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.