Pedigree

Many years ago, when I was an undergraduate, I worked in a lab that studied adrenergic receptors, G-protein coupled receptors that bind catecholamines in the body. Recently, the Nobel Prize in Chemistry was awarded to two of the founding fathers who first began to understand adrenergic receptors: Brian Kobilka and Robert Lefkowitz. Strangely enough, they are almost research grandfathers to me. My principal investigator for my undergraduate research did his PhD in Dr. Kobilka's lab. When I interviewed at Duke for the MD/PhD program, I had an interview with Dr. Lefkowitz and chatted to him about his research. It's funny how small the research world is, and I'm thrilled that the Nobel prize was awarded to these two amazing pioneers who have not only elucidated receptor chemistry but also touched my life as well.

Image is in the public domain, from Wikipedia

Choosing When to Die

A woman in her 60s who has fought a battle with breast cancer presents with odd symptoms of an ascending paralysis. An unclear neurologic illness has slowly picked off her cranial nerves one by one to the point that she cannot even swallow, cough, or gag and has to be intubated to protect her from choking. A PET scan shows a concerning mass on the same side of her body as her original breast cancer, and after multiple tests, we determine that her cancer is causing this odd paraneoplastic paralysis. She is, however, still able to communicate by writing on a notepad.

The oncologists and neurologists sit down with the patient and her family to discuss options. They believe that with aggressive chemotherapy and radiation, they could suppress the cancer and would expect slow return of the patient's neurologic function. The patient, however, does not want this. She communicates completely clearly to us that she would not want to undergo chemoradiation, and in fact, wants palliative care. She has decided it is her time to pass on. She chooses to do it with dignity, without the uncertainty, fear, hair loss, pain, nausea, discomfort, and risk of chemotherapy. She says her goodbyes - hour-long heartfelt tearful farewells - and asks to be extubated. Although we did not think she would pass so quickly, she died in the next few hours. It was as if she had chosen to die.

We choose how we live, how we act, what matters, why we do things. Why should we not choose how we die? This woman surprised me because so many other patients want absolutely everything done to live. But she resolutely and stoutly chose not to try chemotherapy, even though it offered a chance at recovery. Her passing, and the way and timing of it, was entirely of her choosing.

Teaching

One of the best parts of the intensive care unit rotation is the privilege and opportunity to teach medical students. I have always loved teaching and feel that my passion for medicine was very much fostered by the mentors and role-models I had in medical school. Unfortunately, in anesthesiology, there's not as much of an opportunity to teach students. Few students rotate through, and rotations aren't long enough for a medical student to pick up more than the basics. But in the intensive care unit, there's so much opportunity to cultivate enthusiasm and curiosity. I love walking medical students through simple procedures, talking to them about landmark trials, and examining patients with them, especially when the story is still evolving and uncertain. There's something to learn for everyone - from antibiotics and EKGs for the medicine-bound to chest tubes and line placement for the surgery students to treatment of delirium for psychiatry students to evaluation of airway for those interested in emergency medicine or anesthesia. I also try to encourage students to step out of their comfort zones and learn about aspects of ICU medicine that frighten them: pressors and ventilators, end of life conversations, nutrition, lines and tubes. I learn things every day, and I try to make it a priority to teach something every day as well.

Moribund

It may be creepy to say, but sometimes just by seeing a patient, I know they won't make it. After being in the unit long enough, I've seen enough people to get a sense of the ones who, despite everything we do, will die. I met Ms. A in the emergency department a week ago. She had end stage cancer and looked like a stiff wind might knock her over. At first, I thought her frailty encompassed mind and body alike, but then I saw her bat away a nurse trying to place an IV and argue loudly to get a dinner. As her physical strength waned from a battle with chronic disease, her spunk had increased such that she was always ordering her caregivers around. I managed to get her out of the intensive care unit pretty quickly to a medicine floor team but I never quite forgot about her.

When I met her again, she looked completely different. The medicine team called because her blood pressures were sagging, she had a rampant infection, and her mental status was getting worse and worse. When I saw her, I knew. She no longer fought with the nurses. She no longer argued with me. That part of her which was so strong on admission - her will and mental stamina - had given out. I knew she wasn't going to make it. An hour later, she had a cardiac arrest with asystole. Although we regained spontaneous circulation, we soon made her comfort care afterwards.

Occasionally, I see a patient like Ms. A, and even without looking at labs or imaging or the chart, I know what will happen. It is a strange intuition to pick up in medicine, a sort of insight that seems to skirt past scientific explanation, a feeling that settles in the back of the mind and aches until I pay attention to it. I always hope I'm wrong, but most of the time, it happens to be true.

Being a Doctor

On call yesterday night, I admitted an elderly patient with sepsis to the intensive care unit. He needed an arterial line for close measurement of blood pressure and frequent labs. It was one of those non-stop whirlwind call nights, running from one emergency to another, and by the time I brought the arterial line box into the room, it was 3AM.

One thing I have learned about placing arterial lines and IVs is to sit down if you can. It's much better for the back than stooping, it optimizes positioning, and at 3 in the morning, a chair is a welcome reprieve. When I felt the patient's pulse, I knew there would be no problem placing the line; he had a clearly demarcated radial artery. But instead of rushing through the procedure, I took my time and asked him to tell me about his life. While I positioned his hand and prepped his wrist, I learned about how he met his wife, what his children were doing. When I placed the lidocaine, he told me about a daughter he adopted and how proud he was of her despite developmental delay. In the next few minutes while I entered the radial artery, I began to learn of his grandchildren. As I sewed the catheter down, I learned of his job. The entire thing took ten minutes, and by the end, I felt like a primary care doctor, holding a patient's hand, sitting at the bedside, cherishing what it means to be a physician.

Anesthesia's Political Landscape

I don't want to make this blog a forum for anesthesiology's political agenda, but I feel that I should advocate for my specialty. As a resident, I think it is important for me to learn about and understand issues facing the field, and one of these is the role of certified registered nurse anesthetists or CRNAs. CRNAs are a valuable and vital component to the anesthesia team. Nurses who undergo additional training can be licensed to provide general anesthesia, and they work at many places, from community hospitals to academic centers. They are generally supervised by an MD anesthesiologist unless a state opts out of that requirement. California has done so, so in this state, CRNAs can practice independently. The state society of anesthesiologists has objected to this "opt-out" but it seems that it is here to stay. What should you (the public) know about CRNAs? For the most part, they provide anesthesia for low acuity cases; some studies have shown that much of the Medicare billing by CRNAs are for colonoscopies and cataracts. For most anesthetics, CRNAs are a perfectly appropriate provider. However, their training is different than that of anesthesiologists; a nurse's skill set, approach to clinical problems, and background is very different than a physician's. The California Society of Anesthesiologists feels that this is significant enough to warrant physician oversight of CRNAs. I personally cannot comment on it as I haven't worked all that much with CRNAs. Many hospitals, despite the "opt-out," still have physician supervision of CRNAs. There are also other issues with CRNAs, especially in performing pain procedures, and again, anesthesiologists as a whole are reluctant to allow them to practice independently. In any case, all patients should know who their providers are and be aware whether a CRNA is practicing with an anesthesiologist or independently.

Book Review: The Gone-Away World

Although I ought to be studying anesthesia, lately I've been hankering for some immersing nonfiction, and a friend recommended Nick Harkaway's The Gone-Away World. His first novel, it attempts to be and succeeds as an epic all-encompassing science fiction stream of consciousness that dallies in mysticism, philosophy, the industrial complex, physics, ninjas and mimes, identity, and love. It reminds me of Kurt Vonnegut's Cat's Cradle in creating a world teetering on the edge of collapse and following it through. The writing is witty, crisp, hilarious, and tongue-in-cheek, almost Douglas Adams in nature. It does have some of the hallmarks of a writer's first foray, however, and is quite long and occasionally loses itself in tangents and diatribes. But it's been one of the most fun new reads I've had this year and figured I'd mention it on this blog.

Image shown under Fair Use, from www.nickharkaway.com.

A 14 Gauge Needle and Strong Arm

In Samuel Shem's satiric novel, House of God, there is a housestaff rule: "6. There is no body cavity that cannot be reached with a #14G needle and a good strong arm." Though quite blunt, this is not a completely ridiculous adage. Over the last two and a half years of training, I have become much more comfortable placing a needle into someone who needs it. During intern year, I'd done a number of paracenteses: the drainage of fluid from the abdomen. Patients with liver disease often accumulate a lot of fluid in the belly and occasionally, it should be checked for infection or drained for symptoms. I hadn't done a paracentesis for over a year, but when a patient came into the ICU with end stage cirrhosis and severe ascites, I felt comfortable doing the procedure. I begin to see things in the way I imagine surgeons see them. Using a few basic principles, it's not too hard to access a vessel or body cavity with a needle. The skills of using ultrasound, the Seldinger technique, careful intentional movements, and manual dexterity apply to central line placement, arterial line placement, epidurals, spinals, thoracenteses, paracenteses, and other procedures. With a 14 gauge needle and a strong arm, any body cavity can be reached.

Emergent

As part of the intensive care team, I have to be ready to respond to emergencies and rapidly changing clinical situations in the hospital. The anesthesia residents carry the airway pager and respond to code blues. But even in the intensive care unit, our patients are so tenuous that emergencies arise daily. One patient who was recovering from a severe neurologic illness was becoming close to transferring out of the intensive care unit. He had been in the ICU for 2 weeks, most of that time on a ventilator. Because of a progressive disease that took out cranial nerves, he didn't have much of a gag reflex or a strong cough. Unfortunately, that put him at high risk for aspiration - choking on secetions. When we were called to bedside, he was hypoxic and minimally responsive. After mask-ventilating him to bring his oxygen up, we used a flexible fiberoptic bronchoscope to take a look and saw a lot of junk down one of the lungs. We decided to reintubate him and put him back on a mechanical ventilator. I then took a look with a bronchoscope to suction out the airways and do a bronchoalveolar lavage, testing for infectious organisms. Despite the hope of having the patient leave the unit, one small event set him back two weeks of recovery. This reminds me that even patients who seem to be doing well can easily have setbacks, whether from new infections, a blood clot from not moving, or deconditioning from prolonged illness. Although we hope for a smooth trajectory of recovery, patients often have a much more day-by-day progress-and-obstacle circuitous route to leaving the unit.

tPA

Tissue plasminogen activator or tPA may actually live up to its name as a miracle drug. It dissolves clots and is primarily used to treat acute ischemic stroke. An older gentleman with no significant past medical history has a witnessed change in mental status. He is eating with his daughter when he suddenly stops talking, "acts oddly," then falls to the ground. At that point, the daughter realizes he cannot move his left arm or leg. He is emergently brought into the emergency department. There, a head CT is negative for bleeding, and tPA is given. When I first meet the patient, the tPA has not yet had effect; the patient can only say his name and cannot move the left side of his body at all. He has a prominent facial droop and it is difficult to understand his speech.

Several hours later, after the clot is dissolved, I go see him. He tells me his name, the city, and gets the date right within a week. He wants "cerveza" and chocolate. Although his left side is still weaker than his right, he can grasp my hand and push his toes down reasonably hard. His left facial droop is nearly gone. Two days later, he goes home and soon will be back to tending his garden. After seeing the remarkable and dramatic neurologic improvement, I really gained a new awe for tPA.

Image of molecule shown under Creative Commons Attribution Share-Alike License.