Self

The care of the self is the foremost task for the healer. We cannot take care of others if we ourselves are in trouble. We are stricken by the same things all others are. We get physically injured, we get chronic diseases, we get emotionally distraught, we get psychologically troubled. We get tired, we get depressed, we get stressed. These are normal things that happen to people, but unlike many others, doctors often do not take time off to nurture themselves. This is deeply ingrained in our training; missing work is considered a weakness, a burden on others. Only recently has physician well-being become a catch-phrase. But it is such an important thing. We want our doctors to be healthy, sound of mind, clear of judgment. In order to have that, we need to build a system that gives our physicians time, space, and support to care for the self.

Gratitude

I got a holiday card from a patient thanking me for a good surgical/anesthesia experience. I was even more surprised when I opened it up and realized she had written a lot - it was like a five paragraph essay. It's not terribly common to get thank-you letters or cards, but it does make a big difference for someone like me. Thank you.

Sugar

A man with no known history of diabetes comes in for a resection of a brain mass. He hasn't been on any steroids, but on arrival to the pre-operative area, his blood sugar is 450. How do you proceed? Questions like this (I think) are pretty good boards questions because there is not necessarily a black-and-white answer. On boards, you pick a side and justify it as best you can. You don't waffle, but you know that if you have sufficient reasoning, you'll do okay. In real life, though, what do you do?

On the one side, there's a patient who has a brain tumor expecting to have it taken out. Delaying or canceling the case can have serious neurologic consequences. How long will it take for the patient's internist to get his sugars under control? How quickly might this tumor progress? Where is its location and what symptoms has it already caused? Is it really fair to go to a patient who has been planning on this for weeks, who has been fasting for a day and say that you have to cancel for something that is not his fault? What if you cancel this case and the exact same thing happens two weeks later? And there are systems issues too, though they are less important. What happens to your relationship with a surgeon if you cancel too many cases? What's the effect on OR efficiency? Is this really necessary?

On the other hand, 450 is a very high glucose. Someone with undiagnosed severe diabetes has an increased risk for surgery. He may also have undiagnosed coronary, vascular, or kidney disease. How many other things haven't been figured out? Could this be diabetic ketoacidosis? A patient who is going into DKA has a significant risk of dying; he may have hypovolemia, acidemia, and metabolic disturbances. Even if this is just pure hyperglycemia, it leads to increased infections, poor wound healing, and higher mortality. Furthermore, the stress of surgery itself leads to an inflammatory stress response which increases sugars. Even if he is not in DKA right now, surgery can tip that over. How can you justify taking him to surgery?

Of course, real life plays out a lot less dramatically. I consult several of my colleagues and talk to the surgeon about the risks and benefits. Then I spend a lot of time chatting to the patient about my thoughts. Ultimately, we decide that the best course of action is to delay the case several hours to get the glucose under better control. I check labs so that I know I'm not missing any other diagnoses. I administer intravenous insulin until the glucose is better. In the operating room, I place an arterial line and check frequent glucoses to keep the sugars under control. I consult a medicine hospitalist so that he has someone managing his sugars postoperatively. It takes a lot of extra work, but it's the right thing for the patient.

Blood

The unanticipated bleeding airway is quite rare. Most times, when we encounter blood, we expect it - a trauma victim with a smashed face, a bleeding tonsil, a patient with a tongue mass. So unexpectedly encountering blood on intubation can be a little alarming. A patient having a routine gallbladder surgery goes off to sleep. When I look with a laryngoscope to intubate her, I notice a frondy pedunculated mass in the back of her throat. It's bleeding. It can't get my laryngoscope around it without touching it, and the slightest pressure causes it to bleed. I react instinctively: I don't think I can intubate her easily so I go back to mask ventilating her and call for help. Another anesthesiologist comes in with a video laryngoscope and we take a look at the mass together. The surgeon also peers at the screen and notes that it looks very much like a lesion from HPV (human papillomavirus). With the video laryngoscope, I manage to intubate the patient, but the experience is a little stressful. Even as I suction blood from the back of the mouth, touching the mass inadvertently causes more bleeding. The blood pools continuously so it is challenging to do anything for more than a few seconds. Time feels strange; even though just a few minutes go by, it feels like so much longer. I also have to multitask; I remain cognizant of the patient's vital signs and depth of anesthesia. I draw up and give additional medications as needed. There is a conscious effort to suppress panic, but also an awareness to assess risk. On the one hand, I can wake the patient up, cancel the surgery, and have her assessed by our ear-nose-throat surgeons. On the other hand, I can "just intubate her" through the blood, risking failure and getting blood into the lungs. Fortunately, well-trained instincts lead me to the best option: to call for help, reassess the situation, formulate a plan, and proceed cautiously. After intubation, we checked her coagulation panel and platelets to make sure we weren't missing anything. In the end, the patient did fine. After the surgery, we gave our ENT consultants a quick phone call, rechecked the airway before extubation, and watched her in recovery a bit longer than usual. When I talked to her in the recovery room, I was not surprised to hear that she actually does have some bleeding when she brushes her teeth, and was planning to see her dentist. We managed to set her up with an appointment with an ENT surgeon as well.

Splinting

When a patient has multiple rib fractures, the dreaded complication is actually pneumonia. Rib fractures are surprisingly painful, so much so that patients splint when taking a deep breath or coughing. Splinting is the sudden arrest of a breath, often quite involuntary. Instead of taking slow, deep breaths, these patients take shallow rapid breaths. We often have to coach them to take fuller breaths with a device called an incentive spirometer.

The issue is that coughing is the body's natural way of getting secretions up from deep within the lungs. If a patient can't cough, they can't clear these secretions, and that provides a perfect medium for an infection. While rib fractures and lung contusions are rarely life threatening, a bad pneumonia in a patient who can't take deep breaths or cough is quite serious. This is such a problem that we often place epidural catheters in trauma patients with multiple rib fractures or lung surgery patients in order to help the patient breathe deeply and cough.

On a hike over the weekend, I slipped and fell on a log, and probably had some sort of rib contusion as a result. Compared to multiple rib fractures, this is really nothing, but for the first time, I experienced splinting. When I take deep breaths or try to cough, I can feel my muscles tense up, resisting me because my body knows its going to hurt. I was surprised how involuntary this felt. I takes so much willpower just to do the simplest motions. Now I know have a little more empathy for my patients who have much bigger injuries.

Image showing rib fractures shown under Creative Commons Attribution Share-Alike License, from Wikipedia.

Off This Week

This week I have a "staycation," a word I've been hesitant to use, but now that an emoji is "word of the year," I suppose I can incorporate some portmanteaus. I have some projects I am trying to motivate myself to work on. Although I love blogging and it has a therapeutic quality for me, I am trying to work on other writing like formal essays, creative nonfiction, poetry, and short stories. It's so easy for me to defer on those bigger projects and just write a blog, but I hope this week to push myself to setting ink to paper and pursuing something different.

Risks, Benefits, and Alternatives

The problem with risk in medicine is that complications happen infrequently, but dramatically change the lives of the patients it befalls. When I, or any doctor, talks about the risks of what we do, we are serious. But it's hard to be sure a patient really understands. If the risk of a complication is only 1%, 99 out of a hundred people will do fine. But that one remaining person may suffer tremendously. How do we convey that to a patient? I can say it many different ways and ask a patient to repeat back to me, but how does our brain comprehend such statistics? Is it fair that we put these abstract numbers out there and expect them to make sense?

We think our health care system so advanced, our medications and technologies and surgeries so cutting-edge, but we will never take risk out of the equation. It may be banal to talk about risk, but it strikes me so profoundly when I hear about that 1 in 100 unfortunate outcome. I read case studies in journals. I hear about these situations from colleagues. For example, bypass surgery seems like such a common thing, and it is. So many people have had it. It seems so safe. Yet the risks and complications do exist. A patient has a paradoxical reaction to the blood thinner and clots off his blood vessels. A small surgical tear in an artery leads to hemorrhage. A patient wakes up from surgery with a stroke. These are rare, but they change everything for that one patient.

This is not to say that I don't believe in modern medicine. I am proud to do what I do, and I accept those risks I take and do my best to help patients understand them. But I blog about it because there are so many nuances. How do we communicate these things clearly? When that rare bad outcome happens, how do we help our patients? How do we cope with it ourselves? Risk is inherent in what we do. Complications happen without our making a mistake, without our committing malpractice. They are part and parcel of medicine, and we (you, I, patient, doctor, medical community, society) must determine how much we can accept.

Neurocritical Care

I think for many critical care intensivists, neurology is the most challenging knowledge to master. The anesthesiologists are comfortable with cardiac physiology, vasopressor pharmacology, and ventilator management. The internists and pulmonologists are great at reading X-rays, formulating antibiotic regimens, and managing renal insufficiency. But a surprising amount of critical care is neurologic in nature. While like most intensivists, I am comfortable managing analgesics, sedatives, and other neurologic drugs, there's a lot I wish I were better at. I have a great respect for neurologists who are proficient in critical care and those who do two years to subspecialize in the field.

Even in a community hospital, I see so many variations on altered mental status in the intensive care unit. A patient with a history of seizures has jerking motions; the treating physician gives too much benzodiazepine and the patient is so somnolent she is intubated. She has significant liver and kidney disease, and in the ensuing few days, we have to tease out whether her persistent somnolence is nonconvulsive seizures or residual anti-seizure medication. After an emergency surgery for a bowel perforation, a patient is very slow to wake up. When he does, he cannot move his arms, but the distribution of his weakness does not occur in a common stroke pattern. An alcoholic with cirrhosis comes in with a stroke; after several days of confusion, we struggle to figure out whether it's encephalopathy from his liver, symptoms of his stroke, or the beginning of alcohol withdrawal.

None of these situations are altogether too difficult, but seeing so many in a week helps me realize that I want to get better at neurology. I am working to better understand how to read head CTs, when to order EEG, and how to use a precise neurologic exam to tease apart similar diagnoses. Luckily, we have a dedicated and brilliant neurology consultant who takes his time to dig deep into these problems and teach us when he can. This, I suppose, is one example of how learning never stops.

2016

This year, I hope to continue learning and growing. In all aspects of my life, I have so much to think about, work on, practice, and improve. I begin that life-long journey of continuing education. When I think about this, I don't necessarily want to gain more knowledge, though of course, I will continue to expand that. But rather, I hope to find that indelible and inscrutable stuff that only experience can give us. (Tom Kealey's short story "The Birds in Your House" has an awesome line referring to grit, pluck, and mettle). I am scared of but look forward to weathering those rough-and-tumble years that wise elders reminisce about with a glint in their eye. I will have those moments when I don't think I will get through, but I will be all the stronger because of it. It is a vulnerable stage of life; done with formal training, I strike out on my own. But the values and foundation I have developed will be the forge that transforms these experiences into a more durable, lasting character. I am only allowed to write so flowery on New Years.