Notes

The Patients That Scare Me

2012-02-16T18:04:00.000-08:00

Each physician has his weakness, and mine is the heme/onc patient. While everyone who comes into the ICU is critically ill, I know how to approach most of them. I'm generally okay with strokes, seizures, heart attacks, heart failure, arrhythmias, respiratory failure, hypercarbia, GI bleeds, kidney failure, electrolyte imbalances, septic shock, cirrhosis, even the patient who has been in the hospital for months. These are people I cared for in medicine and who I care for now in the operating room. I understand the diseases and the physiology well. But the one population of patients that scares me is the neutropenic crashing patient.

Cancer patients, especially during and after chemotherapy become susceptible to so many different kinds of infections, including all the weird ones. The cancer itself can wreck the body with phenomena like tumor lysis syndrome. Patients are often malnourished, with weak immune systems, suffering the side effects of their chemo. And when they come into the ICU, they are so ill. Since I did not do a hematology or oncology month as an intern, I sometimes find this to be a big black box. So it is my focus to learn as much as I can about these disease states, ask for help early, and recognize my vulnerabilities.

Sadly, we had a very young patient after a stem cell transplant for a hematologic cancer who had every infection in the book. Her gut could not tolerate any food because of CMV colitis. Her blood was growing multiple bacterial cultures. She had a history of fungal infection. Her kidneys had failed from the antibiotics. Her breathing was labored from a pneumonitis compounded by fluid overload from kidney failure. She was on continuous renal replacement therapy (similar to hemodialysis), experimental antiviral therapy, and a ventilator. In the end, she could not cope with her disease, and we had to transition her to comfort care. It's so hard for young patients. We want fervently for them to do well and try everything we can, but sometimes it is not enough.

Holiday

2012-02-15T21:32:00.000-08:00

Despite my last post about the importance of laboratory tests and X-rays in the ICU, I am a big proponent of lab or X-ray holidays. One of my secret passions is scouring each patient's orders and reducing unnecessary labs. For example, liver function tests are often checked daily for ICU patients, but if they are normal and the issue has nothing to do with the liver, then why check them at all? Occasionally in a bleeding patient, we trend hematocrits so frequently that I think the blood draws are making the patients anemic. I also think daily chest X-rays are usually overkill. There are a fascinating story (or urban legend) that at a hospital nearby, radiology techs went on strike so only on-demand X-rays could be ordered. Routine daily films were canceled. There were no bad outcomes for patients. This has also been studied formally and the conclusion is that routine X-rays may be costly and unnecessary. So even in the ICU, I try to be as much a minimalist as I can.

Numbers

2012-02-13T21:19:00.000-08:00

ICU is a specialty driven by numbers. Because many of our patients are sedated or altered, we cannot always rely on symptoms or history. We use laboratory tests to understand the heart, lungs, kidney, liver, infections, blood, and other systems. Much of "rounding" involves reviewing these lab assays, X-rays, microbiology cultures, and other data.

I admitted a rather young patient who presented with the most extreme numbers I've seen. Her arterial blood gas had a pH of 6.99. A normal pH of the blood is around 7.40, and the body regulates this extremely tightly because proteins begin to denature and enzymes begin to fail if this acid-base balance becomes awry. Why did this patient have such a low pH? Her lactate was greater than 20. If you remember back to high school biology, you will recall that the body makes energy through two mechanisms: an aerobic method and an anaerobic one. When cells have oxygen, they prefer the highly efficient aerobic oxidative phosphorylation. But when deprived of oxygen, they revert to anaerobic metabolism, which produces lactic acid. This patient came in bleeding from her gastrointestinal tract and her blood counts dropped so low that she could not carry oxygen sufficiently to her tissues. The cells, suffocating, produced such an overwhelming amount of acid that her pH was less than 7. While I managed to keep her alive overnight, she is currently in multiorgan system failure, and I don't know how she will do.

Asclepion

2012-02-12T22:42:00.000-08:00

"Wherever the art of medicine is loved, there also is love of humanity." - Hippocrates

Image of statue of Asclepius shown under Creative Commons Attribution license.

Margin of Error

2012-02-10T19:34:00.000-08:00

The thing about the intensive care unit is the margin of error is really small. While medicine is a delicate enterprise and each intervention we make or withhold has implications to someone's health, this is accented in critically ill patients. For example, last year on the medicine wards, I never thought too much about sending someone down to the MRI scanner if that's what they needed. But yesterday in the ICU, I was faced with a situation where we wanted to obtain an MRI on someone who had a tenuous respiratory status. Lying flat for an hour could be an ordeal; he could stop breathing and arrest. We ended up settling for a less ideal but more practical CT angiogram because of the confines set on us by the patient's illness.

Likewise, in the operating room, I manage fluids pretty nonchalantly. Whether someone gets 1.5L or 2L of fluids during surgery generally won't make a big difference in the run-of-the-mill surgery. However, in a patient in heart failure, the extra 500mL of intravenous fluids could be the difference between breathing on one's own and needing a ventilator; on the other hand, in sepsis, withholding that 500mL of fluid can lead to low blood pressures, higher vasopressor requirements, and kidney injury. The problem is that on my last call, I admitted a patient with both heart failure and sepsis. My margin of error is so small. How do I walk that fine line between not enough and too much? Sometimes, that space doesn't even exist.

The Post-Op Patient

2012-02-08T21:57:00.000-08:00

The medical ICU takes a few types of surgical patients, mostly neurosurgery and ENT. For the most part, the management of these patients is pretty simple; the neurosurgical patients get hourly neurologic exams and the ENT patients are admitted to watch their airway and breathing. If all goes smoothly, they go to the floor the following day. But sometimes things don't go that well. We have a neurosurgery patient status post clipping of an aneurysm who has since developed intractable seizures. He's spent almost a month in the ICU, and the neurologists have struggled to get his seizures under control. Finally, with six antiepileptic agents, he's stopped seizing, but with all these medications, he's comatose. We're trying hard to find that balance (if it exists) where his seizures are manageable but he is awake and interactive. We also had an ear-nose-throat patient who in the middle of the night developed severe throat swelling that started to compromise his breathing. Three anesthesiologists, with all our tricks and rescue devices, could not get a breathing tube in, and so the general surgeons had to come and do an emergent "slash" tracheostomy. So while post-operative patients usually do well, it's a good thing we keep an eye on them.

Continuity

2012-02-06T21:33:00.000-08:00

One of the often cited downsides of anesthesia is lack of patient continuity, and this is true. Anesthesiologists focus primarily on the intraoperative period and although we see patients pre-operatively and check them post-operatively, we don't see them over extended periods of time. We don't develop the close long-lasting relationships enjoyed by primary care physicians or pediatricians or even surgeons. We are a very episodic kind of physician, sort of like an emergency medicine doctor.

ICU, on the other hand, has some continuity. We see patients day after day, charting their progress, applauding their advances, struggling with setbacks. Even after patients leave the ICU, we try to check on them because there is a sense of ownership; this is my patient who I manged for a week in intensive care. We get to know families, especially in stressful and crisis situations. They learn to trust us, depend on us, or challenge us.

From a professional sense, continuity is crucial. It is medically important to know how each decision we make influences a patient's hospital stay or long term health. The tragic thing about anesthesia is that there are many ways of doing an anesthetic, but we don't always see the extended post-operative course. When we drop a patient off in the PACU, it's too early to know whether our tweaks make a difference. But they do; only with continuity do we understand how our anesthetics influence postoperative pain or nausea or time to recovery.

From a personal standpoint though, it is so much easier not to be in a field with constant continuity. When I am on a pure anesthesia rotation, I don't go home with anxiety, I don't stress at night about patients. But now in the ICU, I am constantly thinking, second-guessing, and following-up on my patients. I send late-night pages to the on call person. I feel incredibly invested in the care. And although this is ideal from a medical standpoint, I can tell you, I don't sleep as well. I don't feel as good.

Ducking Under the Boom

2012-02-05T20:17:00.000-08:00

On my first call in the medical ICU, the airway beeper gives a squeaky buzz just as the overhead paging system blares "Attention: Code Blue." We become hyperaware of these announcements; sometimes, just standing in the grocery store, I start looking around when I hear "Attention: Pears are 50% off." The code is in the cath lab. When I rush in, the cardiologists are in the middle of an angioplasty and stent for a middle aged gentleman with a heart attack. During the procedure, his blood pressures started tailing off and he vomited. He was not mentating well and needed to be intubated.

I quickly strapped on a lead vest since the cardiologists were using fluoro (real-time X-rays). The patient was on the cath table and the cardiologists were taking lots of images, which meant that the boom (in the nautical sense) was swinging around the patient. I quickly prepared my emergency airway equipment and medications. The cardiologists told us to intubate when ready, but they were not going to stop since they were in place to open up the blocked coronary vessel. Even with the boom flying about the top of the patient's head, I managed to secure the airway. Meanwhile, we started several vasopressor drips to keep his blood pressure up. During the case, there were several rounds of compressions when we'd lose the pulse, but eventually, the cardiologists managed to open up the clotted vessel and reperfuse the heart. The patient ended up doing well.

In comparison to the last code I wrote about, this one was quite different. Although we knew the problem in both cases (the last patient was bleeding, this patient had a heart attack), we were already poised to do the best intervention for this patient while we couldn't get control of the situation with the prior case. This was really a case in which we "saved" the patient's life.

A Typical Day in the ICU

2012-02-04T19:20:00.000-08:00

I get there at 6 and get sign out from the resident on call overnight. I pre-round on anywhere from 4 to 10 patients, seeing them, checking their vitals, reviewing their labs and studies, updating medication lists, and entering any important orders. We round at 8 as an enormous caravan. The team consists of the attending, two ICU fellows, four to five residents, a gaggle of medical students, a pharmacy resident and student, and occasionally a palliative care fellow or dietician. We also wheel around two to three computers. Seeing each patient and determining the plan usually takes two to three hours. Then we try to get procedures done, call consults, and write our notes.

X-ray rounds are at 11:30 so we tromp down to radiology and review films with a chief resident. After that, we grab some food for a didactic lecture at noon covering basic topics like sepsis, ventilators, and antibiotics. From 1-3, we continue doing "work," finishing up odds and ends, touching base with consultants, updating families, etc. During afternoon rounds at 3, we review the day's activities on all the patients and revise the ongoing plan.

The resident on call stays while everyone else tries to go home; although it sounds as though we can leave early, for the most part, we stay pretty late helping out. During the day, everyone chips in to take new admissions who can come from the emergency department, outside hospital, floor, or operating room. After afternoon rounds, the resident on call is on his own. There are usually two fellows around until midnight when one of them goes home. On call, we cover all the patients and new admissions, which can be quite busy.

Code Blue II

2012-02-02T21:40:00.000-08:00

This is a continuation of yesterday's post.

In some respects, "running a code" is not hard. In a Code Blue, the first procedure is to take your own pulse (a mantra of the Fat Man in House of God). This is true. Everyone witnessing her first code feels her heart drop to her feet and panic take its place. We are frozen with paralysis, both physically and mentally. We forget the simplest things. We fixate on stupid details. We aren't helping the patient.

I took my own pulse. Then, I went to the head of the bed, ready to intubate. This is not the most important thing in a code; it's not even the first step in the new algorithm (which starts circulation, airway, then breathing). But in the ED where help is abundant, I recognized that the unique skill I contributed was airway management. The fellow "ran" the code, going down the algorithm. The patient was pulseless. Chest compressions were started immediately. I got my airway equipment out. I could mask ventilate the patient. The cause of the cardiac arrest was clear; he was bleeding to death. He had blood in his mouth and bloody bowel movements. We were transfusing as fast as we could, but to no avail. To secure the airway and protect him from choking on blood, I tried to intubate. I took me several attempts before I could do it; intubating in a code situation is never ideal and always stressful. I took my own pulse. Once I secured the endotracheal tube, my job was to bag the patient. Lots of other things were going on, but I kept my role. The ED resident and attending both tried to get venous access, a very challenging thing to do in the middle of chest compressions in a patient with no blood pressure. We activated the massive transfusion protocol, trying to give as much blood product as we could.

This went on for twenty minutes. With ongoing compressions, ribs were broken, the lungs were lacerated, blood started coming up the endotracheal tube. We got a weak thready pulse briefly, but it disappeared. At one point, we shocked the patient for a ventricular rhythm. We got central lines in and transfused more and more, but eventually we realized this was futile. After about twenty five minutes, we called the code and noted time of death.

There is a point in codes, amid compressions and shocks and needles and shouting, that the process sickens me. It is dehumanizing. Rarely, those situations we live for, the insult is easily reversed and the patient is revived. But more often than not, it is a messy prolonged protracted process, something we would never wish on anyone. It is why I think it is so important to talk to everyone about he'd want when he dies. Such things can be avoided, or pursued, but this decision needs to be made by an informed consumer. Medicine needs to empower patients to choose what they want for themselves.

At the end of codes, I also think debriefing is important. I had so many emotions that night. There are so many things about seeing someone die, being a part of the process, trying my very best and achieving so little, that I wish I had time to let it out. In medical school, there were people who tried to do this, but in the middle of the night in the emergency department, we simply did not have that luxury. So here it is. I don't think I could have saved that patient. And it is that vulnerability, that loss, admitting that very fact, that frightens me.

Code Blue I

2012-02-01T18:04:00.000-08:00

I often write about code blues where I run in, intubate a patient, transfer them to the ICU, and save the day. But this is a minority of situations; the real code, the helpless one, the one sometimes shown on TV, the one we all dread, is much harder to write about.

A 90 year old gentleman with a history of high blood pressure, atrial fibrillation on anticoagulation, coronary artery disease, heartburn, and osteoporosis comes in "not feeling well." He had an episode in the morning where he almost blacked out. In the emergency department, he has very low blood pressure and is witnessed to vomit blood. IV fluids are started and stat labs are sent which reveal a hemoglobin of 5 (normal 13-17) and an INR of 25 (normal 1). Meanwhile, the patient has vomited blood again and is having melena (black tarry stools) in the bed.

Immediately, more IV access is secured, but a large hematoma forms where someone tries to get a 16gauge IV in. FFP and blood is ordered and started. The diagnosis is clear: the patient has a "supratherapeutic" level of coumadin; for whatever reason, his home blood thinner for atrial fibrillation has become way out of control. The goal is an INR of 2-3 in atrial fibrillation, and here, his value is way above that, a reflection of how thin his blood is. If he bleeds, he cannot clot. And he is bleeding; the symptoms show exsanguination from the gastrointestinal tract. By textbook, he has an upper GI bleed with hematemesis and melena. ICU is called.

I rush down to admit this patient. When I see him, he is responding slowly to voice, saying "I just feel so weak and dizzy." His heart and lungs are unremarkable but he does have some abdominal tenderness and is having a black bowel movement concerning for blood. The ED resident is doing a quick ultrasound to look at the heart. Both of us spend a minute talking about how we'd like better IV access since we only have an 18g and a 16g IV. The blood products are hanging. In my mind, I know the most important first steps: get IV access, transfuse, secure an airway, and then see if interventional radiology or GI can intervene.

I step outside the room to check the EKG, and three minutes later, when I look back, they are putting the patient in Trendelenberg (head down to help blood flow), wheeling the bed out (a bad sign that the airway has been lost), and calling for help. It seemed that moments after he and I chatted, he stopped responding; I may have been the last person he talked to. The rest of the post tomorrow.

The Unit

2012-01-30T20:42:00.000-08:00

I'm currently on my first ICU rotation this year, and it's really tough. I'm in the medical ICU at Stanford and our team has anywhere from 15 to 25 patients. The disease states vary widely; while we have typical diseases in the ICU like septic shock, respiratory failure, and post-neurosurgery patients, we also have a couple rarer entities like Guillain-Barre syndrome, myasthenia gravis, and tumor lysis syndrome. The patient population can be really sick; we have patients who've had multiple transplants or who are being evaluated for transplant. We have patients who have had neurologic catastrophes and overwhelming strokes transferred for neurosurgery. It's a busy service. There are two teams with 5 residents each and a few fellows, but even with this sizable group, we are hard-pressed to keep on top of everything. Call is every 4 or 5 days and absolutely exhausting. Even on non-call days, we work pretty late to help the call resident out. In any case, I will write about a few interesting patients and interactions, but a dearth in blogs is simply indicative of the busyness of the service.

Resident Retreat

2012-01-29T21:50:00.000-08:00

Every year, the residency program sponsors a resident retreat at Lake Tahoe. I had an amazing weekend with my fellow residents. We left Friday afternoon (the attendings covered the operating rooms) and took a bus up to some wonderful cabins right at the foot of Mount Pluto. I hadn't skied for at least five years, but I had such a good time hitting the slopes. Lake Tahoe is gorgeous and it was absolutely exhilarating to be out there. It was also really fun to get to know my classmates and those in other years in our residency program. Stanford Anesthesia is amazingly generous to give us such a weekend to relax without worrying about clinical responsibilities.

Image is in the public domain.

Poem: Song

2012-01-26T07:20:00.000-08:00

Song

Words nestle into the cadence of the heart,
the body's metronome. Time and sustenance marked
in this alien landscape, its orbiting moons gathering light
in handfuls and dispersing it on the body,
a body alien, framed in blue, rubbed deep brown
awaiting the brave and foreign to part its skin.

The heart knows, accelerando!
the anesthetized body's tongue. Even in this state
the heart has reasons that reason knows not.
Even in this state, the body sings.
We are interpreters of language.
Anesthesia is, willingly,
a fascination with the surrender of the body,
muting before interrogation, a reversal
of things natural, a conscientious poisoning.

The more we inhale those fumes,
the more we realize it is as much a snare
for the recipient as the giver, that as we
tame more and more of the wild,
we become more ambitious
in some quest to cure human ailment.
Where is that border? Where is that limit
beyond which the body no longer sings
but cries out, beyond which we, with all
our draughts and devices and guilement
cannot rescue the body from
the enchanted sleep we devise
and the sleep it craves?

ENT and Anesthesia

2012-01-24T18:23:00.000-08:00

There is some overlap in the domains of ear, nose, and throat surgery and anesthesiology, especially regarding the airway. Surgeons operate on the mouth, throat, and trachea, giving them an intimate knowledge of anatomy and ways to access the airway. On the other hand, anesthesiologists are responsible for the patient's breathing during the surgery itself. And while anesthesiologists have an array of tools to help with placing the challenging breathing tube, surgeons have the ultimate back-up, the cricothyrotomy, a surgical airway involving cutting into the neck to get to the trachea.

Both specialists need to respect each other to keep the patient's safe. The ENT surgeon can often give insight into the airway as they have seen the patient in clinic and occasionally done a bronchoscopy. However, anesthesia is much more than intubating patients, and thus, the anesthesiologist has the expertise in understanding how to mitigate the stress of surgery given a patient's other medical problems. The anesthesiologist is central to the pre-operative evaluation, selecting monitors, and determining the best medications for each case. Teamwork and shared respect are key to a smooth surgery.

Neuroanesthesia

2012-01-23T17:37:00.000-08:00

Some of the more interesting cases I've done are craniotomies for brain cancer, often intense all-day cases. Simply the preparation and anesthesia for these surgeries take a significant amount of time. After intubating the patient, we place extra IVs, an arterial line for moment-to-moment blood pressure monitoring, and a central line for access. Positioning the patient takes time as well; the surgeon often will place pins in the head to keep it in place, allowing him to use stereotactic imaging to precisely locate the cancer. The surgeries are often done with neurologic monitoring; a specialized technician places electrodes in various muscle groups, and throughout the operation, stimulates these to make sure that the brain surgery hasn't damaged any of the motor pathways to those muscle groups. This provides an anesthetic challenge as well because inhaled agents will interfere with neuromonitoring. Each institution has a specialized cocktail, and at Valley, it's an interesting combination of remifentanil, propofol, and low dose sevoflurane. Most of the time, the surgeries proceed pretty smoothly. The neurosurgeons at Valley are outstanding and we rarely run into complications. I often enjoy watching the surgeries themselves; seeing someone operating on the brain is really quite amazing.

Image of brain surgery shown under GNU Free Documentation License, from Wikipedia.

When It Gets Hard

2012-01-21T16:34:00.000-08:00

One of my favorite books as a child was Ender's Game by Orson Scott Card, a science fiction novel that depicts children trained to be military strategists in a war against aliens. There is a scene near the end of the book where one of the characters breaks down. In the middle of a battle, Petra is caught off guard and overwhelmed, and she suddenly falls apart. In the moment, she freezes, breaks into sobs, and needs another player to salvage the situation.

Things like this happen in residency. Both during my intern year and this year, co-residents have had overwhelming challenges that stress and exceed their limits. Sometimes so much is happening that we cannot function effectively; I've had situations where I've received so many pages, I cannot feasibly respond to them effectively. But more than that, something usually tips us over. Superimposed on a baseline of stress, we encounter a patient death, a delayed diagnosis, an iatrogenic error, a clinical mistake. And then we shut down; we cannot function effectively, we are overwhelmed with emotion, we stop thinking. When this happens, we rely on our co-residents to carry us, and as co-residents, we give as much support as we can. The enterprise of medicine is not an individual effort, and when one of us stumbles, the rest fill in to keep everything going.

Trauma II

2012-01-20T15:42:00.000-08:00

For some, those who go into trauma surgery, there is an air of excitement when running down to the trauma bay. Anything can come through the door; there can be multiple injuries, some catastrophic; the interventions can be dramatic, even heroic. It is a challenge of triage, cool-headedness in the face of the unexpected. Many patients can come in at once. There is thrashing, body secretions, knives protruding, the stuff that makes horror moviegoers cringe. Yet in the end, patients who get into gun fights or jump off bridges or have tussles with industrial machinery may walk out of the hospital in a way that is immensely satisfying. That is the lure trauma has on some physicians.

I am not one of those people. I don't like the unknown, don't like the feeling of being unprepared. I don't like blood and vomit and who-knows-what. I am not a trauma guy. My stomach clenches when I see some injuries. I want to survey and catalog before jumping in and intervening. I don't like chaos. No trauma victim wants to be there. They want to jump off the bed, wrestle the lines and tubes out of them, and go home.

Nevertheless, clinical experience with trauma is important. The ability to assess a situation immediately, identify priorities, and accomplish them in the midst of a chaotic trauma bay is really important. From an anesthesia standpoint, quickly determining how to anesthetize, intubate, or support an unstable patient through multiple surgeries is invaluable. So even though I don't crave it, I try to get as much out of on-call trauma as I can.

Trauma I

2012-01-18T21:46:00.000-08:00

A previously healthy young man is a passenger in an awful car crash, an accident that cleaves the car in two. All three other occupants in the vehicle die at the scene. The patient is thrown out of the car, and the impact of landing causes so many facial fractures that his nose and palate - the roof of his mouth - are essentially free-floating, their moorings released. He breaks his scapula, collarbone, and femur. The injury I find most disturbing is a ruptured globe - the eye is under so much pressure, it starts swelling out of the socket. We spend eight hours in the operating room fixing the eye, pinning the facial fractures, closing lacerations, performing a tracheostomy to breathe, pinning a femur, and nailing the hip.

In a separate accident on this MLK long weekend, a mini-van is T-boned at an intersection by someone running a red light. When I go down to the emergency department, I find the mother rushing between three rooms to see her two sons and her husband. One of them, a 10 year old I get to know well, is rushed to the operating room for a broken femur. While under anesthesia, ophthalmologists also have to clean glass shards out of his eyes.

The car crashes do not stop. A woman driving down the freeway, distracted by a cell phone, hits the median and flips the car. Her daughter dies at the scene. Her husband has a severe bleed into his skull. He's rushed to the emergency department where the emergency physicians cannot get a breathing tube in him. We hear an overhead page: "anesthesia stat to the emergency department trauma bay" and rush down. We manage to get a breathing tube in, but then the harder - perhaps hardest part - is talking to the wife who, stricken with guilt, must decide whether we should take her husband to surgery. From his symptoms, imaging, and labs, the chance of meaningful survival is nearly zero. We hold her hand as she decides to withdraw care from her husband.

PIPA and SOPA

2012-01-17T22:37:00.000-08:00

Two bills before Congress, PIPA (Protect IP Act) and SOPA (Stop Online Piracy Act) will dramatically change the Internet, including search websites, blog networks, encyclopedias, and social networks. Many of these Internet giants are protesting these bills. I encourage everyone to learn more about it (https://www.google.com/landing/takeaction/) and make your opinion heard.

Arguments

2012-01-14T21:17:00.000-08:00

Differences of opinion are common. But after watching surgeons argue about which surgery should go first, I have returned to the conclusion that nothing should be done for our convenience as physicians if it is not the right thing for the patient. We can complain about sacrifices we make, but that does not discount the necessity that we make those sacrifices to help those who depend on us.

January

2012-01-12T21:32:00.000-08:00

The winter months are hard in residency. We often work through the holidays. We wish we could spend more time with friends and family. It is dark when we go to work, dark when we leave. Most of us crave sun and exercise and fresh vegetables (I have to admit, though, I am spoiled in California). We've lost the momentum with which we've started the year; our books fall to the wayside, we drag our feet through the day, what once excited us is now routine. And secretly, though most of us would not admit it, there is some grain of resentment that we do not have "regular jobs," that we are sacrificing some larger part of ourselves to this job which does not acknowledge sickness or holiday or the feeling of being burnt out, a job which demands all attention, saps us of our energy. I can't remember when I did not feel exhausted. Winter is hard. Hug a resident.

The Beginning and End of Things

2012-01-10T21:20:00.000-08:00

I've blogged much on the start of anesthesia, but very little on the end of cases. Ending an anesthetic gracefully is really an art. The perfect anesthetic awakes the patient the moment the last surgical dressing is on in a smooth manner without any pain or coughing. That rarely happens. Occasionally we are too optimistic and the patient lightens before the surgeons are completely finished. Other times, we are too conservative and the surgeons wait while we get all the anesthetic gas off. Nobody is happy if the patient wakes up in severe discomfort or agitated or hypertensive. The art of the perfect wake-up is a combination of knowing the surgeons, titrating the anesthetic off carefully, and balancing oversedation from pain medications with the anticipated painfulness of the surgery.

Today, I had a case which did not end well. The patient was too weak upon extubation and although he could initiate breaths, his tidal volumes were simply too low. Prior to removing the breathing tube, he looked like he would fly; he was following commands with stable vitals; he was warm, reversed, and comfortable. Nevertheless, after taking the tube out, he wasn't looking fantastic so we reintubated him to give him extra time. Although it is a step backwards, we have to do what is safest for the patient.

A Taste of Pediatrics

2012-01-09T21:25:00.000-08:00

We occasionally get to do pediatric cases at Santa Clara Valley and so I had a couple days of anesthetizing kids. It's completely different, and fun. Since I haven't had my formal pediatric anesthesia rotation, the attendings supervise very closely and teach a lot. I've done simple mask anesthetics for ear exams and mass excisions in 5 year olds. It's fun because they bring their stuffed animals to the operating room and we reward them with stickers. They are generally pretty sociable (and become even more so after midazolam syrup which gives them the affect of being drunk) but still very different than adults. We flavor the masks with cherry or bubblegum chapstick, we try to avoid placing an IV if possible, and we induce anesthesia with inhaled gas.

The most challenging pediatric case so far, however, has been a two week old baby with a congenital defect in her abdominal wall. The surgeons had to try to reduce the patient's abdominal contents and repair the defect. The newborn arrived in an incubator and was so small I was hesitant to touch her. It can be a little hard working with these children; the patient had a nasogastric tube, central line, peripheral IV, EKG leads, and probably one or two more lines and tubes from her body. I had to recalibrate in my mind what normal vital signs were. We had to work to keep her warm. The intubation was tough; I used a tiny Miller 0 blade and managed to see vocal cords. I learned to limit my IV fluids, to calculate doses precisely, and to move slowly and gently when permitted but quickly and decisively when required. The patient made it back to the ICU safe and sound.

Poem: Perseids

2012-01-08T12:02:00.001-08:00

Perseids

When you came, I left the hospital wearing scrubs onto the hill,
I tilted my head and listened for music. Droplets
flamed and retreated. How when I wished on a falling,
I was reminded of childhood, of the kind of succulent
that dwelt in my heart through teen years
and filled notebooks with poetry. I must be old now.
I don't recognize constellations. I don't write
in margins. I no longer perseverate for hours.
Last time you were here, I was not so practical,
I belted my passions and cared not who heard.

In one sun-tinged voyage, a Perseid year,
my maps unfurled, left me wanderlust.
I captain a ship that once fixated on a single point,
a pivot that deserved obsession, all dream and wish,
every one of those Swift-Tuttle rocks, and now
we flitter starlight to starlight, neither indecisive nor lost.
Everything seemed to shrink since you came last
but now, I look into the far edges of that canopy
and wonder where you came from, where you go next.

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

Wisdom

2012-01-06T11:55:00.000-08:00

The Dalai Lama, when asked what surprised him most about humanity, answered, "Man. Because he sacrifices his health in order to make money. Then he sacrifices money to recuperate his health. And then he is so anxious about the future that he does not enjoy the present; the result being that he does not live in the present or the future; he lives as if he is never going to die, and then dies having never really lived."

Image of 14th Dalai Lama, Tenzin Gyatso, from Wikipedia, shown under Creative Commons Attribution Share-Alike License.

Waste of Time

2012-01-04T19:42:00.000-08:00

We live in a world inundated with TV shows, junk food, social networking, video games, iPhone apps, mindless distractions. There's no question that my friends, my patients, even me - we waste some of our time with these activities. After a long day at work, I watch a mindless movie or scour social networks to unwind. But I can't help but wonder what the world would be like without these distractions. Is it wrong to say that exercise, cooking with friends, and reading books trump clicking through YouTube videos and (say it!) reading blogs? There's no doubt that for centuries we've had unproductive pastimes. But when I read an Economist article that argues video games are the future, I worry that the reason why a 25 year old doesn't have health insurance is not primarily a fault of health care laws or the job market but a surplus of instant gratification in society today. I know that if I slept more and wasted time less, I would be happier. But why can't I do it?

Year After Year

2012-01-03T20:14:00.000-08:00

When I reflect on how I've changed in the past twelve months, I realize I've grown quite a bit. All those call nights and stressful moments do add up. My biggest change is gaining confidence. I have a better sense of when I need help and when I can trust my clinical impressions. I have moved from being a medical student watching doctors handle stressful situations to being an intern guided by my mentors in those situations to now being a resident approaching them with more and more independence. It feels comfortable. Soon I will have to be an attending, the end of the line. More than acquiring medical facts, which we learn from medical school and lectures and books, residency is about developing judgement, acumen, experience, and instinct. I don't notice this from day to day, but at the end of the year, I can tell I'm getting these intangibles.

Resolutions

2012-01-02T12:42:00.000-08:00

Over a year ago, I wrote poems regularly, and somehow that faded away as I started residency. This year's resolution is to get back into the habit of creative writing. I miss reading, thinking about, and writing poems, and even though blogs provide an outlet for something, I want to broaden from just writing about residency.

Happy New Year!

2011-12-31T14:24:00.000-08:00

Wishing everyone a very happy new year. I hope that 2012 is filled with personal growth, achievement, kindness, compassion, creativity, innovation, daring, and courage. Please have a safe New Year's eve, which is not an unselfish request as I happen to be on call.

Cartoon by John McCutcheon is in the public domain, from Wikipedia.

Intubating during a Code

2011-12-30T21:39:00.000-08:00

I used to be terrified of codes. Some of the time, it's nothing serious, a precaution, a false alarm. But other times, it's acute respiratory failure, altered mental status, asystole. As the anesthesiologist, I have to figure out whether an airway needs to be secured and do it. Even though I feel pretty comfortable about intubating in the operating room, emergency situations are scary. I have to slow myself down; even though I am anxious to get the tube in, doing so without being prepared can be disaster. Like procedures out of the operating room, my environment is completely different; I have to check all the equipment, make sure I have things I take for granted like suction. I can't count on the people nearby to know what I need or how to help. I can't position the patient optimally. I don't have a lot of time to learn about the patient but have to select appropriate drugs and doses. Luckily the floor intubations at Valley have not given me unexpected difficulty. Most of them have been for respiratory failure, but all have allowed me five or ten minutes to set up everything as I need it. I always have supervision and backup. It is a satisfying challenge and I'm feeling more and more comfortable with it.

Turnover

2011-12-28T13:25:00.000-08:00

Turnover is really important in the operating room. While patient care takes the first and foremost priority, when we are in between cases, efficiency becomes king. Once a patient is out of the operating room, the entire place needs to be cleaned and disinfected, the anesthesia cart restocked, the next case cart readied, and surgical equipment prepared. The goal is to have all this done within 15 minutes. From an anesthesia perspective, I need to bring my patient to the recovery room, make sure she is stable, sign out to the nurse, dispose of any opiates properly, finish documentation, meet my next patient, review the history and physical, place an IV, and then prepare all my equipment and drugs. Surprisingly, the most quiet time for an anesthesiologist may be during a case and the most hectic time that period from extubating one patient and intubating the next.

At Stanford, we even have outside consultants who look at our processes to try to optimize them. We get occasional emails telling us how different checklists have been changed, why we aren't getting our patients to the operating room soon enough, and displaying graphs on our efficiency. I don't particularly like it, but I recognize that this is the way to make things operate more smoothly which can ultimately save resources and make everyone happier.

Holidays

2011-12-27T20:57:00.000-08:00

Does surgical volume increase or decrease around the holidays? I wasn't sure what to expect as I started work this week, but Santa Clara Valley didn't seem to change too much; the operating rooms are as busy as ever. Most of the cases are urgent and emergency rather than elective cases, but there are certainly enough of those to go around. I'm guessing volume is slightly lower at Stanford and the VA as there are systems there to figure out how many residents are needed each day. While it's a little hard to have to work during the holiday season, it is still much better than last year where I was on q5 call at the VA.

Burn Surgeries

2011-12-26T13:48:00.000-08:00

Burn patients are a little different than regular patients. As Santa Clara Valley is a burn specialty center, we see inhalational injuries, deep burns, and burns involving large areas of skin. The surgeries vary widely; there are the typical skin grafts, but I've also done anesthesia for knee amputations for a burn that was too severe as well as dialysis line placements. Burn patients lose a lot of heat and water through their injuries, making the job of keeping them warm and resuscitating them difficult. Those with smoke injuries can have swelling of their airway. And the extent of their burns may limit IV access and other monitors.

Understanding the patient population of a hospital changes perceptions of things. I found out one of my patients got a whole-body burn "cooking." Astutely, my attending asked what he was cooking - turns out he was trying to mix meth and heroin. That is not an advisable hobby.

Image of third-degree burn is in the public domain, from Wikipedia.

Happy Holidays

2011-12-24T18:05:00.000-08:00

May the holidays find you surrounded by those you love and those who love you.
-Craig

Image of Rockefeller Center Christmas Tree shown under Creative Commons Attribution Share-Alike License, from Wikipedia.

Crash

2011-12-23T18:03:00.000-08:00

The Cesarean section can be done with various anesthetic techniques. A spinal injection into the cerebrospinal fluid will achieve surgical numbness. An epidural catheter can be bolused with local anesthetic to achieve the same effect. Both of these "neuraxial" techniques have the advantages of minimizing drug exposure to the baby and letting the patient see her baby once she delivers.

We only elect general anesthesia in exceptional cases and emergency "crash" sections. Although it is the fastest technique, exposes the baby to medications and involves a challenging airway in an urgent situation. I was called to a stat C-section for fetal distress. Fortunately, we had the room set up for an emergency and my attending was already present. When the patient rolled in, she was terrified, confused, and in pain. It was chaotic; normally, operating rooms are an exemplar of order, but here, people were yelling for assistance or medications or supplies. Although the patient had an epidural in place, bolusing it would take 5 minutes for surgical anesthesia, and we didn't have that much time. I pre-oxygenated, my attending put on monitors, the nurses opened the case cart, and the surgeons scrubbed. When the surgeons were ready to cut, we induced; ten seconds later, I took a look, saw vocal cords, and intubated the trachea. Immediately after that, my attending gave the okay and the surgeons cut. Before I had finished taping the endotracheal tube, the baby was out. I hadn't even given the surgical prophylactic antibiotics; there was no time. All the steps were compressed to minimize risk to the baby and keep the mother as safe as possible. Fortunately, the baby and mother did fine. It was an incredibly stressful moment but in that situation, I felt pretty calm; afterwards, I was trembling. Much of anesthesia is routine, but occasionally, we have to react under extraordinarily stressful and life-determining situations.

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

The Epidural

2011-12-22T09:16:00.000-08:00

While we do epidurals for many surgeries, when most people think of the epidural, they think of pain management for labor and delivery. Right now, I find the procedure a little challenging, but I know it will get easier. Like IV placement, intubation, spinals, and other hands-on things we do, it simply takes practice and repetition. In a laboring woman, placing the epidural is a little more challenging because we have to do the procedure in between contractions. The procedure itself is quite safe and I am becoming more and more facile with it, so the question becomes: when should we do it?

I get asked this a lot, equally by patients as by other healthcare providers. Should I get an epidural or not? There's no easy one-fits-all answer to this. If a patient feels strongly one way or the other, I support them completely. Some people want as much pain relief as possible; others want the natural childbirth experience; I am happy with either. If she is uncertain, I don't press too hard but always leave the option available. Some people like to say, "If I were in your place..." or "If you were my mother, sister, or daughter..." but I never do that; I'd never be so presumptuous as to pretend to know what it's like to be pregnant, nor to recommend to a family member what to do in this situation. (I do use the "If you were my mother, sister, daughter," phrase in cases where I feel something is medically clear-cut such as whether to go to surgery for life-threatening appendicitis).

There are few scenarios in which anesthesia can empower a patient, but here is one; the choice is always up to the patient. For most surgeries, I don't ask the patient what kind of anesthetic technique he'd like; when I present risks, benefits, and alternatives, the alternative is not to do the surgery. But here, it is perfectly reasonable to choose an epidural or not, and so part of resident learning is presenting the options in the most appropriate fashion.

Image of an epidural catheter shown under Creative Commons Attribution Share-Alike License, from Wikipedia.

How Doctors Die

2011-12-19T22:04:00.000-08:00

An article on "How Doctors Die" by Ken Murray, a family medicine doctor at USC, has been circulating the Internet. It's a fascinating read because I do think there's a dichotomy between how doctors and non-doctors view their deaths. A lot is written about the medicalized end-of-life, the dramatized ICU bed with tubes out of every orifice, no dignity, aggressive care that spirals into suffering, a drawn-out dehumanization with no end. And a lot is written about the so-called ideal death, surrounded by friends and family in one's own home, medications to ease any pain or suffering, and a quick end. Put that way, it's easy to choose.

But this article argues that patients overwhelmingly choose the first while physicians choose the second. Why is this? Is it a failure to communicate a faithful image of the end-of-life? Is it that we've seen what happens and understand the nuances of "do everything possible to keep him alive?" Is it that we think about death and dying far more than the average person? Is it that we view death as a natural part of our existence whereas others view medicine's abilities as limitless? Is it that we understand probabilities of survival given certain circumstances? Is it that we're more willing to give up on ourselves?

We can't impose our feelings on anyone else; if someone understands what happens with CPR, emergency surgery, the ICU, and dying in those situations, then I won't argue otherwise if that's what he chooses. But I can say clearly that even though I might become an intensive care doctor, there are very few situations in which I'd like to become an intensive care patient.

Anesthesia

2011-12-18T15:57:00.000-08:00

Looking at it from some very strange way, anesthesia is the specialty of controlled overdose.

Lark

2011-12-16T14:49:00.000-08:00

My friend Julia Hu invented a silent alarm clock, Lark, and founded a company based on it which has taken off tremendously. Since it is that time of year, I figured I'd mention it in case anyone is looking for a holiday gift. She came up with the idea after realizing that traditional alarm clocks are incredibly disruptive both for the sleep of the person waking up as well as any roommates or sleeping partners. She designed, engineered, and created a pleasant vibrating wristband that gently nudges the intended individual awake, leaving any others sleeping in peace. She's worked with sleep experts to create a personal sleep coach where the wristband monitors and records the quality of sleep at night. Since I started using it, I've been quite surprised to find how easy it is to sleep with, how pleasant it is to wake up, and how fascinating it is to track my sleep schedules. I've been getting even less sleep than I expected. For someone with a variable schedule, it's a great device; I've even tried it on call and found it perfect (soon, I hope they connect it to the paging system). In any case, I rarely write about products, but this one I like. Visit Lark for more information.

Image shown under Fair Use.

There is a Fracture

2011-12-15T07:36:00.000-08:00

When I see a patient right before anesthetizing them, only a few things give me pause, and chest pain is one of them. On my last call, an older man came in after a motor vehicle accident; he was driving and suddenly lost consciousness, running his car into a pole. As a result of the accident, he also fractured his ankle. He extricated himself from the car and was picked up by EMS and brought to the emergency department. The workup was a little spotty; he had normal labs, including a troponin, and a negative head CT. No chest X-ray was done, though of course there were ankle films. Orthopedics jumped on it and said his open ankle fracture was an emergency. He arrived in the operating room ready for me to anesthetize.

When I spoke with him, he said his ankle wasn't really bothering him, but rather a substernal chest discomfort. He had a rather sizeable bruise as a result of the airbags, but I was concerned. Why did he lose consciousness? Did he have underlying heart disease? Could there have been an aortic injury? Was this pulmonic?

Although it disrupted OR flow and delayed the surgery, we decided to get a chest X-ray and EKG. Both were normal. We still decided against general anesthesia and did a combined spinal-epidural instead, so that the patient would be awake if his chest pain worsened or he had neurologic symptoms. Ultimately, the patient did fine, and post-operative workup was negative. We may never know what caused the accident, but we have to treat it with caution.

For Example

2011-12-13T13:05:00.000-08:00

Being on call at the Valley means lots of pages, a little multitasking, and no sleep. On one call night, I started with a 10 year old requiring removal of an external fixator for an old tibia-fibula fracture. It was my first pediatric patient, but at least he wasn't a child. The attending walked me through the anesthesia for adolescents, from the way we explain things to dosing of medications to preparation of equipment to induction of anesthesia and securing the airway.

Once I had placed the breathing tube, however, I was called for a series of code blues. I went with the other attending and found one person with congestive heart failure and an oxygen saturation of 85%. I quickly got my equipment together, positioned the patient for intubation (difficult due to his underlying disease and shortness of breath), induced anesthesia, intubated the patient, and put him on a ventilator. Before I had time to clean things up, I got paged with another floor patient with acute respiratory decompensation. This one was far more challenging, however, because he was 300 lbs and septic with low blood pressure, necrotizing fasciitis, and acute renal failure. I was very nervous, and due to his renal disease, we decided intubate the patient without a muscle relaxant. Despite his weight and the non-ideal conditions outside the controlled and familiar operating room, I managed to get the tube in pretty easily. It was incredibly satisfying.

By the time I got back, we were ready with another case in the operating room: a cystolithopaxy to remove a kidney stone in a gentleman with acute renal failure. After I started that case, I was paged with two epidurals on labor and delivery, and so I rushed up to place those, including one in a woman whose body mass index was 60 (normal is 20-24). The evening ended with a straightforward appendectomy, and by that time, I was exhausted.

The cases come so fast that I can't even log them all, and after a call night, I have to think pretty hard to recall each anesthetic I provided. I've learned to just paste patient stickers on my sleeve to keep track of them all. On my second call night, I had two appendectomies, an incision and drainage of an abscess, a dilation and curettage, an epidural, and two C-sections, one done under a spinal. On my third call night, I placed two epidurals, managed two C-sections, intubated someone on the floor, saw two appendectomies, and took a patient to the operating room for a perforated viscus with air under the diaphragm. Despite the busyness, I really enjoy it, especially since it's often a lot of fast cases, good procedures, and solid learning.

Call at the Valley

2011-12-12T11:40:00.000-08:00

Call at Santa Clara Valley is exhausting. Even though the shifts aren't long, it can be much more tiring than calls at other hospitals or on medicine. We arrive at 3pm and finish up cases or tackle add-ons. At around 5pm, we try to cut down to only two simultaneous operating rooms. By now, the add-ons start piling up, and around that time we start covering obstetrics as well. We have 3 attendings and 2 residents in the late afternoon and by 10pm, we're down to 2 attendings and 1 resident.

There are a lot of add-ons at Valley, and I'm not sure why; we see a lot of appendectomies, ectopic pregnancies, orthopedic injuries, and other urgent cases each night. There is a considerable amount of trauma at Valley so we have to be ready for a big surgery at any time. The on-call anesthesiologists also split up pre-operative evaluations for any inpatients for the following day so in between cases, I run around the wards to see patients and rifle through charts.

However, Valley call can be tiring because it involves a lot of things that first year anesthesiology residents haven't seen yet. We get the occasional pediatric case, and although attendings help us greatly for these patients, it's something I am less prepared for and less comfortable with. We hold the code pager, and there are a surprising number of code blues requiring intubation. I'm always supported by an attending, and the nurses, pharmacists, and respiratory therapists are outstanding in helping us with equipment and drugs.

The biggest challenge, however, is labor and delivery. I had not been up to L&D since third year of medical school, and relearning the nomenclature, pertinent aspects of pregnancy, and common peripartum illnesses took some time. But it is the place to learn about epidurals. These are still tough for me; I still struggle to find the best entry point, but once I'm in the right place, I've gotten more facile at the technique of placement. There's a lot of learning on call and even though it's very busy, I really enjoy it.

Generics

2011-12-11T11:24:00.000-08:00

Within the next six months, a number of widespread brand-name drugs will become available as generics. Atorvastatin (Lipitor) which made Pfizer $11 billion in revenues last year, clopidogrel (Plavix), valsartan (Diovan), and montelukast (Singulair) will all become generic as the patent protection for big pharma runs out. Naturally, the pharmaceutical companies are doing everything they can to soften the blow through legal challenges, deals with the generic companies, marketing strategies, and hunting for loopholes. The truth is, much as I respect what they do and how challenging it is to bring a new drug to market, I don't have all that much sympathy for big pharmaceutical companies. I've seen too many patients who cannot afford the medications they need, spent too much time filling out insurance authorization forms, and struggled too long with the question of how to control healthcare costs that I think cheaper, generic versions of drugs, as long as they are equally effective as their brand-name counterparts will be good for our system.

Valley Logistics

2011-12-09T12:35:00.000-08:00

There are just a handful of residents at the Valley, which means that we can get fairly complicated cases since there aren't a lot of senior residents vying for the "hard" rooms. In fact, on my second day at Valley, I was assigned to endoscopic abdominal aortic aneurysm repairs, cases that go smoothly most of the time, but if something goes wrong, it can be an instantaneous disaster. The cases we get are pretty diverse, and I got my mix of general surgery cases, urology, orthopedics, neurosurgery, and out-of-OR procedures like endoscopy. But I noticed that compared to the VA and Stanford, there were far fewer scheduled cases and far more add-ons from the emergency department or the inpatient wards. This may simply be a reflection of the patient population which uses Valley more as an emergency department, urgent care, and episodic care center rather than a long-term continuity of care facility. It may also reflect the fact that follow-up can be unreliable, and so if a patient has a disease that requires surgery, admitting them and doing the surgery may be better for the patient than discharging them with an appointment.

Santa Clara Valley Medical Center

2011-12-08T11:55:00.000-08:00

My current anesthesia rotation is at Valley Medical Center in San Jose. I was last here about a year ago for my medicine rotation, and I am happy to be back. It's a little bit of a commute, but I love the county hospital feel. The underserved population reminds me of the importance of health care reform, the immigrant population allows me to practice my Spanish and Mandarin, the hospital's wide catchment area allows me to care for diverse diseases, illnesses, and injuries including trauma and burns. Although resources are quite limited, the heart and passion of providers to care for this community is overwhelming and inspiring.

The operating room setting feels like the Veterans' Administration; it's a small group of anesthesiologists and surgeons operating in about 12 rooms. There are some differences between Valley and the other hospitals though. Because resources are limited, we are extremely aware of wasted medications, turnover time, and costs. At night, there is no anesthesia tech so we make our own IV bags, set up our own equipment, and calibrate our own instruments. The hospital uses a hybrid electronic and paper medical record so we don't have all the information about our patients until we meet them. And yet, the efficiency is impressive; I feel that the pace is just as brisk as the other hospitals I've seen.

Image is in the public domain, from Wikipedia.

Why Are People Still Smoking?

2011-12-07T11:15:00.000-08:00

This ashtray showed up in my Google Plus feed and I thought it was pretty clever.

Image is shown under Fair Use, in the public domain.

Operating Room Management II

2011-12-05T23:08:00.000-08:00

The scheduler also has to deal with add-on, urgent, and emergent cases. Emergent cases are relatively simple; they must go to the operating room as soon as possible, and the scheduler just needs to find an anesthesia and nursing team. But how do you distribute urgent and add-on cases? At 5pm, it might not be reasonable to start a 5 hour case, but a 45 minute laparoscopic cholecystectomy should go. What anesthesia team does the cases? In theory, it should be on the on-call anesthetists, but they may still be in on-going cases. Do you assign someone who should be leaving soon to 5pm surgeries? At some point, there should only be a handful of surgeries going, and then just one or two rooms running as the hospital can't pay all the staff overtime. And as staffing ratios get slimmer through the night, the scheduler still needs to have the resources to respond to an emergent trauma case if necessary. I don't know how all of this works, but it's pretty fascinating.

If an emergency comes in and all the operating rooms are already assigned, then someone will be "bumped." That is, a surgeon's protected elective surgery time might be superseded by the emergency. How do you account for this? Does the surgeon get credits? Do his cases get greater priority in the future? As I go from hospital to hospital, I see various systems and committees dedicated to solving this problem.

Ultimately, money is important in operating room management. Operating rooms are incredibly expensive, and so you want them running at full efficiency if possible. Downtime means that a surgeon, surgical resident, anesthesiologist, anesthesia resident, circulating nurse, scrub nurse, technicians, and housekeeping are all idle. So part of managing the operating rooms is that puzzle of packing a suitcase: you want to get as much to fit in there as possible with minimum wasted space.

Operating Room Management I

2011-12-04T22:53:00.001-08:00

After six months in the operating rooms, I have only a glimmer of knowledge about how operating room management works, and I can already tell it's incredibly complex. An anesthesia attending acts as the "scheduler," in charge of determining the order of cases, assigning the cases to anesthesiology teams, dealing with add-on cases, and probably playing a lot of roles I don't know about. For the most part, surgeons have protected block time when they do elective cases; each attending knows when he operates. But how do you determine the order of cases? Some cases have to be last if they involve an infection; others which may involve two surgical teams ought to go first when you know everyone will be free. But do you schedule a long case before short ones? When do you schedule a case with indeterminate length (such as a cancer surgery where it's unclear how extensive the resection will be)? If you schedule it early, then subsequent patients may be waiting inappropriately. If you schedule it later, then it can potentially go on past when you should be staffing elective cases. And a scheduler has to look at the big picture; not everyone can schedule cases requiring intraoperative X-ray at the same time, and not everyone can schedule a 2-hour case first thing in the morning because if all the patients arrive in the PACU (recovery room) at the same time, the nurses there will be overwhelmed. This may be the sort of problem that decision-making software and analyses can aid.

Signing Out Patients

2011-12-03T23:20:00.000-08:00

Anesthesia is one of only a handful of specialties that allows the full responsibility for care of a patient to pass through multiple providers. At the end of the day, those on call will "relieve" the non-call anesthesiologists. We sign over the entirety of care to those taking over, something only seen in places like the emergency department. While on other services like medicine, surgery, or pediatrics, a night person often "covers" patients while the primary providers aren't in house, the main provider stays the same. So becoming comfortable with this new concept took me some time.

On some level, it makes a lot of sense. A surgery may be incredibly long, and fatigue is the anathema of the anesthesiologist (our motto is "vigilance"). We give each other breaks, and an extension of this is to sign over all the care of the patient. This means we have to encapsulate all our thoughts, our plans, and our anticipations for a case in a brief summary to another provider; it also means that if we're taking over, we have to quickly assimilate to a new situation to care for a patient safely. We have to deal with differences in anesthetic approach, quirks, or complex situations, but for the most part, this is fine; there are only so many ways of providing anesthesia, and all anesthesiologists need to be facile with managing any of them.

The trade-off is that we lose continuity of patient care, but we build a trust and relationship with our colleagues that is quite remarkable. This system also allows a shared responsibility for the burden of long cases and call; as a result, anesthesiology is known for its quality of life.

1400 (ish)

2011-12-02T23:31:00.001-08:00

Image of Phyllis Siegel and Connie Kopelov, the first same-sex couple to get married at the Manhattan City Clerk's office, is shown under Fair Use.

Interview Season

2011-11-30T22:45:00.001-08:00

The end of November marks the beginning of the residency interview season. I recently had dinner with anesthesia applicants, and how different it feels being on the resident side! No longer is it a scramble to get from place to place, to present oneself formally, to try to absorb a whirlwind of information about each program. Instead, it's great food with wonderful company, a time to share stories and meet potential residents. The process reminds me of all the hoops I had to jump through to get to where I am (and possibly portends the hoops I have yet to go), and it's kind of amazing I've weathered it all and still have a relatively decent attitude about it.

Graveyard Shift

2011-11-29T21:09:00.001-08:00

My last week at Stanford Hospital was on the graveyard shift, from 7pm to 7am. Night shifts are always hard for me. Though I'm able to switch over, it's exhausting, and no matter how much sleep I get, I always feel behind. When I arrive at 7pm, I usually finish up late-running cases from the daytime. It feels a little odd, closing cases that I didn't start, but the system works best this way; those anesthesiologists who didn't expect to stay late (and presumably have to work early the following day) get to go home. Then I take care of any add-on cases that weren't able to be done in the morning. I check the trauma room. And if all goes well, I get to take a nap while waiting for any code blues, traumas, or emergency surgeries.

For the most part, something comes up each night. I had exploratory laparotomies for acute abdomens, appendectomies, ruptured ectopic pregnancies, and a fracture causing compartment syndrome. It's a pretty good mix and ensures that I have to be ready for anything. I don't have much time to prepare so I have to formulate and execute an anesthetic plan quickly. I didn't have any major codes or serious traumas during my nights and so it wasn't too bad at all.

Frequent Fliers

2011-11-28T08:15:00.000-08:00

One reason why healthcare costs in the U.S. are spiraling out of control involves frequent fliers in the emergency department. I don't have any numbers or statistics, only a gut feeling borne of experiences in the emergency department, wards, and operating rooms. There is some small population of patients who utilize healthcare resources far more than anyone else, and furthermore, they use costly venues of healthcare delivery. These patients have chronic pain or uncontrolled psychiatric illness or social problems or addiction. They come repeatedly to the emergency department but aren't otherwise followed by a primary care physician. The E.D. places a band-aid on the problem, encourages them to get insurance and find a doctor, and sends them out. But we already know that they'll soon be back.

These repeat customers drain the system of resources. They drive up healthcare costs by hopping from one emergency department to another, getting a battery of tests, occasionally being admitted, and being sent home (or to the street) without a solid plan of care. Their diseases could be controlled in the right circumstance, but they have no incentive to do so and instead become frequent fliers on an episodic basis. Even some patients with chronic pain prefer to come into the emergency department to get boluses of IV opiates rather than control their disease long-term with a pain management plan.

I don't think this is either appropriate or sustainable. However, our solutions have not worked. There have been many initiatives to get patients like this a primary care doctor or medications or an urgent care clinic to visit, but the problem is still persistent. I think the only way to make headway on this problem is to get buy-in from the patients. We need to contract with them; if they come in with chronic pain complaints and have no other etiology for pain, then they only get pain medications they could have taken at home. If they frequently have psychiatric crises, they do not need the battery of laboratory tests we normally send (we usually send a complete blood count, electrolytes, liver function tests, HIV screen, thyroid function tests, urinalysis, urine toxicology, and EKG prior to admitting the patient to psychiatry). We find some incentive for patients if they are sent to the emergency department by an urgent care clinic or their primary physician. We need to search for solutions for this problem, especially as resources get more and more limited.

Not All Cookie Cutter

2011-11-26T20:59:00.000-08:00

Some people perceive anesthesia as being fairly straightforward, and most of the time it is. Many surgeries have a routine: assess patient, start the IV, bring the patient back, place monitors, induce anesthesia, intubate the patient, give antibiotics, maintain anesthesia throughout the case, wake the patient up, extubate, and bring the patient to recovery. And there are many days when we do not deviate from this steadfast course. But like everything in medicine, it isn't the routine that pushes our skills as physicians, but the exceptions.

When a day goes smoothly, I am thankful and I learn things, but I await those cases that challenge me. Some may seem minor; for example, I anesthetized a patient who had nausea and vomiting after every other surgery in the past. So we took out all the stops, giving steroids at the beginning of the case, multiple antiemetics at the end, avoiding emetogenic agents, and maintaining anesthesia with an intravenous infusion of propofol rather than inhaled gases. The outcome? She was thoroughly impressed and very satisfied with the anesthetic after the surgery.

Other cases that stress us involve life-threatening disease states. While on call, I was asked to prepare a patient for anesthesia who had a solid organ transplant, a bone marrow transplant, and active chemotherapy; all her blood counts were flagged bright red in our electronic medical record. Prior to incision, we gave two units of FFP, platelets, and packed red blood cells. Her infected knee was likely causing a low-grade sepsis, she had altered mental status, and her kidneys were failing. While a knee incision and drainage isn't a serious surgery, this was a patient requiring us to use all our available tools to maintain homeostasis.

Lastly, it's not just the medical and technical aspects of anesthesia that are challenging. One morning, my first case of the day was for a patient with Down syndrome. Although relatively high-functioning for someone with trisomy 21, he acted more like a child than an adult. I had to sit with him and coax him to allow me to take a look at his veins. He was understandably scared and reluctant to have anything done, and it took me ten minutes to place an IV (luckily, I got it on the first try as I knew he wouldn't let me have a second). I had to develop a trusting patient-physician relationship before he'd let me do anything.

Black Friday

2011-11-25T22:29:00.000-08:00

I don't really partake in the Black Friday craze, but the concept is interesting to me. How can a holiday be created by commercial forces? Five years ago, this day didn't even have a name, and somehow it has become a phenomenon which has retailers opening stores earlier and earlier, customers forming lines far in advance, and, most frighteningly, injuries from shopping.

All of this is fascinating to me because of the psychology involved. I don't know much about psychology, but as I talk to friends about this, I want to learn more. For example, right in Menlo Park, a jam study was held at Draeger's looking at whether customers bought more jam if more choices or fewer choices were given. While customers sampled more jam when offered more options, they bought more when offered fewer options. With Black Friday, I browsed some online websites and felt myself drawn to investigate deals on items I would never have bought otherwise. What's the psychology involved to lure me into spending more while thinking I was spending less? While many of us use supermarket "loyalty" cards (like a "Safeway card") because it affords us discounts, and we think supermarket chains use them to build up repeat customers, the true value of loyalty cards lies in allowing the retailer to track what we buy and learn our habits. This is an immensely powerful tool for them to tailor their sales strategies to individual customers.

These are just a few examples of how we as consumers are unconsciously influenced. I don't mean to judge whether they are good or bad; rather, I think they are quite clever yet scary in exploiting vulnerabilities in human psychology. But since it is Black Friday, I figured I'd spend a moment to jot something down about it.

Thanksgiving

2011-11-24T09:11:00.001-08:00

I am thankful for those I love and those who love me.

Image of "The First Thanksgiving at Plymouth" by Jennie Brownscombe is shown under Fair Use, from Wikipedia.

The MRI

2011-11-22T21:08:00.001-08:00

Like endoscopy, the MRI is a dreaded place for the anesthesiologist because it is a remote out-of-OR location. I had to provide general anesthesia to a patient who required an MRI but could not tolerate the positioning and duration. I went down to the depths of the hospital, uncertain of what I'd find. MRI is a tricky business because the strong magnetic field it creates limits the equipment that can accompany patients. Before entering the room, I emptied my pockets and even took off my badge. The MRI-compatible anesthesia machine and monitors were old and confusing.

We had a patient with a difficult airway and we were miles away from any other anesthesiologist. Although we initially tried an asleep fiberoptic intubation, we could not see the vocal cords, so instead, we did a direct laryngoscopy and managed to intubate the old fashioned way. While we were struggling to get a way to help breathe for the patient, I was terrified. In the operating room, we have so many more resources - other anesthesiologists, fancy equipment, nurses and anesthesia techs to help. But in MRI, we had only what we brought (luckily, we had anticipated this and brought the difficult airway cart).

The scan itself was a little scary as well. The patent's blood pressures required constant vasopressor support so I kept on popping in to give more medication. I had heard this from patients, but MRIs are loud and the noises they make are unpredictable. During the scan, we didn't have access to the patient's IV site, airway, or body (if we needed to start chest compressions). It made me realize that environment plays a lot in determining the difficulty of our jobs.

Image is in the public domain, from nihlbi.nih.gov.

The Person and the Procedure

2011-11-21T21:00:00.000-08:00

At the beginning of anesthesia residency, we discussed three factors and how they influenced the morbidity and mortality of a surgery. What makes a surgery risky? Is it the patient and his comorbidities? Is it the surgery itself? Or is it the anesthesia? While of course it is difficult to tease all these factors apart, from what we can surmise, it is actually the stress of surgery that makes up most of the risk. Even though an appendectomy and a liver transplant both involve the same anesthetic technique, one is clearly a bigger procedure than the other. A knee surgery can be done under a spinal anesthetic or a general, but the difference in risk between the techniques is minuscule.

This is important to me because as the anesthesiologist, I am complicit in whatever we do, yet I bring the lowest risk to the table. There have been multiple times where I look at a patient or procedure and I worry. But most of the time, all we can do as anesthesiologists is to reduce the risk as best we can. We select more monitors, place better access, anticipate possible emergencies, and pre-emptively treat evolving clinical situations. This is the art of anesthesia.

I had to provide anesthesia for a middle aged man getting a tunneled dialysis line. This doesn't sound too bad until I realized that he had a cardiac arrest 9 days ago with pulseless electrical activity as well as congestive heart failure, atrial fibrillation, congestive hepatopathy, coronary artery disease, diabetes, and ascites. His cardiac arrest lead to acute renal failure, and now he is dialysis dependent. This is a scary anesthetic to provide; even though the procedure was minor and I would be administering as little as possible, the risk for something bad happening was very high.

Sometimes I feel that anesthesia is about tempering those dangers of surgery superimposed on a frail patient, and it is times like these that I feel I can utilize everything I've learned about medicine to use a gentle hand to guide a patient through a stressful situation.

Urology

2011-11-19T21:57:00.000-08:00

I also spent two weeks doing anesthesia for urology cases. Similar to my orthopedic anesthesia rotation, the faculty have created a curriculum to teach the aspects of anesthesia that are specific to procedures like transurthetral resection of the prostate, robot-assisted radical prostatectomies, cystoscopies and ureteral stents, and kidney surgeries.

There were two urology surgeries that were particularly interesting. Both were surgeries for prostate cancer. For one, the patient had a recent severe heart attack with multiple cardiac stents placed. The ejection fraction of the heart, normally 55-70%, was merely 20%. In the second case, the patient had tetralogy of Fallot, a serious congenital heart defect that causes babies to be blue. He had this repaired as an infant when they had just started doing cardiac surgery for this anomaly. This, in fact, was his first surgery that didn't involve cardiopulmonary bypass.

I was paired with a cardiac anesthesiologist in both cases, and intraoperatively we examined the heart with a transesophageal echocardiogram (TEE), a probe placed into the esophagus that uses ultrasound waves to examine the heart from within the body. It was really fun and amazingly educational to see each chamber and valve. I always enjoyed learning about transthoracic echocardiograms (TTE) and this is an intraoperative analogue to help monitor the patient.

Diagram of TEE shown under Creative Commons Attribution License, from Wikipedia.

A Taste of Our Own Medicine

2011-11-18T14:53:00.000-08:00

As an intern, some of the most common pages I got were: "patient requesting something for sleep" or "patient is itchy." Diphenhydramine (Benadryl), shown above, was an occasional response. I'm currently on night shifts (a future blog later) and so I took some diphenhydramine to help sleep during the day. It hit me hard. I got a ton of side effects, including dry mouth, ataxia, blurred vision, difficulty concentrating, dizziness, and irritability. It didn't even help me sleep all that well. It was a taste of my own medicine. It reminded me that even medications we consider routine can have potent side effects, and when given to elderly, sick, hospitalized patients, can lead to adverse events like falls. Nothing is completely safe.

Image shown under Fair Use, from myhealth.ucsd.edu.

Charon

2011-11-17T06:38:00.000-08:00

Charon is the ferryman of Hades in Greek mythology who carries souls across the rivers Styx and Acheron to the land of the dead. Perhaps a morbid thought, but occasionally I have wondered if anesthesiologists are similar (but distinctly different) mariners. We dare to cross that threshold with the faith that our trips are not one-way. We take those, coin in eye, who have some need of transient depth, who trust us as navigators and cartographers. Are patients the modern day Heracles and Orpheus? Do we carry them across some mythical river and return them safely from their katabasis?

Image is Gustave Dore's illustration to Dante's Inferno, in the public domain, from Wikipedia.

Hodgepodge

2011-11-15T13:27:00.000-08:00

Working in the general OR means that I get assigned to different cases each day, forcing me to think, plan, and learn about a variety of surgeries. I'm just starting to get over my fear of the spine. Spine surgeries are intimidating; they are long, can have large blood loss, and the patients are prone (on their belly). In prone cases, we have less access to the airway, there is a risk of damage to the eyes or nose, and flipping the patient is not as easy as it sounds. But after doing a cervical spine fusion and a couple lumbar laminectomies, I'm starting to feel a little better about spine cases. The cervical spine fusion was interesting; a neuro tech monitors specific muscle groups intraoperatively to ensure that the surgeons don't damage any nerves.

Of course I had my share of general surgery cases such as exploratory laparotomies, appendectomies, and cholecystectomies, but the most interesting cases were the sleeve gastrectomies. I spent one day providing anesthesia to morbidly obese patients getting weight-loss surgeries. These patients provide a unique anesthetic challenge because the dosing of our drugs doesn't scale linearly with weight; indeed, most medications aren't tested for patients above a certain weight. Thus, I had to learn about pharmacokinetic principles in the obese patient. Moreover, obese patients provide a challenge for intubation; there's less time because their lungs have less reserve, and there's more soft tissue that can get in the way of placing the breathing tube.

The other rooms I've been assigned to have been pretty typical: lymph node biopsies with ENT, breast biopsies with general surgery, more hips and knees with orthopedics, soft tissue mass excisions with plastic surgery. It's been a really good mix.

Image of spine dissection is shown under Creative Commons Attribution Share-Alike License, from Wikipedia.

Medication Shortages

2011-11-14T12:40:00.000-08:00

When we think of limitations that prevent patients from getting medications, we think of insurance reasons, access to physicians and pharmacies, cost, language barriers, or education limitations. We don't normally worry that the drugs are not available because there's a shortage. But as an anesthesia resident, I have become painfully aware of medications with limited supply.

Today, I was reminded that there's been a six-month dearth of calcium chloride. This boggles my mind. Calcium isn't some fancy targeted immunotherapy. And even more, calcium chloride is a code medication used in emergencies. And it's not just calcium; we have shortages in fentanyl, morphine, atropine, labetalol, and a few other drugs.

How can this be so? How can we have a shortage of drugs we use daily or medications necessary in emergencies? Is medicine this vulnerable to the fickleness of supply and demand? Are there so few suppliers that if one gets into problems, no one can get the medication? And what are the issues for the manufacturers? Medications don't just grow on trees (well aspirin, taxol, and a few others do). But there are a lot of factors doctors don't know. Who makes the drugs? What regulations make it difficult to enter the market? What incentives are there to keep hospitals supplied? What backup mechanisms are in place if a company goes out of business?

Image of Bayer heroin bottle is in the public domain, shown under Fair Use.

Call

2011-11-13T15:11:00.000-08:00

On call, I get paged for an emergency surgery. A patient is transferred to Stanford from an outside hospital for symptoms of a small bowel obstruction. He has inflammatory bowel disease, cirrhosis, hepatitis C, and a history of a small bowel resection and colostomy. He presented initially with nausea, vomiting, and abdominal pain; imaging was consistent with an SBO. The general surgeons told me that they expected to take down some adhesions near his colostomy, and the surgery duration would be less than an hour.

When on call, there's not much time to prepare, and so I set the room up for a general anesthetic, spoke to and examined the patient in five minutes, and put him to sleep. I noticed initially he was tachycardic with a heart rate in the 110s and slightly hypotensive with a blood pressure around 100/60 but I attributed this to his hypovolemia from dehydration and cirrhosis. The surgery initially seemed to go well but he needed intermittent vasopressors to keep his blood pressure going.

Suddenly, I heard a lot of talking over the drape (across the blood-brain barrier). Unfortunately, the surgeons had opened up the belly only to find frank peritonitis; the patient had perforated his bowel and was spilling gut contents into his abdomen. As if on cue, the patient's blood pressure and heart rate started reflecting widespread infection. He was septic. I immediately sprang into action, ordering colloid fluids and platelets given the cirrhosis, placing an arterial line under the drapes and sending an ABG, and starting broader-spectrum antibiotics. I had to start the patient on a vasopressor drip, obtain additional IV access, and secure an ICU bed. Fortunately, he did okay and although he had a short stay in intensive care, the surgeons were able to get the infection under control.

This call reminded me that anesthesia is a dynamic process and that what we expect going into a surgery may be entirely different than what we get and how things look coming out of surgery. We have to be ready to act quickly and escalate our care given rapidly evolving medical and surgical conditions. A situation that appears relatively stable can change rapidly and unexpectedly.

Ones

2011-11-11T11:11:00.000-08:00

When I was in elementary school, I always got excited to see my digital watch create patterns of numbers, and 11:11 was one of them (so was midnight 00:00). There is something secretly magical about moments like these even though we know they're artificially created and silly to imagine. But today, and more specifically, a minute is an instance unlike any other, so make a wish, smile, celebrate.

Image taken by one of my friends.

Waste II

2011-11-09T21:21:00.000-08:00

This is a continuation of yesterday's post.

Part of anesthesia is anticipating emergencies and treating them timely. Clinical situations in the operating room can arise so quickly that we have to be ready to act at any time. Thus, for every case, I draw some "emergency drugs," mostly to control blood pressure. But if at the end of the day I have emergency medications I didn't use, I have to throw them out. I'm not sure how to reconcile this problem. Emergency vasopressors such as ephedrine or phenylephrine can take a minute or two to dilute and prepare, and in a critical situation, this time and distraction can lead to patient harm. After medications expire, they should be discarded. There's no way around this; in order to keep my patients safe, I have to draw medications I'm not sure I'll use. What happens to vials that are drawn but not used (or vials that are broken)? I assume the hospital simply absorbs the cost, and that too, is another reason why hospital finances can be so tricky.

It's not just a problem with drugs. In the same way, prior to intubating a patient, I have two different laryngoscope blades available, one as a rescue blade if I run into trouble. I always have both available, but rarely have to resort to the backup. I used to take out two oral airways until we had a shortage; now I am a lot more conscientious of producing unnecessary waste. I used to have two sizes of endotracheal tubes available, but now I think of each patient to decide whether I need to have multiple prepared. These are all instances where I prepare more than the minimum equipment, thus using resources and my time. But a lot of these, at least in this stage of my training, seem to be necessary to ensure patient safety.

All I can do is to be aware of how much I use and how much I waste, and within the confines of what is safe for the patient, minimize anything unnecessary.

Waste I

2011-11-08T20:03:00.000-08:00

We are in a world and a society that abhors waste. We recycle, reuse, reduce. We compost, ration what we buy and throw out, measure our carbon footprint. We are conscientious of how green we are. I have blogged on this in the past, but hospitals are immensely wasteful. They are slow to adopt this movement that has already taken other industries and lifestyles by wildfire. Anesthesia is no different. I got a comment on my last post about what happens to extra or unused syringes. It got me thinking about anesthetic waste.

Some of our waste is generated by single-dose vials. When I draw up succinylcholine, I draw up a 10cc syringe. Very few patients would require the full 10cc, and furthermore, there are few situations in which you dose succinylcholine twice due to risk of bradycardia and asystole. So for any patient who gets succinylcholine, some amount is wasted. Although I could calculate how much each patient would need and draw up a syringe with just the right amount, the vials are supposed to be single-dose; sterility is not guaranteed if I use a vial for multiple syringes. So like every other anesthesiologist, I draw up the full dose even though I never intend to give it all. This costs the system not only the additional drug, but also the biochemical disposal of the extra medication and the financial costs. This boggles my mind; why haven't we figured out a way to reduce this? And the topic raises other concerns; should patients be charged for the amount of medication they receive (such as 5cc of succinylcholine) or the entire vial (10cc, even though 5cc was simply discarded)? Should manufacturers change their vial sizes? Should we start pushing for multi-dose vials?

Electroconvulsive Therapy

2011-11-06T19:42:00.000-08:00

Electroconvulsive therapy is a psychiatric intervention where seizures are purposefully induced in a patient through shocks delivered by electrodes placed on the temples. It's used for refractory depression as well as other psychiatric illnesses like bipolar disease. The therapy is charged with controversy; no one knows how it works, shocking the brain to cause seizures sounds barbaric, it has a history of use without informed consent, and the patient population may not have rational thinking in deciding whether to pursue this. Nevertheless, it is an amazingly and surprisingly effective treatment for refractory psychiatric illness. I've met patients who say that they've been tried on many, many antidepressants and have had no response or too many side effects, but ever since trying ECT, their lives have completely turned around. I don't know all that much about the psychiatry behind it, but I wanted to talk about the anesthesia.

When we are on pre-operative clinic, we provide anesthesia for ECT in the morning (since clinic doesn't start all that early). It's really fascinating. Usually 4-6 patients show up a day, and many are repeat customers; ECT is sometimes given up to 3 times a week. This allowed me to develop relationships with a few of the patients. The therapy itself is short so I have to set everything up beforehand in order to keep things moving.

I get there early, draw up a ton of medications. While the therapy is short, the anesthesia is complex. We occasionally give caffeine to potentiate seizures. We give patients toradol for post-treatment pain and ondansetron for nausea. Then we give remifentanil as a rapidly acting opiate, induce general anesthesia with etomidate (which promotes seizure activity), and paralyze the patient with succinylcholine (in order to minimize post-seizure pain and injury). After general anesthesia is induced, we hyperventilate the patient with a mask, and the psychiatrists deliver their shock. They monitor the patient's motor activity (through a limb with a tourniquet so it does not get the succinylcholine and will display seizure activity) and electroencephalography. If all goes well, we're done. But I'm prepared to break the seizure with benzodiazepines. I can treat blood pressure with esmolol, nitroglycerin, phenylephrine, or ephedrine. All of this requires the preparation of a cocktail of drugs. I remember drawing up close to 40 syringes one morning.

What's amazing is that it works. After inducing a seizure in a patient, we wake them up, and they have no pain or recollection of the treatment. Most of the patients are completely satisfied with things and go home within half an hour, ready to come back for their next treatment later that week. This experience shows me the diversity of anesthestic techniques and introduces me to interventions I'd not seen before.

Image shown under Fair Use, from psych.med.umich.edu.

The Fifth of November

2011-11-05T23:11:00.000-07:00

Remember, remember the fifth of November,
Gunpowder, treason, and plot.
I see no reason why gunpowder treason
should ever be forgot.

Image is in the public domain, from Wikipedia.

To Be a Doctor

2011-11-04T23:20:00.000-07:00

When I applied to medical school, I had some preconceptions about what it was to be a doctor, and many turned out to be false. I wanted to write about one in particular. How many of us, before seeing what medicine actually was, thought of a doctor as someone who could encounter a life-or-death situation and nurse someone back to health? That being a physician meant that a call would be announced overhead on a plane and we'd rush to the side of a frightened, anxious person and be able to diagnose and cure the malady. That we'd stop at a car accident and make some heroic intervention that saves someone's life. Of course, no one goes into medicine expecting that this will be their everyday expectation. But perhaps we have some faint hope that medicine gives us a skill set that is remarkably versatile, spontaneous, and applicable to any situation.

Unfortunately, this is far from the truth. Even those in specialties that see a lot of undifferentiated illness, like family practice or emergency medicine, depend highly on the setting and allied health care professionals. Gone are the days that doctors carry all they need in a little black bag. Sure, we can diagnose and name treatments for most things, but away from an acute care setting or clinic, there is little we can do. And how many of us (who are not anesthesiologists) remember how to place leads for an EKG or put in an IV? How many of us know how to reconstitute an antibiotic or make a splint from scratch?

Medicine has evolved into a complex beast, one that requires many different people with complementary skill sets. Though some of us dreamed of that time where as a lone physician we could face everything, we quickly realize that such thoughts remain dreams.

A Little Downtime, and Add-Ons

2011-11-03T22:05:00.000-07:00

I apologize for the lack of updates; it's been busy. I've been getting assigned to a bunch of add-on cases after my scheduled cases finish, and it's been extraordinarily draining. Add-ons can be a little daunting because I spend a good amount of time preparing my daily cases. I do a thorough chart review, think through the anesthetic plan, review everything in my mind before going into each case. But with add-ons, we get called after our last scheduled case, and upon learning the urgency of the following surgery, I rush to prepare my room, scan over the chart, meet the patient, and talk to my attending. Often, add-on cases are sicker patients, admitted to the hospital with a pertinent medical condition. Their vital signs are abnormal, they are undergoing antibiotic therapy, their labs are off, they have less reserve. This compounds the fact that I don't have as much time to prepare.

But separately, add-on cases are also highly inefficient. I hear about a case, but it takes everyone an hour to get the room prepared. The equipment and case cart need to be brought in and opened. A team of a circulating and scrub nurse has to be identified. For cases with prosthetics, the representative from the biotech company must be available. We have to assure availability of surgery and anesthesia residents and attendings. So while scheduled cases are expected to turn over in 15 minutes, these add-ons drag on, and it's exhausting. But I'll be back to blogging regularly once my days permit.

Happy Halloween

2011-10-31T13:27:00.000-07:00

You may have to enlarge the picture. I have a thing for clever Halloween costumes. I hope you have many happy trick-or-treaters and a wickedly wonderful evening.

Image shown under Creative Commons Attribution Share-Alike License, from www.flickr.com.

Prior to Incision II

2011-10-29T20:24:00.000-07:00

This is a continuation of the case described yesterday. My attending and I scrambled to resuscitate this anesthetized patient, staving off a code and trying to figure out what was going on. I ended up pushing several sticks of phenylephrine and ephedrine, and finally we resorted to epinephrine. With just a touch of epinephrine, the patient's blood pressures and oxygen saturation shot back to normal. We ended up proceeding with the surgery, and although she required some mild vasopressors during the case, her vitals remained reasonable. After extubation, she did fine.

In the end, our hypothesis was that this patient had red (wo)man syndrome from vancomycin administration. Although she had tolerated vancomycin in the past, perhaps the rate we were administering it led to a transient vasodilation. On the floor, vancomycin is given quite slowly, but in the operating room, we administer it quicker to make sure we have systemic levels of antibiotics prior to incision (especially in a patient who has a history of prosthetic infections). Furthermore, co-administration of opiates and smooth muscle relaxants increases likelihood of red man syndrome. Mast cell degranulation and histamine release leads to transient hypotension and erythema; indeed under the drapes we noted a macular rash. Luckily, despite hemodynamic instability, this syndrome is rarely life-threatening.

Prior to Incision I

2011-10-28T21:56:00.000-07:00

A middle aged woman is getting a revision hip replacement. She has a significant cardiac history, mild congestive heart failure, gastroesophageal reflux disease, asthma, and severe arthritis. She underwent a primary total hip replacement six months ago, but unfortunately, the prosthesis was infected. It was subsequently removed and an antibiotic spacer was placed. Cultures grew methicillin resistant Staphylococcus aureus (MRSA) and she finished a course of vancomycin. After being cleared by the infectious disease specialists, she was scheduled for a revision hip arthroplasty.

After a smooth IV induction of anesthesia and an uneventful intubation, we placed a radial arterial line to follow blood pressures and blood gases, a second IV, and then positioned her in the lateral decubitus position. Her anesthesia was maintained through volatile anesthetics (sevoflurane), and vancomycin was started. The surgeons went out to scrub, and during that time, the patient's blood pressure and oxygen saturation dropped like a stone. Within thirty seconds, she went from 100% O2 saturation to 85%, and her blood pressures went from a mean arterial pressure of 70 to 30. I immediately started bagging with 100% oxygen, turned off the inhaled anesthetic, and pushed phenylephrine. Despite my best efforts, I could only modestly raise her oxygen and blood pressures. It was pretty terrifying. The orthopedic surgeons came back to find me in a flurry, drawing up medications while squeezing the bag, listening to breath sounds, inspecting the circuit, running my IVs wide open. There did not appear to be any problems with the ventilator or circuit, the airway pressures felt reasonable, I was delivering adequate tidal volumes, and yet on 100% inspired oxygen, the patient was at a meager 90% oxygen saturation. The patient had bilateral breath sounds, a mild tachycardia, but pulses were barely palpable. I went through sticks and sticks of phenylephrine trying to stave off a code. The exciting conclusion to this case will come tomorrow.

Endoscopy

2011-10-27T21:11:00.000-07:00

I was assigned to provide anesthesia in the endoscopy suite one day. Initially, I was relieved; after all, how bad could endoscopy be? Upper endoscopy, colonoscopy, and ERCPs shouldn't take too long and they weren't high risk procedures. Little did I know. In 95% of cases, endoscopies are done under conscious sedation supervised by the gastroenterologist; the anesthesiologist doesn't hear about them at all. They only call us if things are really tough. One of my endoscopies was for a woman with metastatic pancreatic cancer, congestive heart failure, oxygen-dependent chronic obstructive pulmonary disease, and renal failure. Managing her airway, fluids, and medications was definitely a challenge. Two of my patients had neurologic defects so they could not follow commands; we treated one like a pediatric patient, doing an inhaled induction and mask-ventilating until we could get an IV in place, then finishing the induction with IV anesthetics. One patient had a congenital defect and did not have forearms; of course, the anesthesiologist is given the responsibility of obtaining venous access. Lastly, I did not recognize how difficult "out-of-OR" anesthetics are; our equipment isn't the same, we are far away from additional help, and even our anesthesia techs who get our supplies are a ways away. It felt pretty isolated, and subsequently, a little scary providing general anesthetics in the basement of the hospital.

Image of an endoscopist is in the public domain, from Wikipedia.

On a Lighter Note

2011-10-26T22:18:00.001-07:00

I don't actually have the citation for this, but one of my friends sent it to me and I found it quite amusing. It is shown under Fair Use.

More Preoperative Clinic

2011-10-25T12:44:00.000-07:00

With the ebb and flow of the rotation lottery, I got assigned to yet another week of preoperative clinic, this time at Stanford. This was the clinic I worked in last year as an intern, and so I knew all the faculty and nurse practitioners really well. It was fun being back in a familiar environment, though compared to the VA, Stanford's preoperative clinic was much, much busier. With time and experience, the process becomes easier, more efficient, smoother, and now that I had been in the Stanford operating rooms, I had a keener sense of what patients would expect on the day of surgery.

5 Year Reunion

2011-10-23T14:42:00.000-07:00

This weekend was my five year college reunion, and oh, how remarkable it was. It was amazing to me how quickly five years passes and yet how much people accomplish in that time. Although I am still on the Farm, I loved the transformation of experience to the college I remember - the friends, the beautiful campus, the fun, the conversations, the memories. Friends came from so far, people I love very much but don't see very often, and I had a satisfyingly exhausting time.

Practice Makes Perfect

2011-10-20T16:17:00.000-07:00

Anesthesia is a specialty that achieves a good balance between hands-on and intellectual processes. While learning the science and art of the practice is a residency-long and life-long activity, it's reassuring to me to find that the hands-on side improves rapidly with time. When I started, I was hesitant, inefficient, and uncertain about procedures like placing an IV and intubation. I required a lot of assistance and help. Now as these become daily activities, I am becoming more and more successful, finding them easier and smoother.

The Entitled

2011-10-19T13:07:00.000-07:00

Medical care should never be different based on a patient's attitudes and behaviors. However, I can say that how patients treat their caregivers and the medical system changes how they are perceived and treated. The entitled patient, self-righteous, demanding, abrasive, and condescending, raises a lot of hair on our backs. This is the kind of patient where we itch to abridge the conversation, find our jobs frustrating, and let the patient's demands dictate care more than it should. Sometimes the patient insists on a specific test or treatment, and we acquiesce even though it is not appropriate. Sometimes the patient only wants to see certain people on the team, and this slows their care down. Sometimes the patient starts taking resources away from others.

Working with the so-called "difficult patient" is hard. As physicians, we have to remain impartial of our own feelings and biases, put aside those negative reactions and interactions and care for everyone with the same exacting standard. This is not easy, and we get training in medical school and beyond on how to work in these situations. However, patients do better if they put themselves in the right light. They must strike a delicate balance between assertiveness and aggressiveness, making sure they advocate for themselves without endangering the relationship with their providers.

Laboratory Tests

2011-10-18T10:46:00.000-07:00

There's no good way of showing this chart without enlarging it, but I wanted to share it on this blog because it is a somewhat mindboggling display of normal ranges for laboratory values for an array of tests. I really like it as it captures some of the complexity of medicine in knowing when to send all these tests and how to respond to the results. Surprisingly, after doing a bit of medicine, many of these reference ranges feel intuitive.

Image is from Wikipedia, shown under Creative Commons License.

A Day in the Life of a Stanford Anesthesia Resident II

2011-10-16T19:51:00.000-07:00

Occasionally, I hear anesthesia characterized by "hours of boredom punctuated by moments of sheer terror" but I keep myself busy. During the case, I do serial surveillance sweeps, making sure all the equipment and IVs are working, the monitors are appropriate, and the patient's positioning and airway haven't changed. We pay close attention to the progress of the surgery, anticipating when dangerous, difficult, or specialized things may happen such as dissection near a large vessel or using cement for a joint replacement. We catch up and maintain the anesthetic record as well as prepare our next case, resupplying our airway equipment and drawing up new medications. Sometimes the attending will discuss salient learning points for the case.

As the surgeons finish up, I begin to lighten the anesthetic, give antiemetics and reversal, and get the patient breathing on their own. Once the surgeons finish, we're again under time pressure to have the patient extubated safely as soon as possible. After extubation and taking off unnecessary monitors and tubes, we move the patient to the gurney and take him to recovery. There, I give the nurse report and fill in the rest of the record. I go straight from recovery to the pre-op area for the next patient to consent them for anesthesia, answer questions, start my IV, and put a note in the computer.

The day proceeds pretty similarly. The pressure is higher when I do a lot of short cases that require fast turnover. Occasionally I have more breathing room with longer cases. If there's extra time during a case, I pre-op my patients for the following day, looking up their history, physical, labs, and prior anesthetic record in the computer.

At the end of all my scheduled cases, I give the scheduler a call. The scheduler is an attending who "runs the board," manages the OR flow, and fields requests for emergent or add-on cases. I'll help with any add-ons or emergencies, but hopefully I'm done with the day. I return my narcotics to the pharmacy, change my scrubs, and head home, usually between 5-7pm. That evening, I give my attending for the following day a call, reviewing the cases we have and my anesthetic plan. I make dinner, perhaps do a few chores, and then sleep pretty early.

A Day in the Life of a Stanford Anesthesia Resident I

2011-10-15T16:19:00.000-07:00

I get up at around 5:15 to make it to the hospital by 6am. Getting things going on time in the morning is incredibly important and a little stressful so I make a bee-line to pharmacy to check out my narcotics and then back to my room to set-up. After a quick survey to make sure all my emergency airway supplies (like an Ambu-Bag and O2 cylinder) are available, I set up the bed and machine the way I like it. The technician usually does the full machine check and I simply make sure the most important steps are working. I set up all my airway supplies, checking my largyngoscope blades and lightsources, making sure I have tape and a bougie handy, and testing my suction. It's usually 6:15 by now.

Then the tedious task of drawing up medications. I usually label all my syringes first, then draw up everything I need to start the first case: midazolam, fentanyl, lidocaine, several syringes of propofol, succinylcholine, rocuronium, cefazolin. I dilute my emergency phenylephrine and ephedrine, occasionally making atropine, esmolol, or nitroglycerin if I anticipate needing it. If I am early in time, I go ahead and draw my neostigmine, glycopyrrolate, and ondansetron. Some cases require preparing other medications like a propofol drip, hydromorphone, morphine, or bupivicaine. I usually have my IV start kit ready before I get to the hospital so at 6:35 I scurry out to meet the patient.

I meet the patient in the holding area and have just a few minutes to establish rapport, answer the patient's questions about anesthesia, review my pre-operative history and physical (which I researched the prior night), and consent the patient for the anesthetic. I then start an IV and fill out a quick note in the chart. After the patient is checked in by the nurse and meets their surgeon, then we're given clearance to roll back to the OR.

Once in the operating room, we get the patient positioned, hook up our monitors, perform a spinal or epidural if appropriate, and pre-oxygenate the patient. Then the pace slows down. The crux of the anesthetic, induction and intubation, demands attention to detail and care. While all of the foregoing things can be efficient and pared down, once we are ready for the start of anesthesia, we control the pace. I've written about intubation before, and right after the airway is secured, the speed of things returns to its prior intensity. Along with the surgeon, we position the patient, make sure pressure points are padded, start a warming blanket, and place any additional IVs, arterial lines, temperature monitors, or orogastric tubes. Then we're ready for the surgery.

Usually, the attending gets me out for a fifteen minute breakfast once the case is underway. Stanford anesthesia provides an amazing breakfast array with hardboiled eggs, english muffins, toast, cheese, nutella, bananas, yogurt, and other goodies. It's a short break to catch my breath, reflect on the morning, and prepare for the rest of the day.

The Real Residents

2011-10-14T16:36:00.000-07:00

Although we are called residents and housestaff, most days of the week, I get to leave the hospital and go home. Over the last few weeks, I have noticed some people around the hospital who are here even longer and later than I am.

We don't often think of our patients' families. Of course, when they are at the bedside and asking questions, when we run into them in the hallways, when we are giving discharge instructions, we are glad they are around. But I often don't realize how hard it must be to be present when the intern pre-rounds at 6:30am, to ask questions when the attending comes later in the morning, to help the patient get to the bathroom, to assist the physical therapists, to accompany their loved one to radiology or endoscopy or other tests, to bring food in the evening, and to hold their hand and watch television at night. It's a full time job, caring for someone in the hospital, and family members are the underappreciated. So next time I see a caregiver, I give them a word of encouragement, a smile, an understanding that they are as central to the healing process as we are.

Intern Year Revisited

2011-10-12T14:42:00.000-07:00

After doing my medicine internship here, it's incredibly fun to see my previous co-interns now as residents, running their teams, teaching, rotating through the ICU, and consulting on patients. I see their notes, run into them in the hallways, and stop by their team rooms to talk about patients. When I was on pain consult, I knew all the residents and some of the attendings for the medicine patients we saw. The bonds we formed in intern year really carry through, and we will do favors for each other and try to make each other's lives easier. It's great to be able to talk about our shared patients with different perspectives and expertise; we teach each other, help each other, and support each other.

Chartomegaly

2011-10-10T21:14:00.000-07:00

The suffix "megaly" means large; cardiomegaly is a large heart, hepatomegaly is a large liver, even acromegaly means large digits. Chartomegaly means someone's chart is out of control. Unfortunately, I think with medical records, everyone is starting to get chartomegaly. It bothers me that now with functions such as copy and paste or printing pre-determined phrases, the majority of a medical record is completely useless. For example, before every anesthetic, I click a button that creates a note that says "The patient's history and physical were reviewed and the patient's condition is appropriate for anesthesia. Please see anesthesia pre-op note for full details." This is a completely useless note and creates unnecessary clutter in the chart. Indeed, patients who go to the emergency department can have dozens of separate nursing notes that say things like, "Consultant at bedside" or "Assisted patient to bathroom." While perhaps somewhere there is legal or financial reasons to keep such information, it dilutes the chart down so that we cannot find what we're looking for.

With paper records, we lamented that we could not find old documents when we needed them. Things have not changed with the electronic record. There is great faith in the electronic medical record by the government and those who champion systems solutions, but in my mind there is a long way to go before useful, manageable, efficient, and informative charts are in place.

Book Review: Hunger Games

2011-10-09T16:40:00.000-07:00

I waffle back and forth on what to read for fun during residency. During the day we are so inundated with complex information, journal articles, diagrams and tables, that occasionally we go home and simply want something to entertain. The Hunger Games by Suzanne Collins did just that. A science fiction novel similar to Ender's Game, it features a futuristic dystopia where a child protagonist is pitted against an all-powerful evil government. It's not an incredibly sophisticated book, but it's an easy page-turner that kept me up past my bedtime. Although it could have done more as a moral and psychological bildungsroman, it instead sells itself as a thriller. However, the rest of the trilogy disappointed me; it seemed as though the author lost control of her characters and plot. But the first book of the series was definitely a diversion from residency.

Image shown under Fair Use, from Wikipedia.

The Spinal Anesthetic

2011-10-08T18:00:00.000-07:00

Orthopedic anesthesia is a great rotation to learn the spinal anesthetic, shown above. The spinal is pretty much the same as a lumbar puncture; a long needle is placed into the low back to access the spinal or subarachnoid space. In a lumbar puncture, fluid is taken out and tested for meningitis or other diseases. In a spinal, local anesthetic or opiate is injected to numb the nerves supplying the legs. Many people are afraid of the "spinal tap," and from the outside, it feels like a terrifying procedure. People are afraid of the spine, cannot see the needle going in, and have to maintain an uncomfortable position. But from a medical standpoint, the LP or spinal anesthetic is one of the more minor procedures where the risks are far lower than the benefits.

I offered a spinal anesthetic for all my hip and knee joint replacements. With total knees, a spinal anesthetic numbs the legs so that the patient does not need a general anesthetic; the case is instead done under deep sedation. With total hips, the patient still receives a general, but the post-operative pain and overall opiate consumption is much less with a spinal. Indeed, the difference between two patients, one who elected for a spinal and one who didn't, was remarkable; it's amazing to be able to wake someone up from surgery and have them be completely comfortable.

Learning the spinal was a good experience. I'd done LPs in the past, but these are different because in the operating room, there's always time pressure. I didn't have time to dilly-dally, and I had to be confident of my movements. But over the course of the last two weeks, I really became comfortable with the procedure, planning everything in advance, understanding exactly how things felt, and knowing when I was in the right space. I'm starting to feel like an anesthesiologist.

Image of spinal anesthetic shown under Creative Commons Attribution Share-Alike License, from Wikipedia

Orthopedics

2011-10-07T21:32:00.000-07:00

I just finished my two week orthopedic anesthesia rotation, which was a perfect re-introduction to the operating room. The orthopedics rotation is designed to teach us about specific anesthetic concerns regarding joint replacement. We work with a small group of anesthesia attendings and surgeons and do mostly hip and knee replacements, which allow us to learn a few surgeries very well. There's a syllabus that covers much of orthopedic anesthesia, from the use of tourniquets to rare events such as cement emboli to proper neuraxial anesthesia techniques. Early in the year, I feel that it's so helpful to have a routine, and when I look at my schedule and see three knees and a hip, I know what to plan for and how to structure my day. I learn to anticipate what surgeons will do at each step of the procedure. I get to do a good variety of spinal anesthetics, general anesthetics, and cases with deep sedation. While at the VA, I approached knee and hip surgeries with one anesthetic plan, on this rotation, I got to see the range of possible anesthetic approaches and how patients did with each postoperatively.

Image of a knee X-ray after a joint replacement shown under GNU Free Documentation License, from Wikipedia.

Stay Hungry, Stay Foolish

2011-10-06T21:58:00.000-07:00

I rarely write about current events and almost never write about people, but I wanted to take a moment to acknowledge how profoundly our world has changed due to Steve Jobs. Listening again to his talks at the 1997 Apple Worldwide Developer's Conference and the 2005 Stanford Commencement really helped me realize how visionary and instinctive he was. He's inspiring as a leader in a way few people are. Stay hungry, stay foolish.

Image is by Jonathan Mak Long, from tumblr, shown under Fair Use.

Pain and Philosophy

2011-10-04T21:06:00.000-07:00

Pain is a fascinating philosophical concept. We have been thinking about it for years, and many seminal philosophy papers deal with the nature of pain. What is it? Why does it happen? How do we quantify it? How do we experience it? Someday I'll probably study this again, but I wanted to share some specific questions that interest me in particular. In medicine, we regard it as a "fifth vital sign," yet unlike other vitals, it has a subjective element to it. A 10/10 pain is different to a child than to a woman who has had three children and kidney stones. The same surgical incision may elicit completely different pain scores from two different patients. It contains a relativistic component; when we say "a 10 is the worst pain you can imagine," imaginations differ widely and experiences differ widely. Pain is contained within the experience of the person who has it, and it must undergo some interpretation for that person to quantify or qualify it to someone else. Every other vital sign is objectively measured, but pain is not. Yet rapidly evolving sciences may someday devise a way to measure someone's pain with a device or instrument. Will we one day quantify the number of C-fiber neurons firing and correlate that with a severity of experience? What will that mean? Is that a fair thing to do?

Pain and suffering also have etiologic questions. Why do they exist? Certainly, there is a survival benefit to withdrawing one's hand if one encounters a fire. But there are a lot of other pains that don't seem to have an obvious Darwinian benefit. Are migraines protective in any way? Why does chronic neuropathic pain occur? Shouldn't a crucially important pain such as angina be more specifically felt by a patient than just "chest discomfort?"

These are just some of the philosophical issues about pain that fascinate me. Pain is much more than something to treat with morphine. It is an experience that profoundly changes patients' lives, their sense of well-being, their hormones, their psychology. Perhaps thinking of pain in a philosophical sense isn't for everyone, but for me, I find it enlightening.

3x5 Cards

2011-10-03T21:33:00.000-07:00

In Samuel Shem's The House of God, one of the residents, the Fat Man, claims anything can fit on a 3x5 card. Every single patient is summarized neatly on an index card, incorporating all the pertinent findings, laboratory values, diagnoses, treatments, medications. As a medical student and intern, I quickly realized this did not work for me. I copiously scribbled every possible bit of information, needing full-sized sheets of paper.

Now on anesthesia where our scope is much more narrowly defined, I find that I am using 3x5 cards again. It's really quite satisfying to capture all the important details of all the patients for a day on index cards that fit neatly in my pocket.

Image shown under Creative Commons Share-Alike License, from Wikipedia.

The Small Things

2011-10-01T20:05:00.000-07:00

I'm finally in the Stanford operating rooms now. After spending a month on acute pain, I'm slowly relearning the basics of anesthesia in the big house. So much of what matters early on is logistic and not medical. My first day in the Stanford OR was so hard because I didn't know how things worked here. Small things like familiarity with the anesthesia cart has everything to do with efficiency. I can tell you what each drawer in the VA anesthesia cart contains. I know exactly where to reach for each medication. But I had to familiarize myself with the set-up at Stanford. Medication vials look different. Each drawer contains different equipment. Even small things like the patient gowns are different. Why does this make so much of a difference? Patient gowns at the VA unbutton at the sleeves but they don't at Stanford; this means that IV's have to be threaded into the sleeve so taking off the gown doesn't get in the way. The first day consisted entirely of learning these details.

Other things I didn't anticipate also posed challenges. The anesthesia machines were different, so I had to re-orient myself to where data appears, how to change settings. Figuring out paper charting and billing feels like a hassle. And simply understanding the process by which a patient in the holding area is deemed ready for surgery, getting them to the right OR (for some reason, OR 21 is nowhere near OR 15-20), and identifying the right PACU slot was time consuming. There was little orientation so being thrown into the mess was a little terrifying, but that's simply part of learning a new system.

Patients on the Pain Service

2011-09-29T21:09:00.000-07:00

I saw a lot of fascinating cases on pain service. One woman who had never taken a pain medication in her life was admitted with a fracture. Her primary doctor put her on escalating doses of morphine but she didn't get any relief. She continued to report severe pain, and finally we were consulted. We suggested patient-controlled analgesia with hydromorphone, a related opiate. She controlled how much she could get; this would allow us to calculate her needs. With one push, she fell asleep and her pain was completely eliminated. For some reason, this woman responded to one opiate but not another. Yet when we tapered her off of her morphine, she showed signs of withdrawal. Although she got no pain relief from morphine, she got all the side effects.

Another patient was a woman who had her arm amputated in a work accident. It was awful; she underwent plastic surgery, but afterwards, had the sensation of phantom limb pain. Even though she had no hand, she could feel her fingers, intertwined, knotted up, highly uncomfortable. Her brain was still sending signals assuming her hand was there. We approached this aggressively; she normally takes no medications, and we immediately put her on six. Yet that strange sensation never left; I realized how elusive certain forms of pain can be.

Lastly, I took care of a patient who had anaphylaxis, a life-threatening allergy, to fifteen different medicines, most of which were pain medications. She could not tolerate codeine, hydrocodone, oxycodone, morphine, hydromorphone. Her chronic pain was controlled with methadone. But she was getting a shoulder surgery, and afterwards we had to tackle her pain despite her allergies. Interestingly, the other medication she tolerated well is meperidine which has a similar chemical structure to methadone. Although negotiating her pain was a challenge, it was also a highly educational experience.

Addiction

2011-09-27T20:23:00.000-07:00

Although interrelated, pain medicine and addiction medicine are separate fields. However, on my acute pain rotation, I was introduced to some of the issues regarding opiate addiction. Addiction is an awful disease. We saw several patients, all young, all of whom became tolerant to and then dependent on pain medications. These are the patients who all the attendings know; they spend more time in the hospital than out of it and each time they are here, pain management gets consulted. Some patients have real pathology; one had an extensive surgery and has real pain, but over a prolonged hospital stay of several months, has required more and more pain medication. Even though now she is actively trying to decrease her use, it is a long road because she's been on opiates for so long. On the other hand, we have another patient who is on sky-high doses of IV pushes, probably because she likes the feeling she gets from it. Converting her to equivalent doses of long-acting medication or even to a patient-controlled machine don't achieve the same effect. She has no intention of changing her regimen and is incorrigible in her demands.

Sometimes physicians find these patients frustrating. Addiction makes patients belligerent, hostile, demanding. It decreases our threshold of safety for medications. It makes doctors wary and we undertreat pain and underprescribe medications on discharge because we don't want things to be abused. But it is also a very real disease. Patients with addiction have no free will at all. They are mentally, psychologically, and physically dependent. They have no choice in the matter, and it is not simply a question of willpower or strength of character. While patients can resolve to fight cancer or do physical therapy through pain, it is behavioral changes like overcoming addiction, exercising regularly, eating well that still proves to be the most challenging.

Image of opium poppy is in the public domain, from Wikipedia.

Home Call

2011-09-26T21:19:00.000-07:00

Home call is an odd concept. On the pain rotation, four of us took turns taking call. When on call, we'd stay late to tuck patients in but go home, available by pager. It's an odd feeling, having that loom over us. We carry our pagers around like a leash. We sleep in our beds, but never soundly. And the following day is a full work day like any other. It makes me respect what fellows and attendings do, because they often have pagers with them all the time. True, they get paged less often, but since the buck stops with them, I imagine the pager still gets checked impulsively.

On pain, most of the time, we are able to address pages remotely. We can troubleshoot certain issues and enter orders at home. But occasionally, especially if it is a problem related to an epidural, we have to come in, and that can be a little painful in the middle of the night between two full days.

Shades of Pain

2011-09-25T19:39:00.000-07:00

Many people think of pain as one sensation, one thing. But as I've learned on the pain service, pain comes in many forms and colors; each distresses a patient in a different way and each requires a separate treatment modality. For most of us, we think of pain as nociceptive pain, the type of pain we experience if we cut ourselves or burn ourselves or touch something acidic. It is the pain we expect someone to have after surgery. And indeed, a majority of our patients are post-operative, and this kind of pain responds well to opiates. But other types of pain include neuropathic pain, the type of discomfort long-standing diabetics feel in the absence of injury. Phantom limb pain occurs when a patient has an amputation but still feels his hand and fingers. I saw a patient with this that was extraordinarily difficult to control. Headaches have many characters but most of them are not related to the pain we feel if we slam a car door on our fingers. Whether a common tension headache, a low pressure headache worse when standing, an electrocuting trigeminal neuralgia, or debilitating migraine, pain takes on many different masks.

The worst pain I saw on this service was cancer pain. Unremitting, relentless, and unabating, cancer is really an awful perpetrator. These are the patients where we pull out all the stops. When metastatic disease invades muscle, nerves, adjacent organs, the spine, we have to tackle the discomfort with everything we have. The most extensive pain regimens I've seen involve patients with end-stage widely invasive cancer; they are on multiple fentanyl patches, suck on fentanyl lollipops, use hydromorphone PCAs with settings that would immediately overdose anyone else. We even use medications that double as street drugs like ketamine. What makes this difficult for me is that cancer pain does not get better. While pain improves after a surgery or a cut or a burn and even occasionally with nerve damage, cancer pain is dogged and challenges our ability to palliate until the end of life.

The 5pm Consult

2011-09-24T23:25:00.000-07:00

Hospital etiquette is to call consults early in the morning so that subspecialty services can see the patient and staff them by the afternoon. Sometimes we get exasperated by the consult that gets called at 5pm, especially if it is not urgent. But after being an intern in that situation of calling and a resident receiving that call, I've learned the far most important thing is to be polite, see the patient, and help the primary team. There's no place for laziness or unprofessional comments. It happens, of course; no one can deny how tiring, difficult, and stressful residency can be. But we always remember that we are here to take care of patients and staying an extra hour or two is hardly a big sacrifice.

Pain Management

2011-09-21T13:29:00.000-07:00

Pain, especially in the hospital, is such a prevalent problem. All physicians (except perhaps radiologists and pathologists) have some facility in treating pain. One of the first things we learn in residency is opiate management, quickly followed by learning the bowel regimen (since opiates commonly cause constipation). For the most part, doctors do just fine. So when do you need a consultation from a pain management specialist?

The pain subspecialty is made up of multiple specialties: anesthesiology, neurology, psychiatry, and physical medicine and rehabilitation. Thus, it is a highly interdisciplinary field that draws tools, skills, and strengths from many different areas. We approach pain in a multimodal manner; from a nonpharmacologic standpoint, we address psychological issues, psychiatric comorbidities, addiction, expectations, physical and occupational therapy, biofeedback, acupuncture and acupressure, meditation, massage. With medications, we use not only opiates, but opiates in many delivery systems: patient controlled analgesia, intrathecal administration, epidurals, transdermal delivery. We use the opiates other physicians fear: meperidine, suboxone, methadone, and sky-high doses of mainstream medications. And along with our multimodal approach, we use nonopiate adjuncts: acetaminophen (both orally and IV), NSAIDs, neuropathic agents, tricyclic antidepressants, selective norepinephrine re-uptake inhibitors, local anesthetics (both locally and intravenously), NMDA antagonists like ketamine.

Lastly, the pain service can do invasive procedures for pain. We block nerves under fluoroscopy in the operating room or ultrasound guidance at the bedside. We do trigger point injections with botox. We place continuous pump infusions into the spinal space. We do pulsed radiofrequency treatments, ablation of nerves, and implantation of spinal cord stimulators. I've done a few nerve blocks and it's incredibly satisfying to see the relief patients get. It's really a fascinating specialty.