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.