Adolescent Idiopathic Scoliosis

When I was on my medical mission trip to Guatemala several months ago, we had a case of a young teenager with adolescent idiopathic scoliosis who underwent a large multilevel spine surgery. We managed to safely and effectively complete the case despite not having our usual resources. Our anesthetic choices were limited, we didn't have arterial pressure monitoring, we didn't have intraoperative neurologic monitoring, and we didn't even have the right bed for the patient. But at the end of the day, the procedure was a success and the patient was thrilled.

My first day back on pediatrics, I was assigned to a similar scoliosis surgery. In fact, we had the same surgeon and team. But here at Lucille Packard, I had the luxury of remifentanil, arterial pressure monitoring, neuromonitoring with a technician and neurologist, prone bed, multiple IVs, multimodal pain therapies with a pain team that would follow the patient, blood products, and backup if we needed help. It was so incredibly different. The patient also did very well, and may have had a smoother post-operative course with our pain management resources here.

In the United States and at hospitals like Stanford, we have a luxury of resources. We get used to having everything, to utilizing state-of-the-art cutting-edge technologies, to relying on a multidisciplinary team of health professionals. This leads to remarkable care. But there are places, times, and circumstances where we may not have such a wealth of stuff. When I compare the anesthetic for the two scoliosis cases, I really think both methods can be done safely and effectively. The key for the case with limited resources was thorough pre-planning, an understanding of what I had available, and a flexibility to make it work.

Children and Midazolam

We often give midazolam, an anxiolytic, to children before surgery to keep them relaxed and prevent them from being traumatized by the operating room. Though I don't know myself, it's often described as feeling inebriated. For young children, we often give oral midazolam, and the effects are pretty amusing; they become ataxic, laugh uncontrollably, relax around strangers. But I've had a couple interesting experiences when giving midazolam IV to teenagers. Sometimes they share information around their parents that they probably didn't intend to. We try to avoid awkward situations, but sometimes we get the teenager who says that "it feels exactly like getting high" or reveals a secret tattoo. The truth is, though, the parents probably already knew.

Multimodal vs. Polypharmacy

Nothing in medicine is certain. For every issue, there are proponents and opponents, pros and cons. Although we wish we could just learn the "right answer" in medical school, clinical medicine is never that simple. Different practitioners view the same problem in polar lights. For example, in geriatrics, there is a strong focus to avoid "polypharmacy," the administration of too many medications. An elderly patient may have several antihypertensives, diabetic medications, pain medications, antidepressants, osteoporosis medications, proton pump inhibitors, and a handful of miscellaneous pills. Anybody with that regimen is prone to confuse things and make mistakes. This can have dire consequences if critical pills are missed, doses are wrong, meds are substituted, or any number of potential discrepancies. Thus, to avoid polypharmacy, geriatricians advocate simplifying the medication regimen to reduce medications, frequency of dosing, and interactions.

On the other hand, pain management physicians advocate "multimodal" pain therapy. We try to tackle pain from multiple angles, targeting many different receptors, creating a cocktail of medications that reduce the doses of any single drug. Instead of putting someone on high dose opiates, we throw in gabapentin, a tricyclic antidepressant, and an NSAID; these adjuncts allow us to lower the dose of the opiate. This avoids the side effects, complications, and marginal gain with high doses of any one drug. But of course, this is simply polypharmacy. We want to use multiple drugs when perhaps one drug might cut it.

Each side has its arguments and probably the right answer differs between patients. For some who have trouble taking medications, we want to simplify the regimen as much as possible. For others who cannot tolerate side effects but are less prone to make mistakes, multimodal therapy might be the way to go. This illustrates how medicine is an art as well as a science, that there are no perfect answers for everyone, and how different specialties may disagree on the optimal management.

Pediatrics

Over the holidays, I was on my third month of pediatric anesthesia, a really fun experience. It was fascinating and a little mindboggling to ask the children what they wanted for Christmas. Elementary school kids are getting presents that I don't even get myself. They are becoming incredibly adept with electronic devices, and I wonder what it says about our society. When I got Legos, these children are getting remote-controlled helicopters. When I got a bike, these kids are getting iPads. I don't think it's wrong or bad, it's just really interesting. There is a part of me that thinks books, building blocks, and board games are the way to go, but electronic devices can stimulate creativity just as much.

In any case, the clinical volume around the holidays was interesting to me too. We had a lot of surgeries before Christmas, after which the volume dropped off significantly. Many of the patients were school-age teenagers with orthopedic injuries using the winter break as a time to recuperate. We also had a lot of outpatient procedures such as urologic or ENT procedures so the children did not have to stay in the hospital overnight.

The second time around pediatrics was much easier and much more fun. I really believe in the educational theory that after being exposed to something new, you go away for a while to let it simmer, assimilate, and integrate. Then when you come back to it, it feels natural, reflexive, and easy. I got to be a lot more independent with these cases and have a lot more fun as I did not have to think as hard about doses, sizes, and procedures. It made me confident that I can safely anesthetize healthy children for simple procedures.

Excluding Pre-Existing Conditions

One of the great victories of the Affordable Care Act is that insurance companies must provide insurance to all applicants regardless of pre-existing conditions. This provision ensures that abuses such as dropping policyholders when they become sick and charging exorbitant fees for those who need health care the most - sick patients - can no longer happen. By doing so, the Affordable Care Act affirms that health care is a right that everyone should have. But this simple idea is also a remarkable one. I bring it up because I can't think of any other insurance policies that act like this. Bad drivers pay more for car insurance, renters who live in a home that's been broken into pay more for their renter's insurance (this unfortunately applied to me), and life insurance policies take into account the applicant's health.

What seems to be somewhat different about health insurance is this fascinating and paradoxical relationship that a pre-existing condition may be the reason why someone wants health care. No one buys car insurance in order to drive recklessly or renter's insurance intending to leave the door unlocked. But someone who is sick wants to get health insurance to get better. (Of course we hope healthy people want insurance in case they get sick, the concept of insurance). But I think this is one difference that makes excluding pre-existing conditions in health care particularly despicable.

The other reason is that we cannot help most of our pre-existing conditions. Someone with cancer may not, for the most part, be able to help that they got cancer. And to exclude them from getting health insurance is an evil practice that we have hopefully eliminated. But there are some factors we as policyholders and patients have control over. Should health insurance cost the same for a smoker as a nonsmoker? For a IV drug-user as a non-user? I'm not sure. Certainly these patients cost the system more, and if these are habits they can (and ought to) change, then should premiums encourage them to do so? For things we cannot help - genetics, heritage, exposure, random chance - health insurance should turn a blind eye. But should it ask us to take responsibility for decisions we make about our bodies that change our disease risks?

Happy MLK Day

Happy Martin Luther King, Jr. Day! Despite all the advances we've made in civil rights with regard to gender, race, ethnicity, religion, sexual orientation, etc., there persists inequalities that bother me. For many diseases, African Americans have worse outcomes than Caucasians, and for most diseases, there is a paucity of data on other races and ethnicities. Minority physicians often face challenges that other physicians do not, especially in small fields traditionally dominated by old white men. Studies show that race-concordant patient-physician relationships have better satisfaction scores; that is, an African American patient will be more satisfied with an African American provider. And I've seen instances where a patient demands to be seen only by a specific gender, race, or type of doctor. Discrimination happens in a myriad of ways; it affects both academic professorships and community positions, physicians and patients, community relationships and personal turmoil, scientific studies and individual patient care. It happens despite our best intentions, it happens even when we try our very best to stamp it out. I am no expert on civil rights and its facets in healthcare, but in my eight years as a medical student and resident, I've seen, experienced, and even been a part of subconscious feelings that betray me. I am not one to point a finger and scorn, and I am not one to exclude myself as part of the problem. This is something we all have to work on together, something we have to teach each other, something we have to remember throughout our careers and lives.

Open Access

Journals are a for-profit business, and for a long time, they hoarded their publications. As a member of an academic institution undergoing educational training, this isn't too much of a barrier. Through a Stanford-wide site license, I can access most large journals, download those articles I need, and not worry about purchasing copies. But for a community physician, scientist, or layperson, it's not easy getting access to journals. Purchasing a single article is expensive, and big publishers are enforcing their copyrights. They even ask the original scientists who did the study to take down copies from their websites. Yet having access to that medical and scientific information is a necessity. I download articles to build a library of groundbreaking medical studies, read new publications to see how anesthesia is changing, and peruse scientific studies and methodologies to understand directions in research.

In response to this "silo-ing" of information, new open access journals have popped up. They don't require readers to purchase articles and make their publications available to the public. Unfortunately, they are not usually as highly regarded as the journals that have always been around. But this clash has raised a question in my head: although copyrights may be an important legal and financial concept, there may be a moral and scientific imperative for open access to medical studies. If technology is hoarded, how we can expect scientists to work at the breaking edge of new research? If medical studies need to be purchased, how can we expect doctors always to be up-to-date? If most research is funded by the National Institutes of Health and taxpayer dollars, then why are the conclusions of that research property of these large journals? If patients volunteer for clinical trials, then don't they expect those trials to be completely available for the biggest health impact? When we talk about medical studies, we aren't talking about a new best-seller or blockbuster being leaked and downloaded. We're talking about government-funded research, public health, and the treatment of individual patients.

The Million Dollar Question

One of the biggest questions I get asked when I'm on obstetric and pediatric anesthesia is how an anesthetic may affect a child. This is a complicated question, both sufficiently and excessively vague. If a child absolutely needs surgery or a mother needs a stat C-section, then any theoretical risks from anesthesia would be dwarfed by the actual risks of not getting surgery. Since pediatrics and obstetrics are rarely amenable to randomized controlled trials, what we know is often incomplete and extrapolated from animal trials or retrospective studies. My conclusions on reading the literature is not easy to summarize. If I give opiate through an epidural, its potency is greatly enhanced, but some of that opiate can cross the placenta. Yet this is much more preferred than IV opiate which crosses at much higher concentrations. But if I withhold opiate from the epidural, then a woman may need much higher doses of local anesthetic to get adequate relief. And perhaps that will increase the risk of local anesthetic toxicity, failure of the epidural block, and even C-section rate. With all these conditional statements and wishy-washy clauses, it's hard for patients to objectively assess the risks and benefits. Similarly, we don't think there are any long-term effects from a healthy child receiving one anesthetic. Yet some studies show that repeat anesthetics, especially in a vulnerable population like premature infants, can have long-term consequences. Are those consequences due to anesthesia or having multiple surgeries or having multiple medical problems and risk factors? How do we present that to a patient or parent?

This touches on the nuances of informed consent. I used to think that informed consent was easy. You'd tell the patient the recommended procedure, what the common and most serious complications could be, what alternatives the patent could choose (including doing nothing), and why it was recommended. Then the patient should have enough information to decide. But in cases like this, where evidence is confusing, much of it poor in quality, much of it contradictory, how do we give a balanced viewpoint to a patient or parent? When practitioners spend hours reading and making our own judgments, how can we expect a patient or parent to decide immediately?

Winding Down the Interview Season

Today was our last group of interviewees for the anesthesia class starting in 2015. It's fun and fascinating talking to these prospective residents. Ebullient with ideas, excitement, and enthusiasm, they remind me of how I was four years ago. Residency is a hard and exhausting journey, and it's easy to forget all those awesome and occasionally-naive ideas about how we want to change the world. Meeting the incredibly accomplished applicants makes me optimistic about the future of anesthesia and hopefully our department. It's interesting to think of how this cycle of graduating and incoming residents will continue indefinitely and fun to meet the future of anesthesia.

Bleeding in Pregnancy

The uterus gets a lot of blood, up to 700mL/min. The average blood volume of an adult is around 5L so this represents 15% of cardiac output. So when the uterus bleeds, it bleeds a lot very quickly. In a normal vaginal delivery, blood loss can be up to 500mL, and up to a liter in a C-section. Compare this to most surgeries where we estimate blood loss to be a tenth of that. Since most women in pregnancy are healthy, they recover and do fine.

But it also explains why anesthesiologists are so concerned when bleeding exceeds the expected. If a patient is losing 700mL/min, we have 8 minutes before she bleeds to death. In those 8 minutes, we have to maintain vital signs, pour in fluid, get additional IV access, administer drugs that can slow the bleeding (oxytocin, methylergonovine, carboprost, and misoprostol), call blood bank and begin transfusions, consider arterial or central access, consider intubation, maintain normothermia, maintain normal coagulation, prevent hypocalcemia, discuss the utility of other surgeons or interventional radiology, and plan for the ultimate disposition of the patient to the ICU. On my rotation, we saw several patients with known high risk for postpartum hemorrhage, and we planned accordingly. But I also had a case of unanticipated maternal hemorrhage, and as you can imagine, keeping up with all those tasks while maintaining a level head is challenging. This is a central issue to obstetric anesthesiology because maternal mortality from hemorrhage should be avoidable, and constant vigilance, practice with simulation, and active teamwork are key to keeping our patients safe.

Cardiac Patients in Pregnancy

Generally, patients in labor and delivery are healthy. They have asthma or migraines or low back pain or most of the time, no other medical problems. It's easy for health care professionals - obstetricians, anesthesiologists, nurses - to simply assume all pregnant patients are healthy. But these kinds of assumptions can get us in trouble, especially at a tertiary care center like Stanford.

We see a lot of high risk obstetric patients. One of the biggest groups we see are patients with cardiac problems. Although it's rare for a woman of reproductive age to have heart disease, when it does happen, it is a major concern. The process of pregnancy and labor put a lot of stress on the heart. The natural changes with pregnancy include a dilutional anemia, increased intravascular volume, an increase in heart rate and cardiac output, and diversion of blood flow to the uterus and placenta. The growing placenta compresses the inferior vena cava leading to decrease of blood flow to the heart. Labor is like a stress test for the heart which has to increase to match increasing oxygen demands. The most dangerous lesions actually involve the lungs and manifest after delivery. After the baby is delivered, the release of vena caval compression causes a dramatic increase in venous return. A compromised heart cannot cope with this and can go into heart failure. A lesion like pulmonary hypertension can spiral out of control. Most maternal cardiac deaths happen after delivery, and many could be preventable with adequate knowledge and appropriate care.

The cornerstone of peripartum care for complex diseases is interdisciplinary, longitudinal, collaborative treatment. We have monthly meetings with obstetrics, maternal-fetal medicine, cardiology, anesthesiology, and nursing about patients with heart disease. This way, we ensure that we have the right tests, understand the obstetric and fetal plan, learn from each other, and plan the delivery. As a group we can discuss the advantages or disadvantages of a vaginal delivery versus C-section, an epidural, peripartum medication management, and contingency plans.

Term

Over my month on obstetric anesthesia, I've wondered a lot about the definition of term. When I was in medical school, a term pregnancy was 37 to 42 weeks, but just several months ago, the American College of Gynecology, subdivided this even to early term (37 weeks to 38 weeks and 6 days), full term, and late term (41-41+6). All this hullabaloo is fascinating to me. Are we trying to medicalize a normal process? Should we be trying to force all women to deliver in this time frame? Although we know that there are risks to preterm and post-term deliveries, it also feels like engineering a natural life event. Is this akin to giving growth hormone to people who are too short? Is it like cosmetic surgery? Should we inducing labor in all post-term patients and preventing labor in all preterm patients? When do we cross the line in controlling processes developed over thousands of years of evolution?

Image is in the public domain, from Wikipedia.

Resolutions

I don't really make resolutions, but I think the act of resolution-planning has some value. What kinds of things do I want to change about myself? What goals would I like to pursue? How can I prevent myself from stagnating in a rut? Although many of my personal aspirations have not changed, I think that I need to review some of my professional desires, especially since this is my last year of residency.

I will read more this year. Studying is a strange beast. For much of our education, we study and study and study. We labor and toil away in the bowels of the library, memorizing obscure facts and figures. Then as residency really picks up momentum, we realize that our training is experiential. We have enough knowledge to get us off the ground, and now becoming a doctor is really case-based learning, seeing patients, treating diseases, making decisions, acting. But now I'm realizing that as the things I do on a day-to-day basis become easy and routine, my book knowledge has lagged behind. There are rare diseases I have not seen and may never see, but I need to know about them, and reading is the solution. I make decisions based on what my mentors do, but I don't know the scientific evidence behind it; that's when I need to pick up the journal or paper. There are connections in medicine waiting to be made, and studying will help me better appreciate the big picture. Especially as I have board examinations coming up, studying will be a big goal for me this year.

I will become more independent this year. When we start residency, we are shielded by the guardian oversight of our mentors. We start to carve out bigger and bigger spheres of confidence and independence, occasionally making mistakes, having things corrected, and learning from them. But in anticipation of making that first leap alone, I have to work on independent thinking, decision-making, risk-taking, and rescuing myself out of trouble. It's a scary prospect but a necessary one as soon I will no longer have a friendly attending checking my every decision.

I will focus on the whole patient experience. It is one thing to be proficient at procedures, a whiz at decision-making, a crafter of perfect anesthetics, and the one everyone wants at an emergency, and it is another thing to have bedside manner. Although I want to be technically awesome, this year I will also work on being the doctor that patients want to see, the understanding face that calms, reassures, teaches, answers, and bonds with honesty, integrity, and confidence. When easing a patient through a tough surgery or hospital stay, I want to address psychological and emotional as well as physical well-being. This sort of learning, I think, happens best with experience, self-awareness, and the right role models.