Almost one year.

I just noticed that this blog is almost one year old... I think i've changed a lot since this whole thing started. We'll have to have some sort of party.

Hmm...

Found out today that there's a Center for Vulvar Diseases here at my institution. Forgive me if you suffer from a vulvar disorder, but I didn't realize there was such a prevalence of disorders that there needed to be specific center for it. If you don't know what a vulva is... you shouldn't be reading this (or look it up)

Christmas Party

Work Christmas party last night. Funny no one is even remotely recognizable in party clothes. You have to visualize them in scrubs before you can associate a name with a face. Weird. I didn't drink too much which is good.

Where does one conscience go under anesthesia?

I was recently asked by a reader (weird to say that... thanks for reading)"Where does one's conscience go when you put someone under?" It's not a question easily answered. One that scholars and theologians probably as well have tried to answer for millenia.

First of all not to nitpick but you probably mean consciousness, meaning sense of one's personal or collective identity, rather than conscience, meaning source of moral or ethical judgement. I only clarify this not to be a jerk, but to make sure we are on the same page.

I don't know if there's really a right answer to this question... First. Is this is the same quesion as "Where does one's consciousness go when I sleep?" Probably in my opinion. Anesthesia is induced sleep (more or less... i can give you a more techically specific definition but that will just be cumbersome in this metaphysical question)

Most would say one's consciousness is just supressed while you sleep or are under anesthesia... it's there but it's unable to express itself or take in new information.

More religious people would say it's there watching over you. A "soul" if you will.

Which is right? I don't know. Is there another alternative? I think the best thing would be to leave it comments and see what people have to say.

Level 1Trauma

This weekend I was on cardiac call... I had to be available for any cardiac cases going on over the weekend. This can be a hit or miss call, sometimes you're in the hospital all weekend, sometimes you're at home all weekend. It had been pretty quiet til then... early out(ish) on Friday, nothing on Saturday. Then my pager went off Sunday morning at 4am. nothing good about that. Apparently some sort of penetrating trauma case that required my attention. Well usually level 1 traumas refer to emergent cases, often going straight up the OR once they arrive at the hospital. I was confused. You don't want to wait for me to drive in (newly and still falling snow) to take care of an emergency, the in-house people will take care of it.... No no... they were stable enough to be transferred from another hospital, then stable enough to go to the CT scanner, now stable enough to wait for the cardiac team to come it. Still it's an emergency. "Ok i'm on the way in"

Now I'm always kinda pissed off when I get called in... half the time I get called in for cardiac it's nothing critical (i know that sounds weird) Someone freaking out for no reason. I know it's my job to be available when they call me in, so I don't think i should be angry.... I still am. I figured if that bullet were anywhere important they'd be dead by now. I'm also mad for other people too. I think "Heaven forbid if anyone gets hurt driving in the snow coming into the hospital for this non-emergent 'emergency' "

I slip and slide my way in. I see the cardiac surgeon in the pump room. I say "hi, what's going on?" He says "I don't know... they told me she was dying and to come in, now we're waiting... i don't know what doing..." Great now the cardiac surgeon and I both don't know what's happening. Oh well easy enough to blame the Trauma service.

The patient finally shows up. Very stable. We put some invasive monitors and access into the patient. I don't see much blood in the pericardium (sac around the heart) on echo. There is some though... not much. Surgeon says it probably looked like pericardial fat because it was well-organzied clot. They take a closer look at the heart... this lady's lucky. The bullet went through the pericardium nicked the right side of the heart and kept going. A half-centimeter another direction and that nick would have gone through one of the coronary arteries and the patient would have bled to death or part of the heart would have completely stopped working. Lucky.

I feel bad now that I was angry driving in.

PACU

(Trying to catch up on old ideas... this actually happened last week... pretend it's today.)

Not a typical day for me. I was the faculty covering the post-operative recovery unit. It's actually not a particularly tough job most of the time since there is a resident assigned to field most questions and problems. There's the occasional problem... nothing big today. Staffing ECTs. (electroconvusive therapy) Done three times a week in the PACU. Signing patients out (i.e. administrative whatever-you-want-to-call-it)

One thing that was unusual was that we had two physicians come through as patients. I guess doctors need surgery too. Didn't want to give special treatment, but did stop by and say hi to both the pediatric anesthesiologist and the cardiac surgeon (who spent the previous saturday on a stretcher in the pump room while his partner finished a surgery they had started together).

Bladder cancer

Had patient here this AM for a cystectomy (bladder removal) for bladder cancer. A tough man... clearly trying to hide the fact that he is terrified (rightfully so.. a big operation) Among the last things he said before going to sleep (taken anonymously without permission.)

I'll be badder without a bladder!

Tough Day

Thursday was a tough day. I was the cardiac faculty on call, so I knew from the start it was going to be a long day. I came in early because there was a conference on echocardiograms that I wanted to go to. Anyway I was wandering in, and my pager went off... never good in the morning. "Case going on in room 7" I change quickly and get in there. A heart transplant. Just starting really... It's patient with bad heart failure that has a Heartmate (a type of left ventricular assist device). Of course he's had about three previous heart operations so there's lots of scar tissue in the chest makin the operation much more dangerous and complicated.
Anyway... the new heart is in the patient about 3 pm or so. It's not going well as we come off bypass, but we're doing reasonably. All of a sudden, the blood pressure drops and I see a bunch of air on the echocardiogram. Part of the hears stops functioning well... So I assume some air has gone down one of the coronary arteries. We crash back on bypass... Left heart starts functioning a bit better but now the right side doesn't look so well. We end up after struggling a bit assisting the right side of the heart with Abiomed right ventricular assist device. This are settling out, the all of a sudden the left side of the heart is starting to look bad.... Now a discussion ensues on if they need to put the patient on ECMO (extacorporeal membrane oxygenation). Ends up they endup supporting the left side of heart with a left sided Abiomed.
Now we are supporting both sides of the heart, and the patient is relatively stable We're pouring clotting factors and blood so the patient will stop bleeding. They'll try to wean the patient off assistance early next week. So this patient came into the hospital with a bad heart and a Left ventricular assist device... now has a different heart and assistance for both sides of the heart. Only time will tell. By the way it's 9pm we're finally done. a quick 16 hour case. I'm so exhausted.

Interviews

As a new attending... I got to participate in resident interviews for the first time. As a resident, I did attend a lot of interviews, and I gave a lot of tours. On the other side it's a little weird. I don't know if I like having any influence at all on people's futures. I can say that the applicants as a whole were insane... everyone had great (not just good) board scores, publications, etc. I can't say that I would have gotten into this residency program now if my life depended on it. Seems though overall that people were pretty nitpicky. Which is okay I guess. We're trying to stratify a couple hundred really top-notch applicants. Don't know if I was too harsh or not. I guess my rankings were close to everyone elses.

Make a wish

Okay... I NEVER watch the news. nothing ever interesting is going on. especially when I can read things on the internet. Especially never local news. Unless I want to see a skateboarding bulldog or a waterskiing squirrel. Anyway, my roomate was watching something and the news was on after it. And they started talking about the make-a-wish foundation and so on. So I was about to turn the channel... then they mentioned an 9 year old and a name I recognized. It was a generic name and could have been anybody, but there he was, a child I took care of as a cardiac anesthesia fellow.

The reason I remember this kid is that he was truely one in a million. The surgery he was having as an eight year old was a coronary artery bypass. He had a disease called hereditary familial hypercholesterolemia. The problem for this kid was that he had the worst kind. He had cholesterol levels 8 to 10 times what a normal person would have, thus he had premature disease of the arteries feeding his heart. Most patients who have this type of surgery are in their fifties and above.

What killed me was that on the news report they did say he had coronary artery disease, but they said that "Sometimes he doesn't feel well" and left it at that. I guess you can't say "Sometimes his heart doesn't get enough blood" on TV. Well at least he got a new puppy.

More Prisoners

So I was on call again last night, and we had a trauma flown in. Now this is not completely unusual, since we are a major referral center, but since the town in relatively suburban, not a lot of violence. Anyway a prisoner apparently had barricaded himself in his room and cut his neck from the middle of the neck to the ear with a razor blade or something. This seems weird to me for several reasons. One, seems like prison is all about being barricaded into places whether you like it or not, so the part where he barricades himself somewhere is weird. Second, I thought you weren't allowed to have razors in prison. Next... you'd have to be pretty determined to slice yourself that wide open. ouch.

Now I understand this guy is a violent criminal, but they bring this guy up to the OR... he's intubated and paralyzed... big wad of bloody bandages on his neck... but despite this fact he still has his arms shackled to his waist. Like he's getting anywhere while he's paralyzed. Then again with the sitting outside the OR while he's under general anesthesia. Oh well. I'm sure the guards are just doing what they're told.

Good news for us, he didn't hit anything too big that we couldn't control the bleeding. (plus they had time to fly him in from up north in the helicopter). Bad news for him... seems like he didn't feel like living anymore.

P.S. I was ending another case with a CRNA and she had only heard part of the story so she only knew we were operating on a self inflicted neck wound. So she said "Life can't be that bad can it?" I then mentioned that he was a prisoner apparently in prison for violent crimes. She then seemed embarrassed "I guess it can be that bad." I chuckled. (proves again -- I'm a bad man)

prisoners in the OR

Had a prisoner as a patient the other day. It was very surreal as always. having two armed guards sitting next to the patient instead of family members. Also the leg chains have some sort of surreal quality to them also. A fellow faculty has the habit of looking up these patients on the Department of Justice homepage. Apparently you can just look up anyone with a criminal record or is currently in prison. I prefer not to know. I think I would be a better person than to let the knowledge of his crimes affect his care, but I prefer not to leave that to chance. The man seemed very nice. Also weird is the insistence that they sit outside the OR for the entire surgical procedure. Like they're going to get off the table and run out while they're under general anesthesia.

A couple of years ago I had a patient undergoing cardiac surgery he was in his mid-seventies. Apparently he had been in prison for twenty or more years. He was a pretty feeble man... still those guards were there sitting outside the OR for the entire case. I really don't know what he did if he had been in prison for that long. He also seemed very nice.

Awful

I'm an awful person. I was bringing a patient the the intensive care unit and I was looking for the nurse practitioner or resident to take report so I could get out of there. anyway, popped my head into one of the beds and it was an ECMO patient (extra-corporeal membrane oxygenation). Basically ECMO is complete support for the heart and lungs when they are not working well (it can also be used for just lung support). It consists of a pump and an oxygenator to take over both functions. Anyway... the patient was going down later today for a procedure and the nurses were wondering if anesthesia presence was going to be required or not. Sometimes procedures are done without anesthesia personnel if the patient is doing well, so I said "I hope not, they're Stable on ECMO aren't they?" I then shook my head wondering what I had said. The phrase "Stable on ECMO" is almost an oxymoron given that they patient is NOT stable thus needs the almost complete support of ECMO. I've spent too much time in the hospital.

On another note, the cardiac case I'm supervising finished early today. Which is good, but it's bad because that means our room is open for add-on cases which are always always always a mess. But our OR bed is broken so I'm hoping nothing comes. I'm a bad man.

Music in the OR part deux

So I don't know if many people at work actually know about this blog. Just a few I hope. anyway not minutes after I post the last post about music in the OR... I get an email from someone in the department. It's one of those with a million headers in the email so it's been forwarded a billion times.

Anyway... it linked to a version of the article and asked why would anesthesiologists cooperate with publicity that that makes it look like they have nothing better to do in the OR other than play music. I never really thought about it that way. We usually are busy doing other stuff. still having a choice would be nice.

On a completely random note, had a pretty decent day on Friday. Working with two very good, very pleasant residents. One paged me because our "healthy" patient had just had a run of V-Tach... for those of you who are non-medical. It's heart rhythm that's potentially fatal if it persists and is untreated. Luckily in this instance it was short and self limiting, but we were sending off some lab tests to make sure it wasn't a fairly simple electrolyte problem. Anyway I threatened the resident with a bad eval if it happened again. I told her I would note on her eval that, "Resident was good to work with, very knowledgeable, but unfortunately arrythmogenic" (irregular heartbeat-causing) She laughed.... I think she was humoring me... then again she laughs at everything.

Music in the OR

Image provided by Freefoto.com
A friend of mine sent me this link...

Are anesthesiologists the DJs of the operating room?

At my hospital the surgeons have control over the music. No choosing by me. I don't think they'd like my music anyway. Hip hop and pop is probably to contemporary for the ORs.

There is a lot of music in the ORs... You can tell what kind of day you're going to be having depending on the music. Country in the Vascular rooms, a little bit of everything in the Neuro rooms... quiet only in Cardiac... music maybe when they're closing.

House

I'm not one usually to watch House M.D. on TV, but i was over a bud's and was forced to. It was the most unrealistic episode ever. Many strange procedures in the name of making a strange diagnosis. I'd review it but I'd be reworking something already done...

Check out the House review at Polite Dissent

Enthusiasm

Worked yesterday with one of the most enthusiastic residents in the program. He's a good guy, but sometimes needs to be taken in small doses. I can't say anything bad about him really, he's a genuinely nice guy.

We were in the cardiac room... staffing is one on one in cardiac in our institution meaning we supervise only one cardiac case at a time. The second cardiac case of the day was supposed to be there already so they could get some invasive lines placed preoperatively. Usually the timing in such so that the most critical portion of the cardiac case is happening while I need to be surpervising those lines elsewhere. Anyway, came off of bypass in the OR, then finally then next patient was ready to get lined. After the lines were placed, I got back to the OR and they were about to transport the cardiac case to the ICU.

I told the resident to go to lunch (we give the breaks when we staff one on one) because I figured that i would get a chance for a couple more hours if he didn't go right away. He came back about 10 minutes early and met me in the ICU. Apparently he had bought me lunch and left it for me down in the anesthesia offices. Way beyond the call of duty... I suppose it's good for brownie points, but I don't believe he did it for that reason. I believe he did it just because he's a nice guy.

Glad there are still people out there like that.

Neurosurgery

Overheard today

Neurosurgery is just invasive psychiatry.

Whoa

On call for the 1st 72 hours of labor day weekend. (Friday through Sunday) Had to work about 14 hours on Friday, otherwise dodged a bullet. No calls to come in for cardiac cases.... I imagined it would have been pretty busy. Not that I'm complaining

Bier Block

Image used without permission, property of original owner

We did a Bier Block yesterday. My new resident was very excited about it... I don't know if he's just an enthusiastic person or if the procedure was all that interesting. I guess we don't do that many of them, plus he's kind of new. Actually it's probably him... he IS very enthusiastic.

For those of you not familiar with the Bier Block it's named after Karl August Bier... some German guy who invented the technique in 1908. It's also called an intravenous regional anesthetic. It's useful only for surgeries on the extremities. Basically you put a pressure cuff on the arm, use a rubber bandage to squeeze out all the blood out of the arm. Then you inflate the cuff and inject local anesthetic into the arm (through an IV you've placed earlier in the hand) The arm stays numb as long as the cuff is holding the local in the arm. This works because in general nerves travel along with blood vessels in most of the body. So if you fill the vessels with local anesthetic, you also anesthetize the nerves.

Anyway now if I can just get that resident to stop calling me "Sir" we'll be in good shape.

Hurricane Katrina

Images from AFP/NOAA-HO used without permission

I'm watching the coverage of the damage caused by Hurricane Katrina. Makes me glad I live in the north... Makes a lot of my problems seem insignificant.
Interesting to hear that many more will die in the aftermath from lack of power and water and food etc.

Tragic. Mother Nature is a vengeful woman.

Avoiding the pain of death

Got a call this morning from a friend. One of her patients had died. She was distraught to say the least. She is a resident in an obstrectrics/gynecology program. Her patient was having a baby by caesarean section. Apparently she went into some sort of respiratory distress, and did progressively worse. It was my friend's second death as a physician. She specifically told me that she went into OB/Gyn just so she wouldn't have to deal with death. I honestly had nothing to say to her. First of all I don't know how to talk to crying women. Second of all, She really had a right to be upset, there's really nothing to say. She really does put herself into her job.

This has been much different from my experience. I of course am in a different field. There is much more "volatility" in anesthesia. We deal with critical patients all the time. I, myself, have had particularly bad luck in this respect. I watched one of my patients bleed to death on my first day of anesthesia residency. It was very traumatic. I considered not coming back for a second day. Then I realized that was part of the job that I come there to do. I still remember that day vividly. I don't think i've had a case that bad since. I also had a patient die my first call as a attending staff. We did everything we could to keep that patient alive for three hours, but nothing helped. That was also very "character-building".

So how do we avoid death as physicians? The only way I can think is to avoid taking care of patients. I could quit tomorrow to drive a cab or work at Blockbuster. At what cost? I could throw away years of schooling and hard work, I could throw out the desire to practice good medicine. Unacceptable. I enjoy my work, but as a result I need to be able to deal with death. Hopefully not very often though.

My friend needs to learn this too... I think she'll come around. She's worked hard to get where she is... unfortunately she's pretty miserable these days. Hopefully as she gets further into her residency she will enjoy her work as much as I enjoy mine.

Monster Garage

Image taken from Thoratec Corporation website without permission. Image property of Thoratec Corporation


I've been a full time cardiac anesthesia staff now for about a month. I thought I would be spending more time in the heart room, but it only ends up being about one day a week. Oh well. i don't mind the general ORs.

Wednesday was an interesting day in the OR. Two big cases by the newest cardiac surgical staff -- he just started in July, the same time as I did. They're giving him pretty big cases even though he's the most junior. Maybe it's a way of breaking him in or something. I don't know.

Our first case was an exchange of an abiomed LVAD for a heartmate LVAD. LVAD stands for left ventricular assist device. It's type of support to help the heart when it can't function well enough on its own. The difference between the two devices is that the first is a mini-fridge size device that sits next to the bed and has tubes connecting it to the heart... the second is an implantable device (think softball sized tuna can) connected to the heart to help pump. Patients with this devices can even go home. Mostly it's used as a bridge to transplantation. It wasn't a terribly long case, but it can be complicated. There's multiple vasoactive medications, nitric oxide, and a transesophageal echocardiogram to deal with. Also a tangle of IVs and lines. Went very well though.

The second patient had an even sicker heart. He had a Heartmate LVAD(see above) supporting his left heart and a abiomed RVAD (right ventricular assist device) supporting his right heart. He had recovered enough function in his right heart to have the RVAD removed. There's no cardiopulmonary bypass, but you have to deal with the possibility of a lot of bleeding. ALso the possibility exists that the right heart isn't ready to come off support yet and will fail after you cut off support. Again it went pretty well so I can't complain. But there's a lot to think about and take care of. I guess that's why I like being in the cardiac ORs

Dinner with my mentees

Had dinner tonight with my mentees. They seem like a couple of good guys. I wanted to say all things considered, if I'm a horrible mentor, that at least I took them to dinner. Apparently some if the other CA-1's are jealous, because they don't even know who their mentors are or they haven't had any contact yet. I hope i'm not making anyone look bad. It's just something I wanted to do.

horrible

had a horrible day today. couldn't start an iv, an aline or an epidural to save my life. worse yet, wet tapped that same patient (a complication from placing an epidural for those non medical types). argh. luckily i killed no one. ended up with a femoral aline and several neck lines (several patients)

(apologies for the extremely lingo filled post. had to vent.)

on the plus side went to have arab food with my buddy who finished his cardiac anesthesia fellowship. it was a good time, tasty food, good conversation, damn road construction detours though.

new residents

I showed my new residents how to put together an IV tubing setup today... they seemed extremely excited. i guess i take the easy things for granted.

Heard from a resident in the ICU

ECMO is easy, you just got to keep them from bleeding to death, and keep them from clotting to death.

(ECMO = Extracorporeal Membrane Oxygenation... more on ECMO another day... so complicated)

Insanity

I sat for my boards (for the second time) last Saturday. I can't say i feel any better about compared to the first time. We'll see i guess. In my post boards insantity I invited the whole anesthesia department to my house for a BBQ. We'll see how many show up... I hope people show up, I can show off my messy new house, but I hope there's not too too many people.

Mentees

I just got assigned two new anesthesia residents as mentees... I guess that makes me a mentor. Scary huh?

I am wondering why if there are dozens of faculty members why I got assigned two residents out of twenty-four to be mentees. Whatever... I don't really mind.

First Day?

Technically, i believe that friday was my first day as an attending. I've had very bad luck on other first days of sorts. I had a patient die on my first day of residenc. And there have been many almosts on other various first days. No one one died. Yay. One guy did "accidentally" blow off part of his face with a shotgun. very unusual for this town. very lucky for him if it was truely an accident despite the fact he lost an eye. Hope people have a safe holiday.

Graduation

Yesterday I attended my last graduation. Probably not the last one i'll be at, but the last one for me.

At the end of the month, I am no longer a cardiac anesthesiology fellow... I am a cardiac anesthesiology faculty.

A little bit of a strange feeling. Last year's graduation from residency was more significant. A bigger milestone, and I won an award I wasn't expecting. But it wasn't the end. I knew there was more.

Now there's no more. Just the "real world"

Scary.

happy dad's day

Thanks for all you've done.

What do you get the man that's made it possible for you to have all that you need?

My dad got DVDs. A small token. Thanks

Tamponade

(preamble: I've been told by a good friend that sometimes my stories feel like they are over her head. I'm sorry. Most of these anectdotes are written for medical professionals rather than the lay person. But I don't want to exclude the lay person so I'll try to explain more as i go along. Sometimes though the stories need to be written in a technical way. i'll try to do better... today's story will be technical.... i'll call you later and I can clarify things)

I've been on cardiac call this weekend (as faculty). This means I sit at home waiting for my pager to go off, dreading any possible emergency cardiac cases that come in. I'm usually a wreck all weekend for two reasons. One, i know as soon as I plan to do something like meet friends for lunch or go to a movie, Murphy's law will kick in and I will get called in. Two, as a relatively new cardiac faculty, I'm probably not as confident in my skills as I should be and I have doubts about whether I can handle what comes it.

At 2:45 this morning. I get a page... "emergency bring-back bleed.... phone number blah blah blah" I call in and someone's coming straight down from the ICU. Now this isn't all that unusual. People have heart surgeries all week long, and sometimes they bleed more than they should afterwards. They ooze for a few hours, they are indecisive about coming to the OR... finally in the middle of the night they decide they've had enough and need to operate. They come down to the OR, the surgeons poke around a little and they use their electrocautery to buzz a few little blood vessels, say they can't find much, and then you go back upstairs. No big deal. The reason this is considered an emergency is that there is a possibility that there is a major bleed somewhere and it can compromise the way the heart functions. The heart can stop working because there can be blood clot all around it (rather than blood pumping through it)

So I assume it's one of those slow oozing bleeders, but you need to come in anyway and take care of the problem. I roll out of bed, do my best to fix my bed head and hop in the car. I'm at the hospital within 15 minutes, and changed in the locker room less than 10 minutes later. I walk into the OR expecting the nurses to be setting up and waiting for me to bring the patient down. Instead I see the general call residents and staff hovering around the patient. She's pale looking and her eyes look like they're half rolled back in her head. Now I'm thinking "aw, crap... this is for real" The cardiac surgery resident is throwing a few lines and we're scrambling to get this patient ready for surgery.

Now this is one of the special circumstances in anesthesia. You need to have the patient ready for surgery BEFORE they go to sleep. These compromised patients are using all their reserve to keep up their blood pressure, catecholamines rushing though their systems, peripheral vessels clamped down, all trying to compensate for this unstable state. When you put them asleep this relaxes their compensation and they can "crash" as soon as they're asleep. Also our medications to put you asleep tend to lower your blood pressure too. So to combat this, you have them prepped and drapped for surgery with the surgeon standing there ready to operate as soon as they are unconscious.

The cardiac surgeon pops his head it to see what's going on. His resident lets him know that this is the heart transplant patient from earlier in the week and that they need to get started NOW. They wash hand quickly while the nurses rush to prep the field. The drapes go up. And they let me know they're ready. I put the patient asleep and they get started immediately. My anesthesia resident puts in the breathing tube under the drapes and the surgeons open up the chest. Immediately you can see blood welling up out of the chest and a squirting bleeder. Immediately the blood pressure drops. We've lost about 2 liters of blood in about 10 seconds. We get the rapid infuser going and pump in some blood quickly and I give the patient some epinephrine(one of our stronger drugs) to get the blood pressure back up. Luckily they get the bleeder under control and about 2 hours later we get back up to the ICU.

We were pretty lucky today. I can help but think that if it had taken me 10 more minutes to drive in, or that if the team in the hospital hadn't been so proactive in getting the patient to the operating room that this lady might be dead. I'm relieved.

It's 530 am. I'm tired, i'm thinking of going home. I over hear the cardiac surgery resident, "blah blah blah accepted a lung transplant blah blah blah..." I know I'll be back later today.

Running

Tomorrow i'm staffing a thoracic room and an ENT room.

The thoracic room has two moderately sized cases... requiring epidurals and alines.

The ENT room has 6 short cases, at least 2 requiring awake fiberoptic intubation.

The kicker? The two rooms are about as far apart as you can get in the ORs. My room assignments got switched today because they opened up a 3rd cardiac room. I'll be running my ass off tomorrow. If i'm smart i'll pack a lunch. I probably won't though.

Happy Birthday Morphine!

Apparently Morphine turned 200 yesterday. I forgot and didn't buy a present.

Kelly did not forget and collected some anecdotes in honor of morphine's birthday.

I'll send a card later.

Tangled Bank

Tangled Bank for the week is up at the Chronicles of a Medical Mad House. The Tangled Bank has evolved over the year to include medicine and topics closely related to science. If you read my blog you've read my entry already, but check out the others!

Blogging when people you know read your blog

Just read a post from an article about tips for bloggers (from the Right Wing News) Last on his list...

25) Given that there are plenty of people who've been fired or disciplined at work either for blogging on the job or for something they said on their blog, the fewer people at your job who know about your blog, the better.

I know at least 2 people at work know of my blog... should it affect how I blog... probably not. Does it... probably. I not only have to worry about getting fired. I have to worry about being sued and patient confidentiality. I don't blog at work.

Coincidentally... a friend of mine who has an incredibly insightful blog (and she didn't want to tell me about it -- I haven't linked to her at her request) said yesterday.

Even now, I am concious of what I write because of those who know about it or have ever visited it that may know me.

I think it affects what I write as well. One of the comments from the first article said it best.

Blog because you want to, ...It's the passion that readers will respond to.

Blog on.

Happy Mothers day

Happy Mom's Day. Thanks for everything.

Thanks to all the moms out there.

Vomiting Ferrets?

Fidgett the ferret (maybe it's Waffles the ferret... i don't know them so I can't tell) from ToyKeeper.net. Images used without permision

Today while hanging out with some of my smart friends, I learned randomly that ferrets apparently are used in lot of research for nausea and vomitting. I thought this to be rather strange. I also began to have images of a cage some where with liitle piles of ferret vomit in the corners.

I began also to wonder why this is. So I went to our friend the internet...

Most animal research on nausea is performed on ferrets, apparently one step up the evolutionary tree from rodents, which do not vomit.

-- From Palliative Care Perspectives, James L. Hallenbeck, M.D.

Juggling

Logo of the 6th Swiss Juggling Convention, in Zürich 1992, used without permission

So I feel like I'm not getting enough done.

I'm trying to buy a house, do a good job at work, study for boards, read to prepare for talks, plan a vacation with some college friends... all while trying to get enough sleep and also not go insane, which means decompression time.

Mortgage insurance, home inspection, radon, homeowners insurance, down payment, closing costs, argh!

They say life events are very stressful. Several are going on now. I don't even have kids or a wife or girlfriend to distract me. I've been neglect the cat. I don't know how some people do it. They are amazing.

Damn, I need a haircut too.

Board Review

Image used without permission from USGS via Wikipedia.org

Just got back from an intensive 3 1/2 day Board Review Course in Chicago. It kicked my butt. I hope I'm ready in 10 weeks. I've gotten great traning in anesthesia, but I still don't feel ready to take the boards (again). The course was worth the extensive fee though. We'll see if it was really worth it when I get my scores.

Trick Daddy

I may be the only anesthesiologist that listens to rap. It's good stuff. It's amusing though... occasionally they throw in that random medical term in.

Lately on the radio they've been playing (Gimme Some) Sugar(remix) by Trick Daddy, featuring Ludacris, Lil' Kim, and Cee-Lo. It's a great song. They have some amazing rhymes.

One verse by Lil' Kim goes "I give ya high blood pressure like a diabetic". I know they're trying to relate the diabetes theme in as the title is Gimme Some Sugar, but I don't know that diabetes cause hypertension. They are associated however it seems. I guess she's saying she's so hot she raises your blood pressure.

Oh well, I can't hold it against them. I still like the genre. I still like the song.

Litigation

Today we heard about a case where something had been done that had litigation potential.

There are several things that would have to occur to make this a successful suit.
First of all, it requires a bad relationship with the patient. In this case, it was fully explained to the patient, and the procedure to correct the problem was immediately arranged. The patient seemed very understanding. For the second reason we need to go to my lawyer buddies.

A tort is a wrongful act other than a breach of contract that injures another and for which the law imposes civil liability. There are four elements of a tort as I understand it

1. Duty
   
2. Breach of Duty
   
3. Damages/Harm
   
4. Causation
   
   

If all four are not present a tort should not be successful. In this case, there was a duty, and that duty was definitely breached. Most of the time, the act in question does not involve arguing breach of duty, it is assumed to have happened. There also needs to be damages or harm associated with the breach of duty, and the damages must be caused by the breach of duty. If there is no damages, there is no tort. If there are damages, but no causation, there is no tort. In this case, there were no damages to the patient other than having to go through the corrective procedure. So there should no sucesful tort possible.

PS. Hmmm...

looking through my visitor statistics, apparently I'm the 27th choice for a google search of the movie SuperSize Me. Interesting.

Grand Rounds XXIX

Grand Rounds XXIX available at GruntDOc

Difficult Airway

So as a fellow I usually just help out where I can. I'm at the point in the fellowship where I staff rooms as the attending about twice a week. So today I'm helping out this morning and then this afternoon I figure I can sit in the library and work on a lecture I'm giving to the medical students later this week (another responsibility of my increasing faculty duties).

I'm sort of sleepy there looking at my laptop screen in the anesthesia library... and I hear "Anesthesia Staff Stat to ER!" This is not normal. This is usually our safety system in the OR, if something crazy is happening in the OR and you need emergency help or an extra hand, anyone can call overhead to get someone into the room. Residents, CRNAs, or even faculty anesthesiologists can call out and get help. i.e. "Anesthesia staff stat to OR 12." So to hear this page at all means something isn't going well. This is the first time I've heard this call to somewhere other than the OR. Usually that is reserved for the Anesthesia group pager or the code Blue pager. So I figure I'd better get off my butt and see if they need a hand. I walk quickly down the hall (I never run, because 1.If I fall on my face they'll be two patients instead of one 2.I'm out of shape ) A couple of other staff are headed the same way. One of them is relatively new and she doesn't even know where the ER is so she joins us. We cruise down the stairs, swipe our IDs through the security door and head toward the trauma bays. Quite a few others are there already in addition to the ER people, some various nurses and other doctors.

I look at the patient and you know they're in trouble. In medical circles it's sometimes referred to as FLK... funny looking kid... A small really tiny kid with small receding jaw with a massive overbite. Almost Pierre-Robin like in look (GIS for Pierre-Robin) I know immediately that he's going to be difficult to intubate. Now as misunderstood as I usually claim anesthesiology is, most would agree that in addition to the ENT surgeons, we are airway specialists. I see them take a look with a laryngoscope and they see nothing. They look with a fiberoptic scope and they see nothing... by now they've called ENT and peds ENT for a possible emergent tracheostomy. Peds anesthesia has been called to bring their code box and airway equipment. Lucky they are barely able to mask ventilate the patient. I also notice the scar on the patient's neck indicating a previous tracheostomy. They're still having no luck with using a fiberoptic scope for intubation. Incidentally someone mentions that this "kid" is 28 years old.... something like 60 pounds and change.
He's starting to breathe now. He had stopped breathing earlier for some still unknown reason. Seizures and sleep apnea are mentioned. Since he's breathing now and still maintaining his oxygen saturation we decide to get up to the OR where more instruments (and a more controlled setting) are available.

So we run up and this patient recieves and awake tracheostomy, which is the ultimate in secure airways. Ends up that this "kid" as an unknown syndrome and some history of autism (though lives on his own) and has been trached in the past for losing his airway during a seizure eight months ago.

This is an anesthesiologist's nightmare. We have all sorts of tricks and techniques to control the airway. But sometimes we fail. The trick is knowing when to call for help as a good senior anesthesiology resident did, and when you've tried things and they aren't working to call for a definitive surgical airway when necessary. It's hard to ask for help. In this case I think we saved this guy's life. Now someone just needs to figure out why he's having seizures (already on two anti-seizure medications)

Garage?

Taken without permission from an email I received today at work.

Yesterday, a patient remarked as we rolled him into OR 6, "This is the operating room?? It looks like a garage!

Dedication

I wasn't there Monday. Apparently one of the cardiac surgeons almost passed out during surgery. He said he felt weak and they rushed to get him a chair. He sat down and asked them to call one of his partners down to help until he was feeling better. Evidently they wheeled the patient's transport stretcher in the room and he laid down for a bit. And they used the blood pressure cuff to check his pressure. The other surgeon came down and helped for a bit at which point the surgeon got up, scrubbed again and finished the surgery. I doubt he even went to see his doctor.

Now I don't know if this is all true. I'm hearing it second hand. But i heard it from two people.

(BTW, he's a great surgeon)

Rounds

Grand rounds XXVIII is available at Polite Dissent

It's my first submission and post there...

If you're not familiar with term Grand Rounds... it's basically a conference where people talk about a particular subject or recent events in the department. Often there's a guest speaker or something. Evidently it's taken from John Hopkins hospital back in the day. The patient's rooms were in the rotunda and to see them you went "a round" Everything medical has to have "rounds" after it it seems


Seeing patients with your team before the attending arrives is "work rounds"
Seeing patients by yourself before work rounds is "pre-rounding"
Seeing patients with your attending is just "rounds"
Seeing patients with special attending for education purposes is "teaching rounds"
"Grand Rounds" is usually the department's weekly conference.
Eating is "p.o. (per ora) rounds"

Staffing friends

Today I staffed 2 rooms with residents in it. Basically that means being in charge of what happens in both rooms. Also that means I need to try to teach residents. It means that I need to watch them perform procedures that are sometimes tricky. It's very stressful watching someone do something you could do yourself.

Also it it means staffing friends. I've become friends with a lot of the residents because we were in the same program before I was an attending, and we've remained friends. I try to be laid back about the whole process. This morning we bring the patient back into the room after the resident puts in an arterial line and thoracic epidural in the pre-op area. I look at the top of his cart. Now there's supposed to be a bunch of medications available for me to help put the patient asleep. And in addition there's supposed to be some emergency drugs there 'just in case' something happens. I look and there's a couple of syringes of paralytic sitting there. Nothing there to put the patient asleep, nothing to use in case of emergency. He turns and says he forgot the induction agent so we send our medical student running to the pharmacy while we put the patient on monitors. I didn't want to make a big deal of everything so I draw up some emergency drugs while he's fiddling with things. The student comes back and we put the patient asleep. We're getting things worked out and just comment to him that even though we're friends we need to be a little more prepared to do these cases. He gives me a funny look and chuckles. He points to his pocket and the emergency drugs are there ready to go. He says he was wondering why I drew up the other stuff. Ha ha.. now don't I look silly. SO STRESSFUL... people need to tell me things

Plane trouble

So guess where i'm supposed to be... Madison. Guess where I'm not... Madison. So I'm on my way to the airport to give some short presentations at a conference in Madison. On the way to the airport I get a call saying my flight is cancelled... So obviously I think it's a prank. So in actuality, my flight is cancelled. In the next 5 minutes I get about 4 calls from people who were also supposed to be on that flight and they have heard the same thing. Apparently there's some sort of crew shortage and we've been rebooked on a flight tomorrow morning after the conference starts. We go to the airport figuring we can work something out there to get to Madison. We get there, to find some very unhelpful staff... I'm on my phone the whole way there trying to get alternative travel arrangements made. Ends up being that the people on the flight have been put on about 6 different flights, mine being one of the later ones. In the midst of trying to get stuff squared away I'm trying to adjust my car rental so I can pick it up in the morning rather than this evening. The man at the car rental place tells me I need to call the website I booked the car with. I call them and they say I need to call the car place. I explain that I've already done that and they assure me that I just need to make another reservation and the other will just go away. Go away? I question this so I don't get a charge on my credit card and she accuses me of not listening. ARGH!!!! At this point i feel like vomitting. This is the first problem i've had with an airline in the past that I can remember. So instead I'll arrive at the conference just before one of my presentations. hopefully the flight in the morning will go well. At least my cat won't be lonely tonight.

Eww!

I learned yesterday though a convoluted conversation that there is such a thing as "defecography". Don't ask how we got to it... Don't even ask what it is...

Defecography is a test used to evaluate the disorders of the lower bowel that are not evident by direct visualization. Radiologic liquid is instilled into the rectum. Then the patient is instructed to empty the rectum while a fluoroscopic exam of the pelvis is carried out. This radiologic test allows the doctor to evaluate the pelvic floor muscles and rectum during defecation. This type of test, although awkward, provides valuable information that will aide your doctor in diagnosing your problem.

The following is a list of conditions for which Defecography can be used to gather more information and/or confirm a diagnosis.

-Rectal prolapse, irritable bowel syndrome, obstructed defecation
-Solitary rectal ulcer, proctalgia, fugax,a rectocele/enterocele
-Fecal incontinence, internal prolapse, constipation
-Rectal/anal intussusception anismus (inappropriate spasm of the anal sphincter)
(UMHS website)

Apparently the "liquid" they use for this test is the consistency of mashed potatoes.
Thank god I'm an anesthesiologist. I'm glad on the other end of the patient.

Death

I'm watching a documentary filmed at my hospital a few months ago. I've written about it a few times in the past. I've critizized it for being a bit melodramatic and ignoring anesthesiology. That's all okay. Today the showed someone who almost got a liver transplant twice and had it unable to be done for various reasons. Then they showed him dying after having life support withdrawn at somepoint after that. I think they did a great job actually showing that not everything turns out well in the hospital. Not the usual perfect outcome that's usually portrayed. Even though I've seen death in the hospital before it still hits you. Rest in peace.

Supersize Me

Just watched "Supersize Me". As good as people say it is, even though I did doze off a bit in the middle. I can't say it was completely objective or scientific in nature, but it did make a good point. From now on, my Big Mac is eaten with a DIET coke.

(Really I'm just kidding. I haven't drank sugar soda in years.)

Extra room

So today I was on cardiac call (as faculty) usually that means you do cardiac cases during the day and then you take over the other cardiac rooms as your cases finish up, then you relieve others and you end up being 3rd from last to leave for the day.

Today was a bit different. The case that was scheduled in our room was cancelled so that a case that had been cancelled because of emergencies, scheduling, etc had been cancelled two days in a row could go. Unfortunately the original surgeon wasn't available so his colleague agreed to do the case for him. The patient wanted her surgeon to do the case, so she didn't want the case done today. So instead of one or two cases as usual, we had none. This you would think is a good thing. It's not. That means ANY case can be put in your room.

The day starts off with a page while I'm driving in that a cardiac case from yesterday needs to come down emergently for bleeding (well he's been bleeding all night) so I take over from the night staff. Usually in cardiac you are staffing one case/one resident at a time. Apparently there's some sort of flu going around (which I think I have, by the way) because two staff anesthesiologists call in sick (which never happens). We end up giving a bunch of clotting factors during the case, plasma, platelets, recombinant factor seven even (something like $5000 a dose) before the guy quits bleeding. As we're finishing up. I get a page. "Would you mind covering another room because we're short staffed?" I say sure no problem figuring they'd give me an easy room because 1) I'm a fairly new faculty and 2) I'm already covering a cardiac case (not a pump case but still) "So we have a ruptured aortic aneurysm coming in and by the way it's a relative of one of our nurse anesthetists" No pressure right? Yikes. If you don't know, a ruptured abdominal aortic aneurysm (AAA) is an anesthesiologist's (and surgeon's) nightmare. Only fifty percent of these patients even reach of the hospital. Another fifty percent of these never leave the OR, a fraction of those leave the hospital (alive that is) Luckily it ends up being a contained rupture of a previous endovascular AAA repair so it's much more stable than you'd think (which is good)

By this time. There are add-on's in my cardiac room. Not cardiac cases, but ENT cases instead followed by a neurosurgery case. bleah. PLUS i'm doing the to-follow vascular case in the other room. That's the breaks. Not bad for a day's work. I did get to leave fairly early for a call day despite the liver transplant added onto the schedule.

Television

I just saw the side of my head on TV.

Cool eh? I'm famous!

Well not really. The Discovery Channel was at my hospital a few months ago filming stories about residents. I help in part of a heart transplant, so you can see the side of my head over the surgical drapes. Not that I want to be on TV, but they seem to gloss over the anesthesia portion of these cases a lot. Oh well. Surgery makes better television.

Trust

Now that I'm more often than before taking the role of an attending anesthesiologist I've decided it's not about your skills, but more about your trust in others. First of all, for those who aren't familiar with the structure of how academic anesthesia works (most private practices I guess also) -- there is an attending anesthesiologist. He/she is "in charge" if the anesthetic. Usually she/he makes the plan and is there for the "critical" potions of the case. In academic anesthesia, usually there is also a resident involved. This is someone who is a licensed doctor, in the midst of her/his training to be a specialist, in this case anesthesia. That person is present for the entire case, and follows the plan of anesthesia set out by the attending. In private practice most places, and some academic centers too, there are also nurse anesthetists. They are nurses that go to special school to perform anesthesia also, usually under the supervision of an attending anesthesiologist. They would perform the same function as a resident -- being present for the entire case and performing the primary anesthetic. (For the rest of this, when I say "resident" I mean "resident or nurse anesthetist") The attending is usually responsible for one to four cases in total depending on the time of day and what type of cases are being performed. Now here are where trust issues come in to play. If the attending was present for the whole case, he/she could perform all the necessary functions and deal with any crises that arise without problem (most of time) because of their previous training. When you are supervising fours rooms, unfortunately you can't be four places at once so you rely on the residents to call you when there are problems. Most of the time, patients receive excellent care from residents -- sometimes even better than if the attending was performing the anesthesia him/herself. Occasionally because of the level of training there is a lapse in judgement, or a delay in calling for help. This is where you can get into trouble. If the resident doesn't call you... and there is a problem still... you are still responsible for the outcome. I trust most of the residents I work with, and I want to give them some space to learn and make their own decisions, but it's hard when i'm responsible for everything they do. So you need to trust their judgement and hope they have a low threshold for notifying you of a problem. I find myself walking from room to room checking things out from the doorway, even though I know everything should be fine. I'm told this nervousness gets better with time. I'm not sure I want it to. A healthy dose of doubt...

why?

Why do doctors talk about work when they meet outside of work. Usually complaining of some sort, or occasionally something freaky or interesting. Maybe it's only residents that do it.

British rotators

Last night was the 2nd annual "Go back to your own country party". It's where we celebrate the leaving of the rotators that come through our department. For some reason, our department has had a history of foreign anesthetists (as they are called at home) come and spend a year or so here as a part of their training. Most are from the UK. Their training is much longer then it is here, so they act as attending anesthesiologists when they arrive here because of their experience. Anyway for the most part they are well trained, relatively young, and very enthusiastic. They are part of the strength of our program in my opinion. It's nice that the department is willing to pay for such a celebration. It's a good boost to morale, especially since it's March already and there's still snow on the ground. Lots of fun was had by all. Even me, though I couldn't drink on the boss's (sp?) dime because I was on call. bleah. Still I had a good time hanging out.

Discovery Health

I'm watching Discovery Health Channel. I try not to watch medical problems when I'm at home since it's all I see at work. But the hospital I work at is featured. I remember the camera crews walking around a few months ago and it's interesting to see how things are portrayed. Seems like most of the things focused on are surgical procedures. I guess that makes good TV. Being an anesthesiologist I see that they gloss over much of what we do. Oh well. It's also all very melodramatic too. Not that the situations aren't critical, but things are so black and white on TV. I remember speaking to one of the camera women. She said to me, that it's a few hundred hours of footage for every hour of television. I guess you can tell any story when you can edit so much out.

Patient Management

Different groups of doctors manage patients in different fashions. The internal medicine doctors do it a certain way, surgeons another, and I have to say anesthesiologists another...Being an anesthesiologist in this setting is difficult. It's hard to please everyone. But you are put in the situation where you take a patient that you believe has not been managed optimally, you take them, fix them to the best of your knowledge, and then bring them back to the people you took them from and turn them over back to management you disagreed with in the first place. Also, you run into the problem where those other groups think you've mismanaged them in the interim.

I've seen situations where a patient has had surgery, received some fluid during the procedure, discharged home, and readmitted upto a week later, with a diagnosis of too much fluid during anesthesia when there are clearly other issues in play. A week later! I've seen surgeons blame anesthesia for kidney failure in a patient who had a liver transplant, when that is clearly a known complication during such an extensive operation. Seems to me that in particular surgeons are micro managers... at least in general... at least at the University level. I've had surgeons ask me to give blood products to patients at the same time not to raise the central venous pressure (which is a measure of volume status and raised directly by giving fluids or blood)

I'm not saying anesthesiologists are perfect. I'm saying that we've been to medical school too, and we've gone through specialized training. Give us a break.

Heart trouble 2

My dad went in again (scheduled this time) for more heart stents. They put 3 more in. Kept him overnight. There was much waiting at the hospital. I'm buying a treadmill tomorrow.

Thirsty

So today one of my patients says to me, "I'm really thirsty, can I have a drink." Now my general response is no. This is because before surgery we keep patients NPO or "nulla per os" which is Latin for nothing by mouth usually for a least 8 hours before surgery, or sometimes from midnight the night before. This is because one of the the most dreaded complications of anesthesia is aspiration. This is when stomach contents get into the lungs. This can cause a chemical pneumonitis which can result in lung damage, ranging from minor effects up to and including death. This is obviously preventable with prescheduled surgery. Anyway I didn't think too much about it, it's actually a pretty common thing for people to say before their surgery and reassuring that they didn't eat or drink before their surgery.

Later I'm giving the resident in the room a break while we're on bypass and I look at the intraoperative lab work. The hematocrit (aka "crit"), or percentage blood count, is 41 on the slip -- it's circled and the tech or perfusionist or someone had written "Outstanding!" next to it. This struck me as kind of funny. Someone was impressed enough with the lab value to comment about it.

A "normal" hematocrit is generally listed at 42-54 percent, but in my experience cardiac surgery patients tend to be a bit anemic and run in the 30-40 range. Now after you go onto bypass the hematocrit tends to drop a bit because the bypass pump is primed with fluid so the blood volume gets diluted and a hematocrit above 27 tends to be acceptable for most patients. Some patients start low and drop further on bypass and receive blood as a result. So 41 is really doing pretty good. I look back to the first set of labs before the patient is asleep and the crit is 48. Again still within the normal range, but quite a bit higher than we usually see for our cardiac patients. Explanations for this are many, and include disorders such as polycythemia vera where the blood is abnormally thick. In this clinically setting the most likely diagnosis is dehydration. In this instance, it was caused by us, in our instructions for the patient not to eat or drink.

So when this patient said he was thirsty... he really meant it.

Heart trouble

So, my dad had his heart catheterization yesterday. They found narrowings in at least 3 vessels. That's pretty shocking to everyone considering he had no symptoms prior to his test. Normally that would mean that he would need heart surgery. But one of the main vessels had blockages all the way down the artery. This means that if they were to do a heart bypass there would be no where to bypass the artery. So instead they put in four stents. Four! And then they stopped because they had used a lot of contrast dye to place those four stents. They kept him overnight and they want him to come back in two weeks and they want to put some more stents in. Yikes.



Anyway he had an uneventful night in the hospital. And we picked him up at the hospital after being dumped on by 8-10 inches of snow. It sucks. I shoveled the driveway at home and after an hour I had to shovel another 2 inches off... what gives.

Mortality

Nothing like mortality to bring you down to Earth. I see life and death situations most days at work, but you work through it because if you don't someone dies. It's different when something happens to family.

Yesterday my dad called me and told me had a positive stress test. That means that there is a high likelyhood that he has some blockage in some of the arteries of his heart. Tomorrow he's going in for a heart catheterization. They will place catheters in his groin, fish them up to the heart and then shoot dye into the arteries of the heart. If there is are blockages they may stent them open, or maybe he will need heart surgery, or maybe none of the above if the blockages are minor. All of these procedures carry their own risks. Likely tomorrow everything will be fine... but I've seen with my eyes bad things happen. Maybe I know too much. I rarely see the results at work of "normal" tests.

This brings somethings into perspective. Here I am. 29 years old. A physician. single. overweight. i don't exercise, i eat poorly. I think I need to make some changes. I've always known better. I just never had a reason to change.

kitty litter

So the other day, I'm helping out in the cardiac room. They're done with the cardiac cases. it's a rare light day. So there's an add on case that needs to be done urgently. A woman has an infection in her abdomen. I let the anesthesia attending know i was going to work on a presentation for a conference since there wasn't another cardiac case. My curiosity gets the best of me and I start looking up this next lady on the computer to help the resident in the room out. So the chart says she got the infection from being scratched by one of her two cats... now i'm thinking that this must be some dirty cat, or some really dirty woman. So i'm going through the notes. In the admission note... there are describing this poor woman's case.... scratched by cat blah blah blah... then they get to the physical exam. General appearance -- usually something about the patient's in no apparent discomfort, well nourished etc. -- this chart said "smells like kitty litter" So I warn the anesthesia attending. He's wondering if that should be in the chart at all... it's not a medical description. I argue that it's a fact... not a opinion so it deserves to be in the chart. He goes and sees the patient. I see him in the hall later. and ask him if she smells like kitty litter... He answers "little bit..." I couldn't help but bust out laughing...

Yay

As I said yesterday today was my first day as cardiac anesthesiology attending. As I said yesterday I have bad luck on first days.... long story short... I didn't kill anyone today. Yay.

I'll tell you about my other first days later.

First Days

Tomorrow I'm staffing my first case as a cardiac anesthesia attending. That means I call the shots... and "the buck stops here". I'm worried.. not because I don't think I can do the job, but more because I've had lots of bad first days. I'll tell you about it sometime. Not tonight.

Awareness under anesthesia

Last night I saw a special on Discovery Health about awareness under anesthesia. Awareness is when people can remember some or all of what happens during a surgery under general anesthesia... usually this in combination with being paralyzed so they are unable to tell anybody about it. i wonder how many people saw that special. I wonder if more people will be worried about it. I know it happens... it has never happened to me, as far as I know.I can't say it's because I'm a better anesthesiologist than anybody else. I think it's because I've been lucky.

Most awareness situations occur due to drug error, which is easy enough because of all the different medications that we use. I've made drug errors, anyone who says they haven't is a liar. luckily nothing serious or life threatening has happened because of this, and I try to be careful.

As for awareness, most times it happens in trauma situations and cardiac anesthesia. During traumas, people don't always get a complete anesthetic for the reason that people are worried about keeping them alive. I say that I'd rather have some awareness and be alive then the other way around. As for cardiac anesthesia, I should be worried about thi more since that's my speciality. I think this is a result of the historical perspective of cardiac anesthesia. We tend to now use a much different combination of drugs then we did just five, ten years ago so I think this is less of a problem.

Anyone out there concerned about awareness during anesthesia... it's a valid concern. Awareness is a rare occurrence but it does happen. Talk to your anesthesiologist before your surgery and let them know your concerns. If you have some awareness after your surgery, let your anesthesiologist know! If you don't remember who he or she was, make the department aware of your problem and they should be able to put you in touch with your anesthesiologist. Sweet dreams?!

Doctor aids juror, mistrial declared

Saw this on Fark.com one of my favorite sites.

NORWALK, Ohio (AP) — A judge declared a mistrial in a medical negligence case against a physician after the doctor came to the aid of a juror who passed out during opening statements.

The defendant, Dr. Joseph Carver, told the 74-year-old juror Wednesday that it appeared he had a heart flutter that momentarily prevented oxygen from getting to his brain and caused the blackout. The juror was taken to a hospital for tests.

No new trial date has been set.

Carver, an obstetrician and gynecologist, is being sued for $3 million by a couple who say their newborn daughter was dropped on the floor of a delivery room in 2000 while under Carver’s care.

They say the baby’s fall caused speech problems, seizures and other permanent neurological injuries.

The doctor can't be that bad of a doctor....

I hate my job

I hate my job.

What is my job really. I'm a cardiac anesthesiology fellow. Which means that I've finished training to be an anesthesiologist and that I'm doing speciality training to do predominatly anesthesia for heart surgery. I'm about half way done with my fellowship. This means I'm in the gray zone between being in charge of the case and just following directions.

Anyway, today we were doing a descending thoracic aortic aneurysm repair under hypothermic circulatory arrest. This probabaly requires some explaination. A portion of the biggest blood vessel in the body, the aorta, has enlarged to a size that risks rupture at any time. The surgeon was going to repair the portion of the aorta that comes down through the chest with artificially material. This requires putting the patient on a cardiopulmonary bypass machine (the "heart-lung" machine). The bypass machine does the work of the heart and lung while it is on. For this surgery, once on bypass, the body is cooled to 18 degrees centigrade. The head is than packed in ice to protect the brain and the bypass machine is shut off. This is the circulatory arrest portion. The surgeon then cuts out the diseased portion and repairs it quickly then returns to bypass. While the bypass machine is off, no blood is flowing through the body. The longer the bypass machine is off, the higher the risk of complications to the patient, including death or stroke.

Anesthesia for this surgery is quite complex as well as you can imagine. These patients require complex monitors to watch their status during the operation. These include a big IV, and arterial line to monitor blood pressure, an introducer in a vein in the neck to give lots of blood or fluids through, a pulmonary artery catheter to monitor their heart function during the operation, as well as a double lumen endotracheal tube to isolate each lung so that one lung can be deflated during the surgery. In addition to protect the spine during the procedure, we routinely put in a lumbar drain to take spinal fluid out from around the spinal cord. All in all... before the surgery starts, as anesthesiologists, sometimes we need 2 hours or more to put all the monitors in before the surgery even starts. That is, if all goes well. Sometimes it takes longer. Today it took longer. First of all, the patient had had a difficult intubation in the past. This meant we needed to use a fiberoptic scope to place a breathing tube in the patient. The other monitors went okay until we placed the spinal drain. Suffice it to say instead of a 20 minute procedure, we took almost three hours to place the damn thing. This ultimately included calling another anesthesiologist in, moving the patient to another bed, placing him prone and using xray flouroscopy to place the catheter.... once it was in, we had to move him back to the other bed and place him on his right side, so the operation could take place. Instead of starting the actual surgery at 10ish.(Thursday is a late start day), we started at almost 2pm. About 6 hours of preping this patient before the surgery even started. I wanted to scream.

It amazes me to think that we can do this surgery at all. I'm sure these people must have just died at home somewhere, or in the mall, or at the post office, not ever knowing there was a problem. It amazes me that we can do most of the procedures that it is possible for an anesthesiologist to do before 10 in the morning.

I love my job.

Hello

Hi there. I'm joining the world of the blog. There's a bunch of medical blogs out there, but I haven't seen many in regards to anesthesiology/anesthesia. Sure there are indirect references but not too many specific ones.

I'm not sure anyone understands what anesthesiologists do. Not even the surgeons with which we work every day. Even the title of this blog isn't quite right. Anesthesia isn't just about putting people to sleep. Sometimes it is... not always. Anyway. I have a lot of interesting stories from work. It shouldn't be overly technical or academic, at least not at first. Hopeful this will be an insightful and enjoyable journey. If not, I at least get a chance to vent. Feel free to send or make comments. I'll do my best to address them if anyone actually reads this.