Finishing Things Up

My last three cases of residency are quite interesting. One of them was a surgery I'd never seen before: a robotic-assisted distal pancreatectomy. It's interesting to think of surgical techniques as evolving over time because it means that someone has to try something new. The change from laparoscopic to robotic approach is not a dramatic difference and robotic approaches are used in similar surgeries, but it is still interesting to be involved in one of the early operations. Although it took quite long, everything went very smoothly. The anesthetic management isn't too different, but positioning the patient to accommodate the robot is an interesting puzzle of spatial configuration.

The following day, I was called for an emergency craniotomy in a patient who bled into his skull and was herniating his brainstem. This is a life-threatening emergency. I rushed down to the ICU and helped wheel the patient into the operating room. He was already intubated but his access was limited. We didn't have time to put in a central line, and I knew that decompressing his skull was the priority. We turned him prone (onto his stomach) and I managed to get two 18 gauge IVs into his feet. It's was definitely necessary because he needed platelets and blood transfusions. The surgery gave me a realization that I am pretty ready to graduate. Although it was a sick patient who was imminently dying undergoing a large neurosurgery, I knew what my priorities were. There is a lot to do: prepare for pinning of the skull, hyperventilating the patient, starting mannitol, determining an appropriate anesthetic in a patient who was altered to begin with, sending off an ABG, ordering blood, wrangling the ICU drips, decide on the appropriateness of hypothermia. It will be a tough recovery for the patient, but we did what we could for the anesthetic to protect the brain.

Tomorrow, I have a patient with severe ischemic heart disease and an ejection fraction of 15% (normal being around 60%). The heart is a failing pump, and designing a gentle anesthetic is a challenge. We'll see how it goes.

Choosing a Specialty

I recently got a great comment from a medical student interested in anesthesia but concerned about the future of the specialty. There is a worry that with independent nurse anesthetists and the development of big business in medicine, anesthesiologists may have a loss of independence, longer hours, and lower salaries. How does someone contemplating a medical specialty factor in these uncertainties into their decision?

I have no crystal ball and have no idea what the future portends in anesthesiology, any other specialty, or medicine in general. Even more, I don't think anyone does. There are many instances in the last few decades where very smart people have made very wrong predictions about medicine's future, changes in supply and demand of the workforce, and the economics of medicine. In fact, within this field, an incorrect prediction in the mid-90s that supply would exceed demand led to a shortage of anesthesiologists.We went through a spell when residencies didn't fill, and jobs were fighting to hire any anesthesiologist. Today, the pendulum has swung to the other side; we have become one of the more competitive fields and the job market isn't wide open. But I've also read predictions that surgical volume will continue to increase, and the demand for anesthesiologists will grow in the future. I honestly don't have the background or skill set to guess what will happen on the business side of things.

When I talk to medical students about this issue (or to undergraduates contemplating medicine as a whole), I have a particular take. I put in the caveat that I have managed to pay off my debt, that I don't have a lot of financial obligations, and that money was never a particular priority. I also don't mind putting in the hours, and I'm generally content wherever I am. If I had the chance to redo everything, I would go back into anesthesia here at Stanford in a heartbeat. I love what I do, I am privileged with the opportunities I get, and I live a very happy life.

But I get the concerns prospective residents have. It's a big commitment, a long road, a lot of work, and the payoff is not monetary. These days, it's not even social status. There used to be a lot of respect given if you were a doctor; where I am, though, it's not a big deal. Medicine has changed; a well-respected occasionally-lucrative specialty two generations ago, it has now lost that appeal.

To those looking at anesthesia in particular, I feel that you have to be okay with long days and hard work. We will see more and more surgeries in the future in patients who are older with more comorbidities. There will be more complex and innovative procedures - today, I was in a robotic pancreatectomy - and we're seeing more out of OR anesthetics in places like interventional radiology. The anesthesiologist's life will not get easier. There will also be a bigger push for things like efficiency and throughput, which might feel constraining on our specialty. Furthermore, pay will not increase; with the huge spotlight on the cost of medicine in America, it's unlikely that Medicare's poor reimbursements for anesthesia services will change. Along the same vein, independent practitioners like nurse anesthetists may encroach upon our specialty. And there are other downsides - patients don't consider us "their" doctor, malpractice insurance can be exorbitant, and larger anesthesia groups are slowly absorbing the older partner model.

Nevertheless, anesthesia is a specialty unlike any other. The things I love about what I do are timeless. Patients come in anxious, terrified, at a crossroads in their life. Though brief, the interactions I have with patients endear them to me, and for some, endear me to them. It can be an intense time for them, and you become their lifeline. Anesthesia is the only specialty where you act as a physician, pharmacist, and nurse all at once. We get immense instant gratification in what we do. We have to multitask in acute situations. We have to be adept at procedures and familiar with every disease state. Other physicians turn to us in true acute crises, and we get that adrenaline, excitement, and terror when a life-threatening situation arises. I love all of those things, and I don't know that many other jobs have the same milieu. Will all that excitement fade away? Perhaps but perhaps not. I think that most physicians who are burnt out and regret going into medicine have lost that magic in what they do. But I also see plenty of physicians - mostly my mentors and teachers here - who are excited and thrilled to go to work every day.

There is no perfect specialty, but certainly some are more suited for particular people than others. I am lucky to have made the right choice for me, and I wish the best for those trying to figure out their life paths. I hope this blog helps.

Gradient of Anesthesia

Although we learn a lot from our textbooks, mentors, and lectures, we're at a stage in life where we develop our own theories, hypotheses, and concepts about things. Over the last four years, my understanding of anesthesia has changed simply from my experiences with it. I've not read this in a textbook or review article, I've never seen it in a lecture, but I've developed a concept of anesthesia where its a gradient of neurologic quiescence. That is, for me, anesthesia is not a black-and-white on-or-off state. It's not a switch we activate and deactivate. It's not a binary brain characteristic. 

This is not how most people think of anesthesia. Although simplification probably makes things easier, textbooks, insurance companies, surgeons, and patients often think of anesthesia as sedation ("monitored anesthesia care") versus general anesthetic. Patients expect "twilight" sedation for a colonoscopy. They expect to be "completely asleep" for brain surgery. When I talk to patients, I often use these distinctions.

But I'm not sure I buy it. Instead, I think of anesthesia as a gradation of varying consciousnesses. I can achieve a state of anesthesia where a patient will respond and talk during the surgery but remember very little of it. I can achieve a state of anesthesia where a patient's EEG is asleep and I don't expect the patient to remember anything, yet she is breathing on her own without ventilatory support. I can achieve a state of anesthesia where the brain is asleep and the patient doesn't breathe, but if they feel pain, their blood pressure and heart rate will rise. I can achieve a state of anesthesia where the body knows nothing; a surgeon can make an incision and the vitals don't budge. All those states are very different, have different risks, require different medications, and have varying level of difficulty in management. Some are required for particular procedures. Some are better for specific patients. All these variables play into the "art" of anesthesia.

Ending in the GOR

I am finishing my last two months of residency in the general OR. In some ways, it's nice to return to the start. These are the attendings and cases that taught me anesthesia, and now, I can be completely independent and hardly break a sweat. Although the cases are challenging, I feel very well prepared to take them on. A man who is 5'11" and 400 lbs undergoes a kidney surgery. The intubation, extubation, and anesthetic management are all up to me. Morbid obesity once scared me because of the significant risks for airway loss, prolonged anesthesia, and PACU complications, but with the training I've gotten, I felt confident about handling this case. A pregnant woman in her second trimester needs an urgent abdominal surgery. I plan an anesthetic taking into account the physiologic changes of pregnancy, using an EEG monitor to titrate my anesthetic since the requirement is lower and I want to minimize exposure to the fetus. Talking to the obstetrician and surgeon, we decide on a plan for fetal monitoring and what to do if obstetric issues or problems arise. Although I get a surge of adrenaline from the airway, I manage to slip a tiny 6.0 tube through the vocal cords. It's an exciting case, and it's also a regular day in the operating room.

Lethal Injections

Here's the ethical conundrum. There have been some instances where people being executed under the death penalty suffered unnecessarily due to problems with the lethal injection. IV placement and administration of the medications is usually done by personnel who have no medical training at all. When something goes wrong - from something as simple as IV infiltration to miscalculation of doses to a lack of understanding of the drug mechanics - people die in awful, agonizing, and unconscionable conditions. This problem has been compounded by the fact that a lot of drugs have had shortages or been restricted from use for executions; some manufacturers won't allow prisons to purchase their drugs (in my opinion, rightly so).

Executions could potentially be much less likely to go wrong if a medical professional were involved. In particular, anesthesiologists have a deep understanding of drugs commonly used for this instance: benzodiazepines, barbiturates, muscle relaxants, potassium. As I read articles about lethal injections, I am shocked by the lack of nuance and understanding of dosing. One protocol uses 10mg of midazolam and pancuronium. That does of midazolam may be sufficient for a drug-naive person, but for a heavy drinker or drug user, that would not guarantee amnesia. That cocktail doesn't even incorporate a quick and painless death. How can we put someone to death under our legal system in a fashion where they may feel paralyzed, suffocating, pain, and misery?

The American Medical Assocation and American Society of Anesthesiologists are very clear on this matter. As physicians and with the Hippocratic oath, there are no circumstances in which we should involve ourselves in the execution of people. Even if we could relieve suffering in those last moments of a inmate's life, we would be going against our oaths. There is no place for medicine on death row.

For me, this is an ethical quandary. I would not feel comfortable standing by if someone were suffering and I had the knowledge and means to alleviate their pain. But in looking at this issue, I think that if we were to involve ourselves with lethal injections, we would be missing the bigger picture. Involving ourselves in this matter is to become passive tools of a justice system that puts people to death. We may be helping an individual inmate, but we would be relinquishing our autonomy as physicians. Instead, we need to influence things at a systems level, in the political arena. If we feel that death penalties are unethical, we need to work on changing it. If we feel that death penalties have a place, we need to argue for systems changes to prevent unnecessary suffering and pain.

The Need for Multidisciplinary Medicine

Gone are the days of the giants of medicine who could master everything. There used to be a time when the undifferentiated physician could do it all - deliver babies, look at urine specimens under the microscope, perform an appendectomy, diagnose pneumonia, administer sedation. But modern medicine is too complex, too big, too nuanced for anybody to know everything in it. We spend years training in residency to become proficient in knowledge in our one small field, surrendering to the fact that we won't be generalists anymore.

I became very aware of this working with surgeons in the CVICU. I have a great respect for cardiothoracic surgeons. They not only master the technical skills involved and perform long, high-intensity operations, but they also have a good knowledge of cardiovascular medicine. Surgeons can look at echocardiograms, understand pathophysiology of disease states, manage pressors. But, I realized, this is not their focus. Surgeons alone cannot run the unit.

As an anesthesiologist, I spend the bulk of my time pondering vasopressors, echocardiograms, physiology, and pharmacology. While the surgeons make delicate decisions about where to cannulate the aorta, I am experimenting with, learning, and understanding the medical management of these patients. In the CVICU and particularly with complex patients, a multidisciplinary approach is absolutely necessary. The surgeon knows exactly what the operation entailed, but his decisions about vasopressor or ventilator management won't be as nuanced as mine. Likewise, I can manage coagulopathy, but if the bleeding is a surgical vessel that needs to be clipped or tamponade that needs to be evacuated, I can do nothing.

Over the month on the CVICU, I learned to trust my training, instincts, and judgment. I've learned the value of the team, of keeping everyone on the same page, of listening to each person's input, and of taking that person's background and training into account. None of us can be masters of everything, and patients benefit most when experts in different areas collaborate.

Nurse Practitioners

Luckily, the CVICU team has a great group of nurse practitioners who help us out. These are some of the best NPs I've worked with as a medical student and resident. Some have been with the CVICU for a long time. There is always a nurse practitioner on during the daytime, and one on nearly every night. They share the patients with the residents and fellows, helping to balance out the workload.

Working with an advanced nurse practitioner is interesting from the perspective of a resident. I have come to admire, respect, and appreciate their training and strengths as well as recognize some of their limitations. They are staples in our system, providing grounding by being there all the time; the surgeons and nurses like them, they know how to manage common situations, and they can act independently. Most importantly, they can get things done. They know how to expedite radiology studies, contact the surgical chiefs, meet protocol parameters. We help each other all the time, whether with making decisions, interpreting data, performing echos, managing emergencies, and getting through the long nights. They are an essential part of the team.

Challenges in the CVICU

The CVICU really puts a resident or fellow's abilities to the test. Over the last four years, I've seen a lot of tricky clinical situations, but none were like the month taking care of post-operative cardiothoracic patients. I've given quick clinical vignettes for the last few blogs, but a few more stand out in my memory. A patient who underwent an "elephant trunk" aortic arch replacement was in cardiogenic shock. He was at maximum doses of epinephrine, milrinone, and vasopressin as well as 1:1 support of an intra-aortic balloon pump. He had an open chest; during his surgery, each time the surgeons tried to close the chest, he became extremely hypotensive, so they put a dressing over it but left the sternum open. When I was on my week of nights, he became frighteningly hypotensive, with augmented blood pressures of 50/20. I wasn't even sure how to code this patient; his chest was open, how could you do compressions? Would you open the dressing, don on sterile gloves, and manually squeeze the heart? In a desperate attempt to advert a code, I gave a large bolus of epinephrine and vasopressin and managed to resuscitate his blood pressure.

A patient awaiting heart transplant had placement of a ventricular assist device for nonischemic dilated cardiomyopathy. His heart was always in atrial fibrillation, beating irregularly, often too rapidly. Whenever he went into rapid atrial fibrillation, his blood pressures plummeted, and he got gram after gram of amiodarone in an attempt to keep his rhythm sinus. Often to keep his hemodynamics stable, we had to shock him. This patient taught me not to be afraid to use electricity to keep a heart in line.

A patient after a routine heart surgery develops refractory hypotension at 5 in the morning when I am pre-rounding. Putting an echo probe on him and examining his central venous pressure waveforms, I recognize that he is going into cardiac tamponade. Blood is filling up the space around his heart, compressing it, and rapidly killing him. I drop everything else I'm doing, activate the operating room, and wheel him back as I dose epinephrine. I stay until the surgeon evacuates the blood and the patient's blood pressures normalize.

Late at night, I scroll through the electronic medical record, scribbling down and calculating cardiac outputs and systemic vascular resistances trying to clarify a mixed picture of cardiogenic and septic shock.

Post-call, I break out of rounds to throw in a dialysis line quickly so the day team can continue seeing patients while I try to rescue a patient from developing pulmonary edema.

At the end of the month, I gained so much more confidence in my medical decision making. When faced with a rapidly changing, highly complex clinical situation, I learned when to rely on my instincts, when to stop back and question my assumptions, when to act, and when to think. This is what medical training is about.

Succeses in the CVICU

As a high-risk high-stakes environment, the CVICU has its setbacks, but also its triumphs and successes. A man with severe interstitial lung disease gets a bilateral lung transplant. The lungs have had a significant ischemic time and aren't all that great; nevertheless, the patient needs them; he's on 6 liters of home oxygen and feels short of breath all the time. Furthermore, the operation is complicated by a need to emergently crash onto bypass because of bleeding on entering the chest. All of these portend a very rocky course, and indeed, the patient had a long ICU stay. Weeks on the ventilator made him incredibly weak, yet he was very motivated to get better. By the end of the month, he was walking with physical therapy while on a ventilator, and when I checked back after the rotation, he had successfully rehabilitated off breathing support.

A young man with a history of rheumatic fever collapses in a mall. He is rushed in and a diagnosis of acute mitral valve rupture is made. He is near death, requiring code doses of epinephrine. Rushed to the operating room, he undergoes a mitral valve replacement. His heart has suffered such an injury that he is put on ECMO while the heart recovers. A machine takes over the job of the heart, circulating the blood in his body, while his heart recovers. To transition him off ECMO, he is given an intra-aortic balloon pump that offloads stress from the heart. After a week of intensive care, all these devices are removed, he is extubated, and he survives this unexpected cardiac catastrophe.

Day to day, we also have our routine smooth post-operative patients. I've seen a patient undergo a replacement of his entire aotic arch for Marfan syndrome and leave the ICU within 24 hours of arriving. I've seen a single lung transplant get extubated within two hours and transferred to the floor within sixteen. We have our patients who come in with Type B aortic dissections who have their antihypertensives adjusted and cocaine-use counseled. Many of the quick in-and-out patients don't stick with my memory because they do as we expect, smoothly and uneventfully.

High Stakes

Cardiothoracic surgery is a high risk, high stakes field. Although in the community, cardiac surgery is often routine, straightforward, and uncomplicated, at a teritary academic referral center, we get a lot of high morbidity and mortality cases. We evaluate patients for surgery that other surgeons have turned down. We get transfers for post-operative patients from outside hospitals where the surgery went bad. We see a lot of emergency cases and complex transplants. And only at a few centers are technologies such as ECMO and total artificial hearts available.

As a result, the month on CVICU had its trying and serious moments. A patient with critical aortic stenosis and multiple other comorbidities is declined a traditional aortic valve replacement but is offered a chance for treatment with a transcatheter aortic valve replacement done through vessels in the leg. The procedure is complicated by pericardial tamponade or bleeding around the heart necessitating emergency conversion to an open procedure, which he was deemed too frail to survive. Although we got him through the surgery, his heart took too much injury and he passed away in the intensive care unit.

A patient undergoing a double valve repair with a long bypass time simply never recovers his mental status. During cardiac surgery and afterwards in the intensive care unit, many factors contribute to confusion and delirium. The patient doesn't sleep, becomes agitated, cannot communicate, and does not return to who he was. Brain scans and lumbar punctures are normal; all we can do is support the brain's recovery. The patient stayed several weeks longer than anticipated in the ICU, needing a tracheostomy for ventilator support and a gastrostomy for feeding, but eventually he wakes up, interacts with family, and starts on a long road to recovery.

A patient sent from an outside hospital for a bleeding thoracic aortic aneurysm, a disease with a very high mortality. He is rushed to our cath lab where a stent graft is placed. Unfortunately, he continues to bleed into his chest and cannot be resuscitated.

Over and over, due to the acuity, comorbidities, and high risk nature of our patients, we have outcomes that aren't ideal. This is what comes with the intensive care unit, and part of my rotation was learning to engage these situations. "We work in the dark - we do what we can - we give what we have." (Henry James).

A Day in the CVICU

The CVICU team is made up of four senior residents, cardiac anesthesia fellows, or critical care fellows. We also have a team of nurse practitioners who help out a great deal. The residents or fellows usually arrive before 5; sometimes, we even get to the hospital at 4 if the service is large. It's a bit brutal, but when we are on our week of night shifts, it's nice to get company at around 4:30 in the morning. There are anywhere from 15 to 25 patients, and because most are quite ill, there's a lot of information to gather before rounds at 6. We usually start rounds by examining all the morning films, then go from bedside to bedside with the cardiothoracic surgery patients. We start with the sickest patients or anyone who might be going to the operating room. After covering the general CV surgery service, we meet the VAD/ECMO team followed by the transplant services to round on those patients. The good thing about rounding with surgeons and rounding early in the morning is that we are usually finished by 10. The first post-operative patients usually come out around noon so we have a gap of time to put in orders, write notes, and complete procedures. There are usually two residents or fellows on during the day, and we try to get one of them home earlier as otherwise the month gets exhausting. Each weekday, we get about 2-4 postoperative patients and 1-4 patients transferred from outside hospitals or the ED. The night shift resident or fellow arrives at 6, and the second day resident or fellow leaves after evening signout. Usually the attending will round again on all the patients once the night person arrives. It's a very fatiguing schedule, partly because of the hours in the hospital and partly because of the complexity of patients and acuity of care.

Wedding

My wife and I had a perfect wedding down in Santa Cruz over Memorial Day weekend. In talking to one of my entrepreneur friends, it was like we signed up for a course in project management a year ago, and finally had our final presentation. The wedding was more beautiful, more wonderful, and happier than we had imagined. Both of us are residents, and as residents, we had to make time and room to learn about, create, plan, and bring to life this little get-together of friends and family. In interacting with the "real world," we realized many things; most businesses aren't available to chat before 6 in the morning or after 6 at night, and we got a lot of phone calls and meetings done on our day off after being on call or during the daytime while we worked nights. In residency, we also found that our creativity had been dormant; at work, we follow guidelines, protocols, the teachings of our mentors, and rightly so. But planning this wedding allowed us to figure out what aspects we wanted to make ours, and that was so much fun.

It went by as a whirlwind, but we were so incredibly happy that three day weekend. To see all our families, relatives, long-lost cousins and aunts who watched us grow up - to have dancing and games and bonfires with friends from high school, college, medical school, and residency - to meet those who were important to each other, to meet significant others and children - to see a melding and conglomeration of all the significant and memorable facets of our lives - it was perfect. We made our vows in a gorgeous fairy circle of redwoods, celebrated our elders with a tea ceremony, danced with a cone of delicious locally-made ice cream, and committed our lives together under the stars. It was wonderful.

I don't write a lot of personal stuff on this blog, partially because I think writing ought to have a purpose and audience, and this blog was intended to be a medical journal. It's also a strange thing to write so personally on a forum so public, and it's a difficult thing to encapsulate such a life experience in a few paragraphs. For our wedding, I thought, I'd make an exception.

Back from Vacation

In residency, work is never far. Three days before my wedding, I got to facilitate a small group session of first year medical students learning cardiovascular physiology for the first time. I had a great time. Teaching and education have always been interests of mine, and although I spent a good amount of time teaching when I was a fourth year medical student, I haven't had much of an opportunity to do so since. Facilitating a small group isn't too tough of a job. The medical students come prepared and eager, and so the small groups tend to run themselves. I am simply available to clear up any confusion, guide the group, and provide my "clinical expertise."

Of course, the day I get back from my honeymoon, I'm on call in the main OR. It turned out to be a pretty reasonable call night, which was a relief, but it goes to show, residency doesn't leave a lot of leeway for vacation. For me, though, the transition from vacation to work isn't too bad; I had a challenging case with a thoracic epidural, inhalation induction, 2.5L of blood loss, and hemodynamic stability. Ah, the life of an anesthesiologist.