Interventional Pulmonology

One of the unique procedures we do in our hospital is interventional pulmonology. One of our critical care pulmonologists has developed an expertise using a bronchoscope, navigational technology, and endobronchial ultrasound to biopsy and sample lesions in the lungs that otherwise could not be reached. The technology is pretty cool; he takes a CT scan of the lungs, and puts markers on the patient and bronchoscope (camera) so that as he moves the camera, the screen shows where in the CT scan he is. This allows him to be much more accurate in sampling abnormal areas than conventional bronchoscopy (since abnormalities cannot always be seen with the camera in the lungs). There are similar technologies for neurosurgery (so a surgeon minimizes trauma to normal brain tissue) and orthopedic surgery (so a computer can simulate how a joint moves).

In the past, if someone had a suspicious lung nodule or lymph nodes, they generally could only be biopsies from outside the body; an interventional radiologist would place a needle through the chest wall. If the lesions were too deep within the lungs, however, that would be too risky. Bronchoscopic techniques where the camera enters the lungs are perfect for those lesions that are deep in the body. With these techniques, we can make sure those who need surgery get it and those with benign or metastatic lesions don't.

The anesthetic requirements are tricky. A lot of these patients have significant medical problems, particularly if they have been long-time smokers and developed COPD or other lung diseases as a result. The procedure is done through a very large endotracheal tube which can make intubation more challenging. The patient is under general anesthesia and cannot move, but the procedures can be quick, so the perfect anesthetic gets them into and out of a deep plane of anesthesia briskly, which can be hard to achieve, especially if they have cardiovascular disease or renal insufficiency. The procedures are done out of the operating room (for us, in endoscopy), and that makes anesthesiologists uneasy.

The next frontier in medicine is more and more minimally invasive procedures. We have been able to do endoscopy and colonoscopy for a long time, but only recently have our technologies blossomed for bronchoscopy, beyond just looking at the airways. As other fields develop, anesthesia must keep up with accommodating these new techniques, and this is one great example of that.

Ponderings on Suicide

Can suicidality exist in the absence of mental disease? I believe it can, though these circumstances may be rare. In considering physician-assisted suicide in states that permit it, mental health disorders must be ruled out as the impetus for ending one's life. In looking at California's 5150 section of the Welfare and Institutions Code, the part that permits involuntary psychiatric holds, a subject must be a danger to himself as a result of a psychiatric illness.

In what situations might someone want to end their life and yet not have a mental health disorder? Certainly, we think of patients with terminal illnesses with unremitting suffering. But we may also think of Socrates, found guilty of corrupting the minds of youth and impiety, sentenced to drink hemlock. We think of the Japanese Samurai code of bushido, or honor, which incorporates ritual suicide (seppuku).

Suicide is a touchy subject around here. Palo Alto has had a rash of high school suicides, leading to extensive debates, news articles, and academic research. It is awful, sad, and shocking to consider that a high school student may jump in front of a train because of stress. I hope the changes local schools are making and the awareness generated by a spotlight put on this problem will mitigate it.

But suicide is not a homogeneous problem. It's hard to empathize with someone who is suicidal because those who intervene have rarely been in those shoes. Experts conjecture on the factors that lead to suicidality, but those experts probably haven't been suicidal themselves. Our best source of knowing why people feel this way are probably from those who made unsuccessful attempts, but should we generalize what we glean from those individuals? It's almost like a group of rich people trying to figure out how to solve poverty; few of the well-meaning people working on the problem have actually felt the problem themselves.

When I rotated through psychiatry as a medical student, I didn't fully understand suicide assessment. At that time, it was almost a black-and-white thing; I had a list of questions and from those questions, I made an assessment of whether someone met criteria for a "5150." But reality isn't so clear-cut. I make a comparison to conversations with patients struggling with lifestyle changes. I probe a diabetic patient about why she isn't taking her insulin; I ask about her lifestyle, her finances, her priorities, her understanding of the disease, her ability to obtain her medication, the obstacles she has with taking it, her likes and dislikes, her hopes and fears. It's a long, painful conversation, but at the end, I begin to glimpse her holistically. Maybe this is the approach we ought to have with those who are suicidal. It is so easy to take a patient who ingested a bottle of pills, 5150 them and refer them to psychiatry. But if we truly seek to understand their behavior, we need to do a little more legwork than that.

Happy Christmas

Today, I met a 26 week old premature infant, delivered in emergency circumstances. I think of what it means to be born this day and what it means to be born over three months early, and also what it means to enter a world that can offer that child a chance. I also think of what it means to have surgery on a holiday, to spend the day in the hospital rather than at home, the subsequent days recovering. I also think of what it means to work today - and not of myself - I'm used it - but for all those I encountered today - endoscopy nurses and technicians, labor and delivery nurses, operating room nurses, anesthesia technicians, operating room assistants. I think of those working in the cafe where I grabbed a quick lunch leaving work. I think of all those who would rather be somewhere else, doing something different, seeing other people, feeling healthy and worry-free. I hope we all have happy holidays - and if not that - at least holidays where we feel loved, supported, and safe.

Code Blue

I am used to code blues being chaotic. In training, there would always be too many people in the room: nurses, respiratory therapists, residents, medical students, interns, consultants. As the ICU fellow who should be running the code, I often had trouble squeezing in, making sense of the din, and commanding the situation. I learned a lot in the first few months as a fellow about crisis management: how to quickly evaluate a situation, take control of it, and manage large groups of people. I quickly identified a lot of problems in these chaotic code blues: no clear leader or too many cooks in the kitchen, too many bodies in the room not contributing to the care, multiple people making decisions without communicating to each other. Eventually, I became proficient at running that sort of code.

In a community setting, the code blue is totally different. In many ways, it was better. On arrival, I noted three people cycling through compressions in an organized and cooperative fashion. There was a physician leader, but when he noted who I was, he quickly handed over responsibility to me. It was quiet; anyone could talk and be heard. I could quickly gather the story and make decisions. Everyone knew their role and performed it automatically; the respiratory therapist bagged the patient while the anesthesia tech set up the ventilator. A recorder and timer counted off minutes between epinephrine pushes. The other physician present, a proceduralist, put in arterial and central lines so we could send labs. I could easily settle into the role of running advanced cardiac life support, figuring out problems that could be reversed, and planning ahead. In the end, I was surprised on how well the code ran.

It makes sense. In a small hospital, everyone knows each other; most people present had been working there for years. There were no extra people (like medical students); everyone who showed up belonged there and had a function. Yet, compared to the residency setting, there are downsides. I wondered what would happen if there was a second code since all the major players were at this one (in residency, there would be enough redundant people that you could allocate resources to another crisis). We don't have last-ditch salvage interventions like ECMO. I don't know if response times are as fast. But I was impressed with how things actually played out.

A Full Hospital

It's a tricky situation. Ideally, a hospital wants to run at perfect capacity. By filling every single bed and controlling all the patients going in and out, it can run with maximum efficiency, caring for the most people, generating the most revenue. But this is never the case. A hospital can't predict how many patients are going to come through the emergency room or be sent from clinic as a direct admit. And though we try, it's also difficult to predict when a patient will be able to discharge home. There are unforeseen complications that send a patient up to the intensive care unit or changes an outpatient surgery to an overnight admission. And this affects resource management as well. How do you staff a unit when a new admission might come at any time? How do you avoid keeping unneeded bodies around but have enough capacity to meet surges of demand? I see this often on labor and delivery. Sometimes, there are extra nurses around to give a hand because the census is light. A few hours later, after a few patients arrive, it's all hands on deck and the charge nurse starts worrying about having to call more people in. These are the concerns of a hospital administrator. If you run too much below capacity or pay too many people to stick around "just in case," you'll lose money. But if you miscalculate, then suddenly you might have a queue of patients building in the emergency department or PACU, awaiting beds.

These past few weeks, the hospital has been running at capacity. I've definitely noticed it in the operating rooms and the intensive care unit. Cases get delayed because it's not clear that when the surgery finishes, the patient will have a bed in the hospital. Pressure is put on the intensive care unit to send patients to the floor and free up needed rooms. Charge nurses struggle to figure out how many extra people to call in. Everyone's tired; the delays make us cranky, and we wonder why we're spread so thin. But I simply remind myself that I am here to take care of patients; I focus on that, and let the administrators work out the stresses in the system.

Star Wars

A bad pun in celebration of Star Wars and being on a 24 hour labor and delivery call.

"Use the forceps..." - OB-one-kenobi.

Electroconvulsive Therapy

We do quite a bit of electroconvulsive therapy at my hospital. Although it sounds barbaric, it is a remarkably effective therapy for refractory depression and other psychiatric illnesses. Most days of the week, we have a handful of patients getting ECT treatments with a psychiatrist. Since treatments are frequent, we get to know each patient pretty well. Although I did ECT anesthesia in residency, we use different medications here, which is interesting. It's fun to see how etomidate (which I used in residency) differs from ketamine (which I use now), though outcomes are pretty similar; we can achieve good anesthesia and lower the seizure threshold to obtain effective therapy. The other big difference is that in training, we had two anesthesiologists doing the ECTs; the resident would give the anesthetic and attend to the airway while the attending charted. Now, I have to do both those roles, and I think that's what makes ECT a little exhausting. They start early in the morning, there's a lot of preparation for each one, and it's a lot of work multimanaging all the different tasks. Nevertheless, it's satisfying; one patient who used to be in a catatonic depression, minimally responsive to others, now talks about going to the Shakespeare festival and enjoying her grandchildren.

Colds

This probably applies to lots of different things.

Image is from xkcd, drawn by Randall Munroe, shown under Creative Commons Attribution License.

QuantiaMD

It isn't common that I stick with a website for years, but I have been using QuantiaMD regularly for a while now. It is a community for health care practitioners (requiring an MD, DO, NP, or PA degree to sign up) with focused educational videos on many topics throughout medicine (from basic diagnosis and treatment of diseases to health care policy to physician well-being). Every field from radiology to surgery to oncology is covered. Participating in it leads to rewards, which makes it fun and engaging. The material is pretty solid and it awards CME credits. If you're interested, check it out: QuantiaMD. It does require you to verify your clinician status. Full disclosure - I do get a referral if you sign up.

Cybercrime and Medicine

Health care has its hands full with the problems we're dealing with now. There's so much that needs attention - cost of care, inequalities in care, systems improvement, personalized medicine. We could spend decades tackling those issues we've already identified. But I also worry about those problems that aren't relevant now, but will soon be game-changing. One of these is cybercrime in health care. The sophistication of cybercrime - hacking databases with personal information, identity theft, fraud, and even terrorism - has become increasingly terrifying. While this is mostly focused on governments, financial institutions, and large corporations, I think it is only a matter of time before health care becomes a target. As hospitals all incorporate electronic medical records, patient information is being stored increasingly in the cloud. Luckily, HIPAA, the Health Insurance Portability and Accountability Act that frustrates so many of us, has limited the sharing and enforced the encryption of this data. But eventually, if we don't turn our attention to the security of our patient's (and physician's) information, an attack or leak will happen. Furthermore, as more devices go online and into the cloud, the danger of malicious attacks on these medical devices increases. Being able to reprogram drug pumps wirelessly seems like such a wonderful convenience, but if that ability is hacked, it can be devastating. Nurses and doctors access controlled medications through specialized dispensing systems, and controlled medications are delivered by autonomous robots; what if the hospital lost control of these systems? Even major devices like robotic surgical equipment are double edged swords. If a surgical robot can be controlled wirelessly, a surgeon can operate on a patient in a remote location or a warzone, and we can expand our delivery of care. But it also means it's vulnerable to those with malicious intent. I really hope that this doesn't become a reality, but I also believe addressing it preemptively is the best way to ensure that.