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.