Happy New Year!

Cheers to a happy, happy new year! I'm on call tonight so drive safely, don't get sick, and watch your drinking! Actually, though I may jinx myself, things are quiet in the operating room right now so I'm going to sleep when I can and hopefully the New Year rings in during an uninterrupted REM cycle.

Justice

I think human nature inherently believes in or wants to believe in a sense of justice. Even though we know things aren't fair, we really want them to be fair. We want to take a world of entropy and cage it in rules, make it predictable and known. And though I know this is irrational, I can't help but feel this way about our recent burglary. When our house was broken into, I was probably anesthetizing a two year old child who had a dogbite. My fiancee was telling a woman with glioblastoma multiforme that her cancer was worse and she had to tell her children she was likely to die in less than a year. On the one hand, our lives are charmed and idyllic when compared to the crises of these patients (and parents and children). We have nothing to complain about; we ought to feel grateful for our good health and fortune. Yet on the other hand - the side of me that is a little ashamed - I think of how unfair it is that right before Christmas, we were working late in the hospital caring for others, when some stranger took our laptops and jewelry. We never did anything to deserve this, I think. I realized that this must also be how patients sometimes feel, the feelings they never share with their doctors. Our child never did anything to deserve a dog bite to the face, thinks the parents of my patient; I never did anything to deserve brain cancer, thinks my fiancee's patient. Oh, in the end, we know that fairness has little to do with it. But this incident has taught me a little more about how human nature reacts and perhaps how my patients feel.

Victims

I've seen a lot of victims in the hospital. We see victims of gang rivalries who go to the operating room for a stab wound, victims of domestic violence during pregnancy (a time with increased domestic violence) who have preterm contractions, victims of child neglect. Every time I see someone who is a victim of crime or violence, my heart reaches out to them. My voice softens, my gestures are more measured, I slow down the rush of things. I apologize for their loss or what they are going through, and I make an earnest effort to make their anesthetic or hospital course a little more pleasant.

But I never really knew what it was to be a victim until now. That feeling of violation, the idea that someone has battered down the door, trespassed into your home, and torn everything apart - it wreaks psychological havoc. It disrupts sleep, blunts appetite, dulls the senses, wells the emotions. I alternate between being incredibly rational and goal-directed - talking to the police, filing insurance claims, cleaning the house, cataloging losses - to aimless thought wanderlust. This transition from general to specific is a terrifying, eye-opening thing - to go from the disbelief that such things happen in this world to someone robbed my house - exemplifies for me the idea that you can know something without being intimate with it. And being intimate with crime - even nonviolent property crime - is an awful, wrenching feeling. When this is mixed in with our nonstop schedules, the holiday whirlwind, the new interactions with insurance and law enforcement, it's hard to pin down what I'm feeling. I wall off my emotions and reflections to get through the day. Somehow, sometime, I will need to sit and process everything I'm feeling. For now, I will persevere, remain strong, check off those boxes to get my life on track and safe. 

I will also have a little better understanding of what it means to be a victim. When I see my next patient who is a victim of violent crime, iatrogenic harm, loss of medical insurance, an accident - anything - my heart will call out to theirs. We heal in many ways.

Happy Christmas

This has been one of more surreal holidays I've had, and that's counting holidays spent entirely on call in the hospital. I'm still reeling from the burglary of our house, but I am so grateful for everyone who's responded with kindness, sympathy, support, and care. I am sure the shock will abate, but the aftermath of this mess - cleaning the house, replacing stolen items, rebuilding music and picture libraries, working with our insurance company - have caused our to-do list to overflow.

Burglary notwithstanding, we had a warm, comforting Christmas with family, and that helped cushion the feeling of helplessness. I also think the things I see in the hospital help give me perspective. The loss of a few laptops, jewelry, and Christmas presents are nothing compared to the things I see on a daily basis. Health and safety are indispensable. Things can be replaced.

I hope your holidays are filled with joy, celebration, relationships, and magic. I also hope they are a time for reflection and a reprieve from the trials and tribulations of everyday life.

Burglary

Our house was burglarized yesterday. I'm still in shock. After a busy pre-Christmas call anesthetizing seven cases, I returned home to find our house in ruins, the door frame shattered, everything astray, valuables missing. The time to process all of this will come. Right now my mind is still reeling that such things happen. What an awful feeling, to be a victim of a crime. And all the things lost that are irreplaceable, memories, sentimentality, security, the feeling of home. To feel ones privacy, sanctuary, safety invaded, rifled, discarded, and missing. More on this later, but I sincerely wish you and yours a safe, happy Christmas.

The Problem with C-sections

I'm not an obstetrician and the decision-making around calling a C-section is complex, but as an anesthesiologist watching from the sidelines, I've developed a lot of notions and opinions. Since the modern C-section was first performed in the 1880s, it has quickly become one of the most common surgeries in the United States with an incidence around 1/3 of all pregnancies. This statistic just amazes me; how can it be that birth happened for centuries and centuries (albeit with a higher maternal and infant mortality rate) without problem but now, a third of all pregnancies end in surgery?

One problem is that surgery begets surgery. Once a woman has a C-section, she's much more likely to have subsequent sections; trial of labor after Cesarian continues to be uncommon. Fetal monitoring has lead to increased rates of C-section, though fetal monitoring has never been scrutinized through well-conducted prospective randomized controlled studies. And in the back of medical economist heads, the question of medical malpractice lingers. A woman who has surgery but a healthy baby is unlikely to sue for unnecessary surgery whereas a woman who did not receive surgery but has infant morbidity or mortality is much more litigious. It's safer for obstetricians to err on the side of going to surgery.

Ideally, we would have informed, in-depth discussions with our patients about the rationale for a C-section, the risks, the benefits, and the alternatives. But with a laboring woman in pain, a fetal strip showing late decelerations, and the commotion of labor and delivery, I've rarely seen the balanced conversation. However, it's important to remember that surgeries and C-sections should not be taken lightly. Though our anesthetic and surgical techniques make it generally safe, complications happen and they can be catastrophic if they do.

Image shown under Free Art License, from Wikipedia.

Obstetric Anesthesia Again

I also had my second month of obstetric anesthesia. The second time around, the rotation was noticeably smoother. Human experience is interesting in that we rarely notice ourselves change or improve. But when rotations are set a year apart, the difference between the two experiences is quite striking. I remember being apprehensive about obstetric norms, diseases, and expectations during the first rotation. Even though it's been a year since then, a year since thinking about pre-eclampsia, magnesium, terbutaline, and ruptured membranes, I've somehow retained that information and navigate it a lot easier. During my first month, epidurals still remained in a little black box; I understood enough but not everything. This time, I better appreciated the anatomy, understood how to troubleshoot, and became more comfortable with "difficult" epidurals. My success rate with patients with scoliosis, morbid obesity, and inability to sit still was much higher this time around. To myself, I was noticeably faster, efficient, and precise. My manual dexterity also got better in ways I don't understand. You don't really think that your ability to "feel" changes, but mine did. The epidural is a very tactile procedure; I got better at feeling spinous processes, determining the different ligamentous layers by their density, and moving the needle with controlled, precise intention.

Although we don't necessarily like to think about it this way, residency and medicine is a practice of refined learning. I am better now than I was a year ago. Did I provide substandard care a year ago? I don't think so. But I certainly provide better care now. The process of learning, improving, and training is necessary. We have to try, do, stumble, repeat before we can feel entirely comfortable and confident. Balancing this with appropriate patient care is hard, but luckily I think I have made it through the tunnel to the other side.

Clinical Volume and the Holidays

Blogs have been somewhat sporadic because the operating rooms have been extremely busy. In trying to understand why, I learned that patients are squeezing in elective surgeries before the end of the year to use their flexible health spending accounts and maximizing their insurance policies. As a result, we've been booking a lot of cases trying to get everything done. Finances are a big driver in patient decision-making. Rather than "waste" flexible health spending accounts, patients will choose to get elective surgeries that perhaps they would have waited on. On the one hand, perhaps we are doing some unnecessary procedures since to some extent money is driving decisions rather than medical necessity. But on the other hand, we begin to understand how economic incentives influence consumer decision-making. Can financial carrots encourage patients to take better care of themselves, exercise, eat healthier, get preventive medicine, take their medications? How do we take advantage of patient motivators to improve health care delivery and outcomes? Important questions to ponder when work gets less busy.

Holiday Party

We had our department holiday party tonight, an incredibly fun and quite swanky affair. The most fascinating thing about it for me, though, is that I don't know the majority of the people there. The administrative staff, research faculty, emeritus professors, lab staff, nurse practitioners, and fellows dwarf the residents and attendings. It's amazing how big the department is and how many people are involved in its daily operation. I begin to realize that perhaps only a small subset of people are at the patient's bedside and in the operating room, but they are supported by a remarkable machine that helps further our mission of patient care, research, and teaching.

The General and the Specific

As medicine becomes more and more subspecialized, the generalists lose skills they used to have. Decades ago, all anesthesiologists did cardiac, thoracic, obstetrics, pediatrics; because there wasn't further specialization, we were expected to do it all. Of course over time, medicine becomes more complex; the surgeries we do today involve much more technology, equipment, skill, and expectation than those in the past. We are doing harder surgeries on sicker patients, a phenomenon that leads to more specialization, more training, and more differentiation.

But after a month of cardiac anesthesia at the VA doing run-of-the-mill community-level cases, I think that there's something lost when generalists no longer do specialized cases. It would be inappropriate for a general anesthesiologist to do an aortic root replacement or brain surgery for a neonate. But it's not out of the question to expect him to manage a simple three vessel bypass or inguinal hernia repair on a child. The problem with subspecialists is that we now expect a cardiac anesthesiologist to do all heart cases and a pediatric anesthesiologist to do all the kids. But with a limited supply of subspecialists and a growing number of surgeries, this becomes untenable. Furthermore, if the generalist lets his skills atrophy, then cases that used to be appropriate no longer remain so, a sad reflection that we no longer practice to the fullest extent of our training.

I understand the nature of increasing complexity and increasing subspecialization. But this does not mean that the generalist's sphere of practice needs to change.

Book Review: Jonathan Strange and Mr. Norrell

Susanna Clarke's Jonathan Strange and Mr. Norrell was my first foray into alternate history fantasy fiction. I'm pretty mixed about the genre, but I really enjoyed this epic book. Over 700 pages long, the book offered many opportunities for me to give up and return it to the library, but I simply could not stop. Set in an alternate fantastical history, it explores a 19th century England in which magic is returning. But the book delves into fascinating themes of what it means to be English, the nature of friendship, and the gray zone between reason and madness. It incorporates history, postulating the use of magic in the Napoleonic wars. It even creates its own history of magic compiled in a wealth of footnotes scattered through the book.

Jonathan Strange and Mr. Norrell captivated me most, though, with the way its written. With almost a tongue-in-cheek playful approach, it tries to be Jane Austen and Charles Dickens and a comedy of manners and a Gothic tale and a Byronic hero all at once. The writing is gorgeous, a little flowery, and proud of it. It really captures the diction, tone, and style of the 19th century. It is a huge tome, though, so only pick it up if you're willing to tackle a 700 hundred page novel.

Image shown under Fair Use, from Wikipedia.

Thoracic, Revisited

As the cardiac resident at the VA, I also do most of the thoracic anesthesia. Like cardiac, it's fun revisiting these anesthetic techniques in the VA environment. It helps me see how much I've really learned as the second time around, these cases are much smoother. After learning something intensely, the mind and body needs a period of time to assimilate and integrate the new information and skill set. Then when I return to those clinical situations, things feel much more instinct and habit than novelty. The thoracic epidurals, double lumen intubations, troubleshooting, and flow and expectations of surgery become a lot easier. We had a wide variety of cases, from simple wedge resections to a full-on Ivor-Lewis esophagectomy. It makes me much more confident in my skills and decision making as an anesthesiologist.

Where Care is Given

The way we deliver medicine changes in strange ways. There are more and more places that deliver care; new hospitals, clinics, ambulatory surgery centers, and procedure centers are being built year after year. We are caring for patients at more diverse and more numerous places than ever before. Several decades ago, the idea of a freestanding outpatient surgery center would have seemed crazy; now, they are a profitable business model. The same thing applies to clinics found in pharmacies, flu shots being given at grocery stores, and independent laboratory and radiology facilities.

At the same time, though, specialized care is being concentrated more and more at certain hospitals. For example, bariatric surgery outcomes are better at places that do a lot of weight-reduction surgeries; as a result, these centers of excellence concentrate all the bariatric surgery volume. Parents may take a child with complex congenital heart disease hundreds of miles to a subspecialist who is an expert in that condition. Some patients fly across the country to see the nation's best rheumatologist, geneticist, or hand surgeon.

To me, this is a weird result of unregulated medical expansion. We want to do the best for our patients, and we want to have a successful business doing so. So all the routine stuff spreads out for patient convenience; why go all the way to an academic medical center for routine prenatal care if the local obstetrician can open a clinic where you are. But all the rare stuff coalesces at discrete centers to ensure that experts remain experts and patients get the best care. With rare diseases, patients are willing to go farther and wait longer to see the best oncologist in the area. 

At a top academic medical center, I really enjoy seeing the high concentration of complex diseases. But as I look at jobs and think of the future, I realize most physicians out there work with run-of-the-mill bread-and-butter most of the time.

CoreValve

Medicine is moving towards minimally invasive surgery, and cardiac surgery is no exception. The VA participates in a national trial evaluating a percutaneous aortic valve replacement with the CoreValve system. Along with the Sapien valve, these two devices are aortic valve replacements deployed through the femoral artery, or less commonly, through the aorta. Patients qualify for these procedures if they are too high risk for standard open-heart aortic valve replacement with cardiopulmonary bypass. The trials with these devices, however, are quite impressive. Although there is a significant risk of stroke, outcomes with these valves are not bad, especially considering how sick the patients who receive them are.

We coordinate the case with cardiac surgery, cardiology, and the cardiac catheterization lab. After placing an IV and an arterial line, we induce anesthesia. Because these patients all have severe or critical aortic stenosis, this is an extremely high risk moment. Unlike our standard cases where we use high doses of fentanyl and midazolam, our goal is to wake the patient and extubate immediately after the procedure so we have to rely on etomidate (and rarely propofol) based inductions. I mention this moment blog after blog because I think it's underrecognized how dangerous general anesthesia can be for these patients with such advanced cardiac disease and even our physician colleagues rarely realize that we employ all our knowledge of cardiac physiology, disease states, pharmacology, pharmacokinetics, and technical ability in these five minutes around intubation. After securing the airway, we place a central line for vasoactive medications and a trans.

During the entire procedure, the perfusionist is on standby in case we need to crash onto cardiopulmonary bypass; luckily, this is a very rare event. The surgeons do a cut-down to the femoral vessels in the leg; if the femoral artery is too small to accommodate the device, they have to do a mini-thoracotomy in the chest and cannulate the aorta (in this case, we have to isolate the lung with a double-lumen endotracheal tube). The cardiologists put a femoral arterial line and temporary pacemaker into the heart. Then, they guide the replacement aortic valve through a large-bore sheath retrograde into the heart. They position the valve with both fluoroscopy and echocardiography. First, the cardiologists do a valvuloplasty to open up the diseased valve, followed by deploying the artificial valve. In order to do this, they pace the heart incredibly rapidly. They don't want the heart squeezing when the valve is deployed because this can dislodge the valve. By pacing at around 200 beats per minute, the ejection fraction is minimal; though this is transient, the changes in blood pressure are quite alarming. After the new artificial valve is placed - in a way blindly since it is only guided by fluoroscopy and echocardiography - we look on echo to look for perivalvular leak. If the valve looks like it's seated well, they surgeons close up the femoral incisions and we prepare to wake up and extubate the patient. Surprisingly, they rarely need high doses of vasoactive drips. Occasionally we have to place a temporary pacemaker because the CoreValve can cause heart block. The whole procedure takes a couple hours and patients can be awake, talking, and ready to eat several hours afterwards. Its quite impressive as recovery seems so much easier with the percutaneous approach rather than the open approach.

Recipes, Innovation, and Convention

Cardiac surgery and anesthesia at the VA follow a very protocolized treatment regimen. The lines, the drips, the surgical approach, and the post-operative management are standardized almost to recipes. And we don't manage patients the same way as they are managed elsewhere. We keep our patients deeply sedated the first night in the ICU where other institutions may aggressively wean sedation and try to extubate. We use extremely high doses of benzodiazepines and opiates, even up to 20mg of midazolam and 4mg of fentanyl. Why do we do this and does it make sense?

It's easy to criticize this management as old and outdated. After all, this is how cardiac anesthesia was described a decade ago. Only more recently have other hospitals pressed to extubate early, decrease ICU stay, and shorten length of time. But the VA has stuck with what's worked for it. Many reasons can be offered; perhaps our vets have a high prevalence of PTSD and trying to wake up and extubate at night leads to delirium or perhaps the VA is less cost-conscious without economic pressures to get patients out of the ICU as fast as possible. But I think the most important reason is culture. Our surgeons, nurses, and anesthesiologists have come to expect cardiac surgery courses to follow a certain arc and barring reason to change it, keeping the status quo is working with the tried and true. Compared to other things in medicine, cardiac surgery is an enterprise that benefits from standardization. While diagnostic mysteries or chronic care have uncertainties, there should be minimal uncertainty in an elective surgery. Cardiac surgery and anesthesia can be performed in many different ways, but the key is for everyone to agree on one standard process and optimizing it as best as possible.