer of these are being produced by physician scientists, who have to contend with the rapidly changing clinical field in addition to the pressure to churn out papers when research ought to be a meticulous, time-consuming, and careful enterprise.

The Last Family Member

A catastrophic consequence of cancer, an accidental car accident, an unexpected heart attack, a devastating stroke - there are so many chance circumstances that can end a person's life. Death and dying have no schedule, follow no agenda. Despite our best intentions as physicians, patients will pass away before all the family members and friends have arrived and come to terms with a situation. When death is imminent, we often get a request to "keep the patient alive until that last family member arrives." When is this appropriate? How long do we continue life-supporting measures for that last family member?

It's a tough question, fraught with emotion and ethical difficulties. On the one hand, caring for a patient at the end of life also means caring for their closest family members as their loved one passes on. On the other hand, aggressive intensive care support is a resource-heavy endeavor that can easily cost tens of thousands of dollars a day, and when these resources are used to support a patient who is dying, they are taken away from another patient who may need them to live. If a patient expresses clearly that he would not want to be kept alive in a vegetative state, but a brother is on his way to say goodbye, is it ethical to keep him going for another hour for his brother to arrive? If a patient has passed away (dead or brain dead), then how is keeping the vital signs "normal" meaningful to that last family member? Do physicians need to respect the family and community of a patient and the enormous act of a son flying across the country to see his father one last time?

I struggle a little with this aspect of end-of-life care. I think I err on the side of accommodating the last person as long as their travel is underway and the time estimate reasonable. But I am very aware of the limited resources this uses and the ethical quagmire it trespasses.

Complexity

There's a fascinating disconnect between a simplified way of envisioning the heart and the actual thing. When most people, including medical students and physicians, think of the heart, it is a simple system composed of two atria, two ventricles, and the valves and interconnections. In most situations, this basic view is adequate. Most physicians can get through their day by reasoning through this four chamber box.

But as I delve deeper into anesthesia, especially anesthesia for cardiothoracic surgery and for patients with complex cardiac conditions, I've been challenged to think of the heart as more than that. In medical school, we learn the details of anatomy, but it is only when I have to interpret an echocardiogram or think through congenital malformations or place a pulmonary artery catheter that I have to envision the three-dimensional orientation of the chambers, recall the relative volumes and pressures, think about the location of each papillary muscle or individual leaflet of a valve.

It is only natural to simplify things to the very essentials of what is necessary to accomplish a task, and so it makes sense that nearly all of us reduce the heart to a four chamber box. But as I remind myself of the details I learned in the past and apply them to clinical situations now, I gain an immense appreciation for this organ.

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

Book Review: Swamplandia!

I recently read Karen Russell's Swamplandia! and I have mixed feelings about it. I was immediately intrigued by its crazy title (with the exclamation point) and opening chapters. Set in a semi-real modern day Florida, it describes a family owned alligator wrestling themed amusement park. The crazy premise drew me into the book, and the first few chapters were amazing in the description of a slightly dysfunctional yet loving family struggling with a disconnect between their perceived and actual reality. The characters, teetering at the edge of believability and sanity, overcome their own internal disquietude through the novel. Unfortunately, the novel's plot lost me and dipped a little too far into darkness. Nevertheless, as one of the more recent pieces of literary fiction I've picked up, it's definitely worth writing about.

Image shown under Fair Use, from Wikipedia.

Epiglottitis

On oral board exams, we are often tested on challenging clinical cases, and epiglottitis is a prototype. One night, we get a call that a 50 year old hypertensive diabetic adult has the diagnosis and is in danger of losing his airway. As this is one of the more frightening anesthetic cases, all the anesthesiologists had a pow-wow, and we found that our collective experience in managing epiglottitis was quite small, and everyone who had seen a case had only seen it in children (where it is more common).

The epiglottis is the horse-shoe shaped fold of tissue that protects the windpipe when one swallows. When intubating a patient, we have to lift it up and navigate around it. In epiglottitis (shown on the right), the epiglottis becomes so angry and swollen it can be difficult to see where the vocal cords are.

The classic presentation of epiglottitis in a child is one of extremis. The child can barely breathe, tripoding himself by leaning forward onto his arms trying to catch air. With any disturbance, the epiglottis may close off, and the patient may die. Even placement of an IV can tip a child over. Here, luckily, the patient had IV access and could talk in two word sentences. He had a hoarse voice and was drooling, signs that things were getting worse. His airway needed to be protected while the antibiotics cleared the infection.

The ENT surgeons had slipped a tiny nasal camera in and they couldn't see anything. We talked about our options with them; we could keep the patient awake and try to navigate a larger camera through the vocal cords with the advantage of preserving the patient's spontaneous breathing. But if the ENT surgeons had no luck with a small camera, we weren't sure whether we'd be successful (and touching the vocal cords or epiglottis could cause irreversible spasm). If we put the patient to sleep, burning our bridge of spontaneous breathing, we had no guarantee we could intubate him.

In the end, we had the ENT surgeons prepare to do a surgical airway; they were ready to cut into the neck if everything we did failed. I put the patient to sleep rapidly then looked with a video laryngoscope. All I could see was purulent drainage and angry red tissue. When I identified the epiglottis, it looked pretty similar to the picture above (left: normal; right: epiglottitis). No matter what I did, I could not see vocal cords; the epiglottis was simply too swollen. But I blindly aimed the endotracheal tube where I expected the cords to be. When we ventilated the patient, we heard breath sounds, got end-tidal carbon dioxide, and confirmed we were in the right place. The surgeons didn't have to cut. The patient's vital signs never budged. It was one of the more nerve-wracking intubations I've had to do, and I'm glad I got the experience.

Image shown under Fair Use, from UpToDate.

Life-Long Learning

One of the challenges of being a doctor is that there is always more to learn. There are always textbooks, journals, review articles, new devices, new drugs, new tests, even new diseases. It is an unending learning experience (similar to what medical training feels like). Even as I've become more specialized and focused, I've realized it is impossible to know everything. When I was on PACU, I had time to look at papers, learning modules, and powerpoint presentations. The amount of material out there is overwhelming. I wonder a little if this is similar to other fields; certainly, academicians need to constantly survey the literature and publish, but are there other professions in which life-long learning is a necessity?

Music in the OR

It might be surprising, but some surgeons like music as they work. Perhaps in the same way coffeshop noise or a background tune facilitates studying, surgeons will have their iPhone playlist or Pandora recommendations all set up. As an anesthesiologist, I get to listen to a pretty eclectic collection as I work with different teams; I've had a surgeon listen to opera and classical music to Top 40 to classic rock to country. In any case, someday I will come up with a list of songs that match the different stages of surgery. As the surgeons begin suturing the incision and finishing up, we'd end with Semisonic's "Closing Time."

Nights

Following PACU, I have a week of night float with six days of 7pm-7am shifts. The graveyard shift is a weird transition. I think everyone deals with it differently. Some people try to get a little rest overnight and maintain a normal day-night cycle. Other people switch over completely. I can never figure out what to do with meals, and my appetite becomes quite opinionated. I spend much of the day in a daze, especially if I have trouble sleeping through the daylight, and I never feel fully rested. I'm sure there are hazardous physiologic consequences as the body tries to cope with a 12 hour jet-lag. I wouldn't be surprised if glucose metabolism, stress hormones, memory and attentiveness, and emotional regulation all become affected during my week of nights.

The cases themselves vary widely. I never know when I come in what I'll get. I finish up ongoing operating room cases, carry the airway pager, and receive traumas or other surgical emergencies. It's a good learning experience as patients can have multiple injuries, unknown medical conditions, full stomachs, drug intoxication, and other unanticipated problems. I have to be ready for any kind of surgery, from eyes to bones to lung to belly to brain. Sometimes, fortunately, we sail through the night quietly.

PACU

Over my two weeks in the post-anesthesia care unit, I've learned a lot about how to manage immediate post-surgical issues. From common complaints like pain and nausea to management of epidurals and nerve blocks to rare things like re-intubation and a stroke code, it's been a good refresher on perioperative care. I've seen how other residents and physicians manage their patients intraoperatively, and it's changed a little of how I will approach patients in the future. The flexible time to direct my own studying was helpful as well as I could shore up the points where I was rusty. Nevertheless, I'm happy to get back into the operating room.

Wise Words from a Medicine Resident

One of my friends Jason wrote these thoughts at the conclusion of his internal medicine residency; I was really struck by them and felt they were worth sharing.

1) I’ve heard a lot of regrets, but I’ve never met anyone on their deathbed who regrets spending too much time with their loved ones.
2) Ensure makes a filling, somewhat nutritious and extremely quick meal when you’re on call and on the run. Chocolate is delicious, vanilla is pretty good and strawberry is tolerable. Glucerna is distinctly unpalatable. Elemental tube feeds (don’t ask) are not meant for oral consumption for a reason.
3) If you wake up in the morning in good health and are free of chronic pains or the onerous weight of a serious diagnosis looming over you, you’re already much, much luckier than many and have much to be grateful for.
4) If a patient starts very inappropriately hitting on your medical student while he’s in the process of doing his first rectal exam, and if said patient then offers to set you up with her underage friend when you politely tell her to lay off your medical student, you know the day is off to a good start.
5) When you can’t think of the right words (or there just aren’t any), sometimes just pulling up a chair and quietly holding someone’s hand is the way to go.
-Jason

Elevator Questions

Near the end of medical school, we had a lecture on "elevator questions." To prepare us for being interns, the lecturer discussed what to do when we got paged by a nurse in the middle of the night with a problem. At the beginning of internship, the answer is always the same: go see the patient. But we were encouraged to begin formulating questions, a differential diagnosis, and a plan while in the elevator (this was at UCSF where climbing 5 flights at 2AM was not popular). That way, we'd have a plan when we arrived at the patient's bedside. I practiced this meticulously, and through my first year in medicine, I had a mantra for chest pain, shortness of breath, hypotension, hypertension, tachycardia, bradycardia, dizziness, rash, and a half a dozen other common complaints. I knew what focused history I'd take, exam I'd perform, tests I'd order, and therapies I'd start even before I got to the patient's room.

Now in anesthesia, I have a similar habit. Usually, the information is pretty sparse, but even with a few words or phrases - "appendectomy," "craniotomy," "lots of bleeding," "compromised airway," "ICU patient," "morbidly obese," "90-year-old" - evokes enough. As I rush out of the call room (or out of my house on home call), my mind is already formulating a plan. How am I going to secure the airway? What kind of IV access do I need? Which medications and anesthetics will I choose? Do I want blood in the room? How emergent is this procedure?

Although many people (including surgeons unfortunately) think anesthesia is the same for each patient, it's absolutely not, and those five minutes of preparation and decision-making are crucial to patient safety, achieving adequate surgical conditions, and minimizing risk. Although I didn't know it at the time, the lecture on "elevator questions" taught me a lot about how to approach urgent clinical situations.

Why Do We Get So Attached to Animals?

What is it about pets that makes us so attached? Why is it that the passing of a beloved dog or cat grieves us so? How come hospitals use pets as therapists? I ponder on the co-evolution of humans and pets. I think of the psychology of a companion who is always affectionate. I think of the neurology of mirror neurons, anthropomorphism of attributing them similar emotional states. I wonder what the dog and cat think too.

Image shown under GNU Free Documentation License, from Wikipedia.

The Second Annual Arts and Anesthesia Soiree

I emceed Stanford's second annual Arts and Anesthesia Soiree. It was a wonderfully fun evening celebrating the diversity, depth, and breadth of the arts and humanities within the department. Seeing everyone gather as a community was important to me; we met significant others, family members, and children of the people we work with every day. We interacted with members of the department we see rarely, involved researchers, technicians, staff, and anesthesiologists.

Art is such an important part of life. In a profession, culture, society, and world that focuses so much on science and technology, we have to recognize the things that give us beauty, meaning, and wonder. These things give us pause. They move us. Yet we can go weeks, months through our daily bustle without seeing, listening, appreciating. This is why I felt organizing such an event was so important.