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 Then they showed him dying after having life support withdrawn at somepoint after that.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.