Hoard

A friend of mine on antiepileptics asked me why physicians only prescribe the exact amount of medication needed. We give a thirty day supply for a month, ninety day supply for three months. We schedule our follow-up visits right before that time's up. There's no leeway for picking up a prescription late or the pharmacy being closed for the holidays or having your physician go on vacation. For some medications like contraceptives, running out of pills is a big inconvenience. For some diseases like seizures, missing a dose is a big deal. It completely incapacitates someone, and once seizures start, picking up a prescription and getting them under control becomes so much harder. Our system also doesn't plan for contingencies like natural disasters. Shouldn't patients have a cache of emergency pills?

From a physician perspective, I'd be happy to give patients an extra week or two in case of an emergency. Other than controlled substances, antibiotics, and medications that can be dangerous in overdose, I don't think there are too many problems in having a few extra tablets. I don't think most patients would abuse this. Perhaps why we don't do this is that insurers have little incentive to provide for an extra week's supply of medications that may never be used. Nevertheless, the insurance against unnecessary hospitalization if someone misses crucial medications might make it worthwhile.

Unusual Cases in Pediatrics

There are many ways of providing anesthesia, and yet, we often get locked into one particular type of anesthetic. It might make sense in pediatrics where children fear needles, deal with pain differently, and distrust physicians. Almost every anesthetic is a vanilla general anesthetic. We manage pain with IV acetaminophen, ketorolac, fentanyl, and occasionally, hydromorphone. But it doesn't always have to be this way. For some painful orthopedic procedures, I decided to put in a spinal for post-operative pain management. We decided to place the spinal awake, which can be harrowing experience for some teenagers. But when I think about it, we often put in epidurals for teenagers having a baby, and they do fine. So I began offering spinal anesthetics to any patient who I think might benefit. Although it is scary to have someone place a needle in the back where a patient can't see, a few older teeangers took us up on the offer, and their anesthetic was incredibly smooth with a great wake-up. It reminded me not to slip into the rut of doing everything by routine, because sometimes breaking out of the norm can really help a patient's experience.

The most interesting case I had during my month on pediatrics was a case booked simply as "extubation in the operating room." Although we had ENT surgeons present, they didn't do anything. A one-month old premature 2kg baby had a repair of a tracheo-esophagela fistula. This was complicated by severe tracheal swelling, and at the end of the procedure, the anesthesiologist felt unsafe extubating the patient. He stayed in the neonatal intensive care unit for several days awaiting the swelling to subside. We then took him back to the operating room. After examining the airway with a tiny fiberoptic bronchoscope and studying his airway mechanics, we decided he was ready and pulled the tube. He breathed independently just fine. It was a great case because it showcased the importance of our decision-making as anesthesiologists. We always think of surgeons as the center of attention, so it's fun when we can bring what we do into the spotlight.

Panel Discussion

I participated as a panelist in the 2014 Innovations in Medical Education Conference down in Los Angeles this weekend. I was part of a breakfast panel sponsored by The American Resident Project (where I also contribute blogs!) where we discussed the relationship between patient safety and health equity. I was joined by leaders in industry, medical education, and academia, and our audience of 60-80 included educators, administrators, community physicians, and residents. We had an engaging, challenging, and lively conversation, and when the session ended, many people still had questions, a sign that the topic was pretty interesting to all.

I don't have a particular expertise in patient safety and health equity, but it's always been an interest of mine. Writing this blog and participating in The American Resident Project have given me extensive opportunities to discuss these timely subjects and interact with thought leaders. We discussed initiatives by health management organizations to combat minority inequity in outcomes, changes in graduate medical education structures to encourage more resident awareness in quality improvement, and the use of interpreters as a case study on how we can overcome language and cultural barriers. As an anesthesiologist, patient safety is something I think about every day, but race, ethnicity, and culture are things I do not regularly ponder. This panel discussion helped me bridge these ideas and focus the spotlight on how we can improve the delivery of patient care. It was a great opportunity to work with brilliant, motivated, and inspiring leaders on an oft-overlooked topic.

Busy Week Coming Up

Hi everyone,

Thank you for reading this blog. I have a busy week coming up with my annual in-training exam and a conference panel discussion, so I'm taking the rest of the week off from writing. If you are interested, I am participating in a breakfast panel discussion at the 2014 Innovations in Medical Education Conference hosted by the University of Southern California entitled, "Equal Care without Safe Care?" We are looking at the role of patient safety in helping to eliminate health disparities. In any case, tune back into this blog next week - I'll have one or two more posts about pediatric anesthesia, then I'll probably discuss some ideas stimulated by the panel discussion.

Craig Chen

Chronically Ill Children

One of the reasons why I decided not to go into pediatrics or pediatric anesthesia is because I have trouble seeing chronically ill children. Although perhaps more "medically interesting," kids with severe debilitating medical conditions are really sad. It can be emotionally exhausting and tough on caregivers and providers to work with these patients who are slow or may never get well. While we all know, have seen, and understand the 90 year old with heart disease, dementia, and debility, seeing a 3 year old who cannot walk or talk is never easy. Unfortunately, this population of children often need a lot of surgery.

I got to know a three year old with a history of seizures and craniopharyngioma quite well. Over my month on the rotation, I took her to the operating room three times for the neurosurgeons to remove an infected VP shunt, place a new one, and adjust it. Neurologic debility in children is devastating. Whereas children with congenital defects in other organ systems may still interact, play, and communicate normally, children with brain tumors, developmental delay, or severe epilepsy can be emotionally tough to care for because they don't make the same bonds. Even older children with neurologic disease have altered relationships. I met a teenager with Lyme disease who had a perfectly normal childhood, but upon developing chronic Lyme, regressed into infantilization.

I saw a lot of caregiver burnout, parents sleeping in the ICUs, at wits end. Working with these patients reminds me that our role as physicians is to take care of the family as well as the child. For any parent, the worst nightmare is taking their child into the hospital for surgery. I held the hand of a sobbing mother whose three year old was bitten by the neighbor's dog who told me that watching us take her injured child into the operating room was the hardest thing she'd ever done. I've gained a real appreciation for pediatric caregivers - anesthesiologists, surgeons, specialists - for their emotional fortitude.

The Changing Face of Medicine

In textbooks, we read about old drugs that are no longer used, and occasionally, attendings will talk about medications that were around when they learned anesthesia. My fellow residents and I always share a glance when an attending reminisces about thiopental, an anesthetic no longer manufactured, or the days of halothane (or for some, even earlier inhaled anesthetics). How quaint, we think, that our teachers know so much about drugs we'll never see again.

But I'm starting to realize, the way medicine changes, I might soon fall into the category of physicians who walk about drugs "we used to use." Back in 2009, I wrote a blog about warfarin. For decades, the blood thinner was used to prevent clot formation and decrease risk of thromboembolic stroke in patients with atrial fibrillation. In medical school and residency, we spend a lot of time thinking about warfarin, reviewing the evidence for its use, stratifying patient risk, checking its efficacy in patients taking it, educating family members and caregivers, seeing its unfortunate complications of hemorrhage, reversing supratherapeutic numbers, and instructing patients on when to stop it before surgery. We have pounded in our head the goal INRs for atrial fibrillation versus mechanical heart valve. We learn its half life, its interactions with leafy greens, its mechanism of action, the way to tweak its dosing (3mg on MWF, 2.5mg on TThSSu).

But soon that all might be unnecessary. Newer anticoagulants, anti-thrombin inhibitors like dabigatran and and factor Xa inhibitors like apixaban and rivaroxaban, may soon make warfarin obsolete. With increasing evidence that its efficacy and complications may make it a reasonable alternative to warfarin as well as significant advantages for patient convenience, they may soon be the preferred agent for atrial fibrillation. I'm sure more anticoagulants are on the market. I can only imagine that in a few years, medical students will learn and read about warfarin as if it were a medicine of the past, a quaint and outdated drug that required close monitoring of INR, adjustment for dietary changes, and the need for "coumadin clinics." They will think me ancient because I spent so much of my training using a drug that's been replaced by something much simpler and safer.

Protecting the Next Generation

There are a lot of things threatening the next generation of children. Those who come after us have to deal with our destruction of the environment, the insolvency of Social Security, threats of nuclear attack and cybercrime. Children now play video games instead of soccer. School shootings make the news. They are surrounded by ads flaunting fast food instead of farmers markets, electronic gadgets instead of books. There are a lot of challenges, and of course many of these things may be less relevant for future generations. But by our values, standards, and wishes, there are a lot of things we do that may hurt them down the road.

I think one of the biggest differences we can make is to combat obesity early. During my month of pediatric anesthesia, I noticed a lot of overweight and obese children. Weight is a topic we all tiptoe around, and if approached poorly, it can cause psychological trauma and emotional scars. We need to uncouple our societal link between beauty and weight. That's not why this is important. Parents, doctors, teachers, and families need to focus on healthy eating and exercise because being overweight can be deadly. After seeing pediatric patients undergoing evaluation for weight-loss surgery or five year olds that have the same weight as a normal ten year old, I've started to raise the topic with parents. No one wants to hear it, and especially not before surgery, but if no one tells a parent or child that they need to stop eating fast food, playing video games, and drinking soda, then the problem will just get worse. As Americans get fatter, they get more heart disease, cholesterol problems, high blood pressure, diabetes, and other comorbidities. Quality and length of life suffer. This needs to be nipped in the bud. A teenager who is a little overweight can still be encouraged to ride a bike and eat fewer chips. But if he doesn't, he'll turn into the morbidly obese man who becomes short of breath with a single flight of stairs, who has no motivation or ability to shed his pounds. Our children are our future. We need to help them before they become like us.

Run of the Mill

So what kind of surgeries do kids get? A lot of my month was occupied by orthopedics. From skiing injuries to bicycling accidents, I had a lot of patients who agonized over choosing the color of their cast (while it was Christmas, we could not convince anyone to get red-and-white-striped candy cane). If the child had a stuffed animal, we'd put a cast, hat, and mask on it as well, which at least delighted parents. We also got a lot of business from ear, nose, and throat surgeons. From ear tubes to sinus surgeries to tonsils and adenoids, much of our days were occupied by fast-moving quick procedures. Children also get general anesthesia for small procedures. I provided anesthesia for many kids getting lumbar punctures, ports removed, dialysis lines, and gastric tubes. For some of these patients, I realized the risk from general anesthesia might have been higher than the risk from the procedure itself, but often general anesthesia is necessary. For the pediatric anesthesiologist, these types of procedures comprise our daily schedule.

Tough Cases in Pediatrics

Pediatric surgeries are often complicated by emotions. While most children manage to avoid the hospital, some arrive here from the worst of circumstances. We mutter to ourselves, "How can we be in a world where this happens to children?" When an adult does something stupid and gets injured, we chalk it up to his foolishness. When something awful happens to a child, our feelings are much more tender. We need to protect our children, not endanger them.

A young child is transferred from an outside hospital with injuries from holding an exploding firecracker. The anesthesia and surgery went fine, but a story like that hits home for me. How, why, what? My mind reels with the range of sad, awful, and avoidable things that happen to the most vulnerable of our society. This is also why I ultimately did not choose to make pediatric anesthesia my career; I just can't keep seeing terrible things like this.

The Flu

The flu is underestimated. It often gets compared with the common cold, a nuisance. But influenza can be a life-threatening or fatal disease, and H1N1 threatens to be that dangerous. At the very least, it's a wickedly symptomatic disease that lands healthy patients in bed with debilitating myalgias. And even healthy patients can't avoid risk; in fact, H1N1 seems to cause the worst pulmonary reactions in young and healthy patients, especially pregnant women. We have had a few cases of influenza in the ICU with patients on extensive life-support, and it's really eye-opening.

In any case, pediatric anesthesia in wintertime means cases are occasionally cancelled for the child with a fever, cough, and sniffles. While I often tolerate minor or improving symptoms, I do cancel cases for the child whose airway is hyperreactive from a respiratory virus. For elective cases, we just don't want to take any risk with children. A single experience with severe laryngospasm is all that's necessary to teach us to respect the sick child and anesthesia.

Independence

While I have been doing adult anesthetics independently for quite some time, doing the same for pediatric cases is a big step. Residency is meant to transition us to independent practice, but it's not that easy. Attendings need to be comfortable with graduated supervision, to nudge us towards flying on our own. In pediatrics, this is especially difficult. It requires a keen awareness, flexibility, and preferably, two extra hands. Kids respond to mask anesthesia in a dozen different ways, some requiring immediate response. Often a single practitioner has to place the IV one-handed, asking a circulating nurse to prepare an arm and darting it in while masking the child. Then, to give IV induction agents and intubate the child. All this may be expected to happen in five minutes. To a seasoned anesthesiologist, this is no big deal, but for a learning resident, it's a lot to manage.

I had a few anesthetics that were completely independent. My attending sat in the back, watched, and gave me feedback. It was hard. If things were not prepared properly, I didn't have an extra set of hands to get things set up. I had to plan ahead, communicate clearly with my nurse, and know what step would come next. But it was always such a thrill when I accomplished everything without the attending getting out of her chair. It gives me confidence that I'll be ready for independent practice when I finish.

Grief and Bereavement

I've always thought it odd that grief and bereavement have medical definitions. We've somehow medicalized the emotional response to loss of a close relationship and the psychological process through which we part with the deceased. A normal grief reaction, apparently, consists initially of numbness, shock, and disbelief. We go through the motions, taking care of funeral arrangements, greeting relatives and friends, and attending to financial matters. But we have not fully comprehended the reality of the death. In the few weeks after a passing, we feel shock, numbness, intense feelings of sadness, yearning for the deceased, anxiety for the future, disorganization, and emptiness. It may even be normal to have visual and auditory hallucinations of the deceased, despair, sleeplessness, appetite disturbances, agitation, chest tightness, exhaustion, and somatic complaints. Rumination on regrets, replaying the final moments, and remembering the relationship is all expected. It's hard to be with others. It's hard to be alone. Grief comes in waves, precipitated by reminders of the deceased, and the grief can be instant, overwhelming, and unexpected. Over months, the intensity of grief recedes. All this is from UpToDate, which also describes abnormal reactions, complicated or prolonged grief, and how to care for the bereaved.

Although I've been skeptical of how medicine can standardize a reaction to the death of a close family member or friend, after a recent passing, I've decided it's extraordinarily helpful. The emotions, reactions, and feelings that come on after a loss are unanticipated, new, immersive, and intense. They are so powerful that we wonder whether this is what happens or if we're over-reacting. We wonder if we're grieving too long, too short, too much, not enough. We wonder if we'll get over the numbness, the emptiness. We wonder if it's okay. We wonder if it will be okay.

Emergencies

There's nothing quite like residency. It's such a remarkably inflexible system with only just the number of residents to cover all the responsibilities of patient care. When an emergency happens, as unfortunately has befallen several times in the last few months, there isn't much room in the system. We work until 4am, take a nap of several hours, drive down to grieving and bereaved family, send a flurry of emails to plan for the clinical week, sleep early so we can drive back to the hospital before dawn. We work as if there is no reprieve, work with the attitude that life will keep hurling obstacles and disasters at us and we will persevere for our patients, families, friends, and the people we love for there is no other end than to do what is right.