The Order of Cases

Here's a very simple operating room scheduling question. If you have several short cases and one long complex case, how do you order them? If you start with the long case, you can tackle the difficult, challenging surgery first. If additional resources are needed; for example, if the surgeon got into trouble, it's easier to deal with that during the daytime than the nighttime. But leading with the complex case means that if it is cancelled for any reason, then there's a big gap that will be hard to fill. If the case is unpredictable in timing, there could be a big delay for the subsequent patients. The opposite, to start with the predictable short cases and follow with the long case gives more predictability to the day, but it means the surgeon might be tired when he needs to be most attentive. Staff who work on shifts such as nurses, and in some cases, anesthesiologists, may change half-way through the long case if it starts in the afternoon.

In reality, there doesn't seem to be any steadfast rule about booking cases. Sometimes, surgeon preferences are honored. Sometimes, patient preferences are acknowledged. But when things get canceled, delayed, or changed, we start thinking about how to make this process a little more efficient.

Room Utilization

The scarcest resources in a surgery center are the operating rooms themselves. Surgeons are always itching to operate, patients want their elective cases done, and you can hire more anesthesiologists and nurses. But rooms are a fixed resource. That's why room utilization is such an important concept in operating room management. After you determine how long each room is going to be open for, you have to fill those rooms with cases. If those cases finish early, the room is under-utilized, and staff expecting to work will have nothing to do. If those cases finish late, the room is over-utilized, and you have to pay overtime and deal with staff morale. So the optimal utilization of rooms is a big deal.

Predicting utilization is really, really hard. Different specialties and different cases have varying levels of predictability. For example, a seasoned cataract surgeon can probably get her utilization optimized fairly easily. A general surgeon who only does large bowel resections will have trouble. Not only are bigger cases more variable in their timing, but they are also harder to slot into block time. That is, if a general surgeon is allocated 8 hours of block time in an operating room but has a 6 hour case, if he does not find a 2 hour case, he will under-utilize the room.

Predictability is important as well. A surgeon may vary on how long he takes to do a specific operation, and different surgeons will vary on how long they take to do that operation. Furthermore, this distribution of case duration is not a normal distribution on a bell curve; rather, most cases will cluster together but the average duration will be pulled up by a few outliers of very difficult or complicated surgeries (such as laparoscopic procedures that have to open). Other problems with this view of OR management is that utilization doesn't necessarily correlate with revenue; a cardiac surgeon may underutilize his block time but make a lot of money for the hospital; utilization shouldn't be a surrogate for optimization of profit.

The problem with utilization is that in order to optimize it, we might want to take away block time from a surgeon who is underutilizing his room and give it to a surgeon who is overutilizing it. This might encourage slow surgeons to remain slow, hoping to get more time, and fast surgeons to slow down, afraid they will lose their time. They may also alter their predictions of case durations; by predicting that they will be faster, they can book more cases. Optimizing utilization means we have to have the data to predict how long a case will take; however, there are thousands of different surgeries, and unless a particular procedure is done frequently (like cataracts or cystoscopy), there will be a lot of unknowns with infrequent surgeries.

All of these variables come into play in real life operating room management, and my two weeks as the ambulatory surgery scheduler gave me a glimpse into this strange world. In medicine, everything revolves around the patient, but in management, everything revolves around efficiency and money.

Ergonomics

Hand-in-hand with the last post, I had an ergonomics evaluation as much of my musculoskeletal strain is from poor posture and mechanics. We spend so much of our time in front of computers, at workstations, doing repetitive motions, but we rarely think about how this affects our bodies. Especially when we are young, we are just unaware, and over time, the toll of tension adds up. I was thoroughly humbled by the ergonomics consultant. Now I adjust my anesthesia workstation first thing in the morning. I change the level of my keyboard, the height of my chair, the position of my monitor. I watch how I push gurneys, move patients, even hang up IV bags. After lifting thousands of one liter IV bags over my head, I've finally learned how to do it without over-exerting my trapezius muscles. So much of what I love about anesthesia is procedural, and ergonomics are important. I'm developing awareness of my posture during laryngoscopy, how I hold the ultrasound probe, how I access my medication cart. I wish I didn't have to think about these mundane aspects of everyday work, but if I don't, I regret it.

Physical Therapy

I have been getting physical therapy for some musculoskeletal injuries, and I've been pleasantly surprised. As a medical student and resident, I always valued physical therapy but I never really appreciated it. I ordered it for most of my patients, especially elderly patients who needed assessment, evaluation, and treatment for ambulating safely. I always signed the orders for the physical therapist's recommendations. I was always pleased to see them working with my patients in the hallways.

But I never really got what physical therapy was. Now that I need it myself, I find it incredibly therapeutic. Physical therapists understand the body and movement in a way doctors don't. Unless we study rehabilitation medicine or sports medicine, we don't fully appreciate how the musculoskeletal system works. As an anesthesiologist, I am enamored by the core organs, the complex and fascinating ones. As a patient, I'm starting to understand how complex and fascinating muscles and movement can be. I learn from my physical therapist those muscle groups that are affected, how to strengthen weak muscles to counterbalance overactive ones, how poor posture reinforces muscle tension, how stretching and stress and strain interrelate. I am truly understanding their role as health providers.

Different Anesthetics

Another responsibility of the ASC scheduler is to give breaks for solo attendings. We relieve them for breakfast and lunch breaks. In doing this, I noticed a lot of unusual, even eccentric anesthetics. They were fine; they got the job done, but it was interesting to see the variation in practice. Every anesthetic decision has advantages and disadvantages and I found it enlightening to see what priorities solo attendings had. Anesthetics can focus on cost, efficiency, quick turnovers, convenience, nausea prophylaxis, post operative pain management, a guarantee that the patient has absolutely no recall, or a dozen other factors, and many of these are exclusive goals. Some anesthesiologists practice how they were trained decades ago. Some are trying newer techniques. But after being in medicine for several years, I know that such variation is common practice.

PACU Emergency

As the scheduler for the ambulatory surgery center, I also respond to emergencies. I've had calls for help for difficult airways, tough IVs, and challenging inductions, but I learned most from a PACU emergency. A patient after an abdominal surgery has increasing amounts of pain. After giving the maximum allotted fentanyl and hydromorphone, a PACU nurse notices his patient is still moaning in pain and tachycardic. I am paged to evaluate the patient. His heart rate is 130, his blood pressures are dropping, and he is incoherent and moaning. This is not normal post-operative pain. One look at the patient, and I knew he was in extremis. I quickly called for help, increased frequency of vitals, put him on a nonrebreather face mask, and started pouring in fluids. Examining the patient, I noticed that his abdomen was quite rotund, and he looked very pale. Within moments, I recognized this to be a surgical emergency. There was bleeding in the abdomen. The patient would need to go back to the operating room.

Resuscitation in the operating room is one thing. We learn that quickly. Anesthesiologists take control, open IV fluids, call for blood, prepare emergency medications. We obtain additional access, insert an arterial line, alter our anesthetics, control the airway. But here, the beast has changed. I needed to be a leader. I directed nurses to put in additional IVs, get fluids, check labs, call for blood. All the things I would normally do, I instead delegated. As the ASC scheduler, I had to plan ahead.

My next step was to call the surgeon. They needed to evaluate the patient and determine if it was surgical bleeding needing reoperation. Though I was convinced, I needed them to cut. Then I had to identify an operating room. I scanned the board, found a room in between cases, and told them to prepare that room for a stat exploratory laparotomy. I had to work with the nursing staff to get a nursing team. I had to figure out my anesthesiologists. Since I didn't have that many available, I ended up starting the anesthetic myself. A lot of other players were contacted: pharmacy, blood bank, the lab. I didn't know if this would require a massive transfusion or fancier resources like interventional radiology or a trauma surgeon. I had to mobilize everything just in case.

The biggest thing I learned, though, is that I had to do this while wearing the hat of ASC scheduler. I continued to be called for routine inquiries. I had to manage the other rooms. I had other surgeons, other add-ons, and other requests bombarding me. In the end, we rushed the patient back to the OR, induced anesthesia again, found a bleeder, and successfully resuscitated the patient. When an emergency like this happens, leadership is critical to patient safety.

Simulation

As part of our education, we participate regularly in simulation exercises. I remember my first simulator experience; I felt out of place, anxious, and unsure. Simulations are essential to anesthesia training because they test rare yet critical diseases, reactions, and situations. It's possible to go through residency without seeing anaphylaxis but very likely that we will see it during our career. While it is easy to study and prepare for diseases like anaphylaxis, some situations like power failure or mass casualty trauma are much better learned through hands-on practice.

This last simulation, at the end of residency, we were thrown much more challenging situations, ones that pushed our medical knowledge and technical ability. But even more importantly, these simulation exercises forced us to take leadership, adapt to changes, work as a team, and manage a crisis. The real value of simulation is in developing this skills that aren't easily gleaned from a textbook. When I think of my education, I do think most of it happens at the bedside, but I'm glad our program recognizes specific aspects that are best taught with other methodologies.

Making the Schedule

Twice a day, I sit with the main operating room scheduler and go over the cases and staffing. It feels like a logic puzzle trying to fit everything in. Case 1 can go after case 2 but only if case 3 is done and case 4 doesn't go too long. A lot about scheduling is understanding patients, surgeons, and anesthesiologists. For example, I will try to schedule pediatric cases first thing in the morning because I don't want a child to be fasting too long. But I also have to keep in mind that only some anesthesiologists are willing to do pediatric cases. Some surgeons run two operating rooms, and we have to stagger them so one doesn't delay the other. Some surgeons have a half-day clinic. Other surgeons have a full schedule of cases but want to follow with an add-on. Some surgeons request particular anesthesiologists, and some anesthesiologists like to focus on particular surgeries. For the most part, we use historical data to plan our rooms; what worked last Tuesday is liable to work this Tuesday, but it still feels like a mess of moving parts.

Despite our intricate planning, everything gets jumbled on the day of surgery. We try to slot in any urgent or add-on cases. I review them to make sure they are appropriate for the ambulatory surgery center. Add-ons change the late rooms which can affect nursing and call staff. I also realized that everything takes longer than expected. If I have an hour gap in the day, I cannot schedule an hour-long add-on; things never fit that snugly, and the add-on will delay everything that follows. Not only do I need the surgeons, anesthesiologists, and nurses, but I also have to account for the time it takes for the patient to come from the floor or emergency department, the equipment needed, the recovery room staffing, and the paperwork. As the day proceeds, some rooms run early and some run late. Patients may be stuck in traffic or surgeons may have a long clinic. I deal with equipment delays and mediate conflicts. I learn to be fluid and dynamic in running the operating room because even the best-laid plans get wrecked by an unanticipated minor change.

Scheduler Rotation

Senior residents are assigned to a two week perioperative scheduler rotation at our ambulatory surgery center. Designed to give us experience in operating room management, assigning cases, resource allocation, and interprofessional leadership, it's a rotation unlike any other for us. Under the guidance of the main operating room scheduler, we are the point person for the ambulatory surgery center. We carry the phone, determine how to accommodate emergency and add-on cases, manage delayed rooms, respond to emergencies, and assure that all surgeries in the 12 operating rooms run smoothly.

I arrive at 6:30 and pick up the phone and schedule. I map out how the day should look; after working with these surgeons for nearly four years, I know which surgeons are faster than expected and which are slower than expected. I look at the physicians I have on call and make a plan for how the day will unfold. Some anesthesiologists need to get to labor and delivery night call, others need to leave early, others have meetings, and some can't be in rooms with radiation (due to pregnancy). I also manage the residents in the ambulatory surgery center; I try to get them high-yield educational cases, relieve them for lecture, and supervise their case starts. I take a look at the add-on list and see if any cases are appropriate for the ambulatory surgery center. Though it's more work for me and my anesthesiologists, I try to offload cases from the main operating rooms because any true surgical emergencies would go to the main. As I carry the phone, I am available for emergencies, anticipated challenging case starts (such as pediatric cases), and PACU crises. I eat a hearty breakfast because once the day gets going, I may be running around nonstop.

Weekends and Difficult Airways

Anesthesiologists plan for worst case scenarios. I've written about this a lot in this blog, but our concerns don't revolve around cases that go smoothly; we worry about that exceedingly rare case that goes bad. In these situations, anticipation, planning, resource management, and crisis response can make the difference between life and death. During weekdays, we have a lot of resources at our disposal. There are a lot of anesthesiologists, technicians, nurses, pharmacists, surgeons, and other providers who can help out in an emergency. But on nights and weekends, the operating rooms can feel like a ghost town. What happens if something goes bad, and you're the only provider around? Your nearest help may be the ICU or code team or ED, physicians that are unfamiliar with the operating room environment. I think about this, and my setup differs whether I'm on call at night or doing routine cases during the daytime.

One Saturday call, I had a patient with a bad tooth abscess causing an infection of the floor of the mouth. She could barely open her mouth, was having trouble breathing, and drooled uncontrollably (as any pediatrician can tell you, this kind of drooling doesn't bode well). I wanted to secure her airway while she was awake, a task that is simple enough when it goes well but can go horribly wrong if she stops breathing. On a weekend, I asked for and set up my difficult airway cart and multiple backup supplies. I walked my attending, nurse, and technician through what I would do in every imaginable situation; if she was not sedated enough, if she was too sedated, if she became agitated, if her oxygen dropped, if her vocal cords closed. I prepared myself and the team more thoroughly than I normally do because I knew that in an emergency, these would be all the players, and I depended on them. The case went very smoothly, and we all had a lesson in what happens if you never brush your teeth.

The following case was an emergency eyeball. A patient with retinal detachment needed immediate eye surgery to preserve vision. Nothing on the pre-operative evaluation clued me in that this would be a difficult intubation. I planned my anesthetic, tailoring my medications to protect the eye. But when I put the patient to sleep, I couldn't see the vocal cords. I calmly tried a different laryngoscope blade and couldn't see anything again. But I was stuck; most of my difficult airway supplies were being cleaned and turned over by our technician because they were taken out for the previous case. I asked the nurse to call for a video laryngoscope, but because it would take time to arrive, I decided to attempt a blind intubation. I knew where the vocal cords should be, and without seeing them, I gently snuck the endotracheal tube in. I was a little surprised when it worked out, and when the technician rushed my video laryngoscope into the room, I didn't need it.

Early on in my residency, I had situations where I couldn't see vocal cords, and I would immediately hand the case over to my attending. They would inevitably sneak the tube or an exchange stylet in. Occasionally, when I asked what they saw, they would say, "Very little" or "Nothing." That validated my laryngoscopy technique, but I was always impressed. How do you intubate someone blindly? Although experience, practice, knowledge of anatomy, and a delicate feel all contribute, the attending would say that when you have to secure an airway, you do it. The buck stops with the anesthesiologist. When my back is against the wall, the motivation is that if I don't breathe for the patient, he will arrest. Anesthesiology is about planning for and avoiding these situations, but they will happen, and when they do, you step up. For this patient, I knew exactly how that felt, and that's how I managed a blind intubation. My heart was pounding. Of course I could have handed it over to my attending, but then I wouldn't have progressed from the junior resident I was two years ago and I wouldn't be ready for independent practice in a few months.

Always Learning

As the end of residency starts becoming a reality, I think of my last few months as opportunities to learn as much as I can. After July, the next time I'm in the operating room, I'll be by myself. In this way, I think that it's great to have a few months in the general adult operating rooms doing a hodgepodge of cases. Every day, I have a new mix of anesthetics, similar to what I might encounter in the private practice world. From robotic gynecologic cases to parathyroidectomies to hardware removal to dermatologic tumor excisions, I've become quite comfortable with being thrown something new every day. I've noticed that I'm much more independent in coming up with an executing an anesthetic plan and that I rarely need to invoke my supervising attending.

Nevertheless, it's important to keep learning. One very fun and fascinating anesthetic I'm learning is the adult inhalational induction. Although we routinely do inhalational inductions in pediatrics for children who won't let us place an IV, we rarely perform it in adults. Almost always we can place a pre-operative IV, and an IV induction is quicker. But there are those exceedingly rare cases where we cannot obtain IV access and choose not to place a central or intraosseous line. In the same way that we cannot translate adult medicine to pediatrics, we cannot simply apply the principles of pediatric mask inductions to adults. But with the help of an attending who used to do these routinely, I've learned the very slow, stable, and surprisingly reliable process of putting someone to sleep by mask. I've learned how to minimize risks and avoid dangers, and it's been amazing. I've intubated patients with nothing but sevoflurane and kept them spontaneously breathing after intubation, all with amazingly stable hemodynamics. True, the anesthesia is quicker with propofol and muscle relaxants, but residency is about adding more tools and techniques to one's armamentarium. This has taught me there are a lot of different and safe ways of anesthetizing a patient.

Strange Cases

Sometimes as a senior resident, you get unusual assignments. One day on general adult anesthesia, the scheduler asked me to take care of an add-on case. The add-on case was "placement of orogastric tube for upper GI radiologic study under general anesthesia." This in itself was bizarre; these cases almost never require general anesthesia. As I dug deeper, the situation got trickier. The listed location was "GI radiology, end of hallway." I found that we last provided anesthesia in GI radiology over five years ago. After talking to the anesthesia technicians, I managed to get a machine, cart, computer, and medications to the procedure room. I had to contact the radiologist performing the procedure and figure out the story. The patient was a young gentleman who had chronic abdominal pain and nausea ever since childhood. He'd had many abdominal studies and surgeries but no underlying cause was found. After a week of hospitalization with intractable pain and nausea, the GI consult team wanted to look at his peristalsis, the coordination of his digestive tract in moving food along. However, the patient refuses to have placement of a gastric tube while awake due to his severe pain on swallowing. While we considered doing this under sedation, he is at high risk of aspiration and had a high tolerance to opiates and benzodiazepines. Although a little extreme, after a long discussion with the patient, we decided to give him general endotracheal anesthesia for placement of a gastric tube, instillation of contrast, and GI films. The case went very smoothly, but it always bothers me when the anesthetic is more risky than the actual procedure. Nevertheless, we determined that it was the best course of action. I learned quite a bit about working in the hospital system as I navigated the process of getting an unusual case done.

Retreat

Each year, our program organizes a retreat for all the residents at Lake Tahoe. We are relieved from our clinical responsibilities Friday afternoon and return by bus on Sunday. For that weekend, we have no clinical duties and we bond with each other on the ski slopes and over delicious meals. The department puts us up at a fancy resort and pays for additional faculty to cover the operating rooms. It's always a blast.

I write this blog because I'm truly grateful to be at my residency program. Although we work hard and we have tough and challenging days, we are really appreciated. When I talk to attendings who cover that weekend, I realize that we make up an integral part of the anesthesia infrastructure and when we are gone on our retreat, everyone appreciates us a little more. It's wonderful, though, that our department is so liberal in having us enjoy ourselves because resident well-being is gaining more and more attention these days. While a weekend off like this certainly helps prevent burn-out, we also bond with each other closely, building our peer support structure. I've had the most amazing co-residents, and I will miss them after we graduate this year.

QuantiaMD

I don't make too many plugs for other websites, but I've been using QuantiaMD for a while now and I really like it. Designed for clinicians (unfortunately, you need an MD, DO, PA, or NP degree to sign up), it's a community based around the idea of continuing medical education. They have short presentations, interactive cases, practice management reviews, image challenges, and other great 5-10 minute videos. In any case, check it out: QuantiaMD. Full disclosure - this link does count as a referral for me.

Intravenous

One of the most basic steps of being admitted to the hospital, undergoing surgery, and presenting to the emergency department is the placement of an IV catheter. Routinely performed by nurses, only a few physicians do this regularly, most notably, anesthesiologists. I remember as a medicine intern being called to place an IV when I knew the nurses who attempted it were much more experienced than I. Yet now, this has changed; I commonly go and place IVs in situations where no one else can get access.

Nevertheless, sometimes even anesthesiologists are thwarted. I heard of an overnight urgent case recently where no one could obtain IV access. A dehydrated drug user with widespread skin and muscle infection needed debridement and had no IV. What do we do in such situations? When I encounter a difficult IV, I sometimes ask patients where they usually get blood draws; IV drug users usually know what areas work and what areas are too scarred to attempt. I also go for a set of rarely used veins; wrist veins, though sensitive, are usually enough to get someone to sleep. Foot veins, deep brachial veins, and external jugular veins all require a bit of skill to cannulate, and so they are often virgin sites. More recently, I've started bringing in the ultrasound early; I've had a couple great successes finding targets invisible to the eye but plump under ultrasound. I don't do a lot of things I've seen others do. I don't slap the arm to make the vein angry; I rarely warm up the arm. While both techniques may help, I don't find them incredibly effective, and slapping someone seems a little mean and the warm towel trick takes a while to work. My favorite trick is to give a little inhaled anesthesia which can dilate the veins. However, this is very limited in scope because I'd only do an inhaled induction in the right candidates under the right circumstances. Having an emergency without IV access is disastrous.

When most anesthesiologists (and physicians) fail to find a good vein, we usually go to the central line. Under ultrasound, most internal jugular and femoral targets can be cannulated. As long as there isn't scarring, infection, or anatomic abnormalities that preclude central line placement, it's usually pretty reliable. Although not incredibly comfortable to an awake patient, they can be made tolerable and are a great backup. Few of us think of the intraosseous line, and I've never placed one outside of simulation and practice. By drilling a needle directly into the bone marrow of a large flat bone, we can infuse IV medications. This is a painful last resort, but it has some advantages. IO needle placement is incredibly fast and can infuse as rapidly as a large bore catheter. I'm sure some day in the future, I'll need to consider it as an option.