Sick

It's that time of year again. Time for flu, colds, etc.

I was in charge of making sure rooms in our building were assigned to residents and faculty the other day. This includes assigning where add on cases go and making sure people get breaks and lunches and relieved at the end of the day.

One of the residents came up to me and told me he might need extra breaks because he's been having some "GI (gastrointestinal) problems" and been running to the bathroom. He said he was probably going to the emergency room after work because it had been going on for five days or so.

Yikes! A few minutes later his faculty came up to me and said his resident looked terrible and diaphoretic (sweaty) and should be sent home. I agreed and called over to the main building to see if there was someone extra to send over.

I went to his OR and told him we were sending someone over to relieve him. He protested and wanted to stay. "This is an interesting case, and I need my vascular cases"

I said, "If you need to go to the ER after work, you need to go to the ER now. You can't get your vascular cases if you fall over. You can always come back if you're okay"

He finally agreed and he was sent home. I think he didn't need to be admitted to the hospital, but earned himself a CT scan and lots of blood tests.

A couple days later, a (different) resident popped into my office.

"You in charge?"

"No, why"

"I just threw up I think i need to go home"

"Fair enough Dr. X is in charge... he just walked past here"

I went out to the break area a few minutes later.

I overheard, "X looked terrible"

"I heard she threw up"

"She must be pregnant"

Laughter from the guys. "No think she's actually sick, she looks terrible"

She walked back by, looking annoyed "I'm NOT pregnant"

Shock of your life

Image used without permission from freepatentsonline.com

I'm staffing a case down in the Electophysiology (EP) lab. Here is where the cardiologists look at the heart from the inside and do various procedures to help fix conduction abnormalities in the heart. They implant defibrillators and pacemakers in the EP labs.

There was a young man on the table, we were getting ready to sedate him for a procedure for an irregular heartbeat. Our anesthesia monitors were being put on and I was looking at the chart. All of a sudden I saw the patient jump up... I thought he was trying to crawl off the bed. Then someone started apologizing....

Apparently she was testing the external defibrillator. This is the device used to put a shock through a patient's chest to put it his/her heart back into a regular rhythm if it goes into a dangerous rhythm. You see this all the time on ER and Grays Anatomy and such. Anyway during this procedures where we are trying to cure these rhythms there is a high likely hood of putting a patient into one of these dangerous rhythms. So as a precaution they always have the external defibrillator in the room and two electrode patches on the patient. In this case during the test of the device someone had already hooked it up to the patient. So this patient got quite a nasty shock. He shook his head like he was stunned and said he was alright three or four times... all the staff were really apologetic.

This would have been a little amusing to me except for the fact that when a person is in a "normal" heart rhythm, shocking them may put them into a dangerous one that is life threatening.

Glad it wasn't me though

Neck mobility

I was in preop anesthesia clinic yesterday. I saw a patient that had been in a car accident and had his neck fused c2-c5 (I believe) and he had very little neck movement at all.

In anesthesia there are markers to predict or at least suggest it may be difficult to place a breathing tube in someone. These include mouth opening, dentition, mallampatti score, which assesses the favorablity of the anatomy of the oral cavity (i.e. mouth), hyoid to mentum distance (essentially chin size), neck thickness/anatomy, neck extension and flexion. No one predictor predicts a difficult intubation, but together they form a picture of how easy or difficult you think it might be.

Someone with very limited neck movement would be very difficult to visualize the vocal cords generally, so I was worried a bit in this case. Apparently he had had two surgeries in the past six months with no problems and the anesthesiologists had not told him anything about his airway. So just to be sure I requested the anesthesia record from the other hospital.

It was your standard anesthesia record, with lots of checkboxes for standard things that you do in the operating room.

Easy mask ventilation - checkmark -- reassuring because that means you can still mask ventilate if you happen to have trouble intubating.

Iv induction - checkmark.

Easy intubation - checkmark

Mac 3 - checkmark

2nd attempt - checkmark

Blind intubation - checkmark
whoa.... wait a minute. it was an easy intubation, but he/she wasn't able to visualize the vocal cords?

So now I flip through the rest of the records... no note about the airway at all, or being difficult or anything. I have to now doubt the accuracy of this whole chart now.... How can I trust that he was a easy mask ventition if she/he was willing to describe the blind intubation is easy.

Enough to drive you crazy.

Perioperative Guidelines

Got sent the new ACC/AHA revised perioperative cardiovascular guidelines for non-cardiac surgery. It was a PDF attached to my email, and I figured I should know what's in them since I work in the preop anesthesia clinic, so I printed them out...what could it be... ten pages maybe...

nope.

I went to the printer and it was still printing and it was neverending.

82 pages!

Yikes... I know it's a complex topic, and I need to know them.

6 pages down... 76 more to read... i think some of them are references though... maybe only 70 pages...

Hand Sanitizer

Image used without permission from childrenshospital.org

Just got a message on my pager.

I accidentally contaminated the sterile field with [brand deleted hand sanitizer] ( that went out of control) --[resident name deleted]

Our hospital has gone to having alcohol based hand sanitizer everywhere, to decrease the spread of infection... there's one on the side of the anesthesia cart. Apparently, the spout had gotten clogged a bit and when she went to pump some on her hands it squirted sideways and hit two people scrubbed-in and the corner of the instrument table... and we're doing a descending thoracic aneurysm repair and they're often super-paranoid (rightfully) so that the artificial graft material doesn't get infected.

Didn't seem the surgeon had flipped out though... probably due to the fact that it's 62% alcohol and probably made the surgical field cleaner.

You can't make this stuff up.

Locked out

I was on call yesterday and there was a fire drill going on so the fire alarms were going off... i was headed to the ORs to wake up a patient with one of the residents and I swiped my ID at the OR doors... Nothing... no click, just blinking lights on the pad. I swiped my ID again. Same. So I pulled on the door. still locked no way to open it. Luckily someone was exiting the locker room and I got in there and cut into the ORs. This happened on one other occasion with a different door soon after the opening of our new addition, which I chalked up to being in a new building. I don't know if this is the case with any other doors, but I'm guessing it is.

This is a serious problem. Luckily I was going to a routine wake-up with a good resident and I wasn't really needed. But we need to get into the ORs, or really anywhere in the hospital where we are needed regardless of whether a fire drill is happening or not, or a real fire, or if the building is falling down. This goes the same for the residents who may be running to a code or emergent airway.

Excuse me while I spend the next half hour composing a coherent email to the higher-ups

Fat

Wow.

One of my rare days now where I'm not doing cardiac or thoracic cases.

The patient had a Body Mass Index (BMI= weight in kg/ [height in meters]squared) of 78! Overweight is above 25, obese above 30. It's a little conservative in my opinion, but this is ridiculous. He was 5 foot 6 or so, and above 220kg. (~500 lbs) fortunately he was here for gastric bypass surgery.

When they're this big, you worry if you're able to get IV access, establish the airway, and whether the surgeons will have difficulty with the procedure.

Anyway, after we put the patient to asleep and intubated him the attending surgeon asked:

"How did you know that would be easy?"

My reply, "I didn't."

I moved along into how we examine the patient and the markers we look for that predict difficulty (or lack thereof)

Luckily no problems.

I did have salad for lunch... I need to work on my own BMI.

Sad

I pulled out my bike from the garage yesterday to ride it to the gas station to get some air for the tires... It's about two miles I guess. Anyway, I was recounting this to my girlfriend who seemed glad I was getting some exercise.

"Well it took you about 30 minutes... that's not too bad."

"Minus stopping for air..."

"You were that winded?"

"... Air... for the tires."

I must be more out of shape than I thought.

Poop

Luckily my friend's dad is feeling a bit better... kicked out of the hospital. No more obsession with flatus. Now family is obsessed with poops.

Abdominal surgery

My friend's father had emergency bowel surgery this past weekend, so I've received many surgical type questions which I'm marginally qualified to answer. In any case I'm finding it amusing with how my attention is being taken to his gastrointestinal tract, specifically the ability to pass gas. Hope he's feeling better soon.

Mini Mall

Ever heard of grand mal seizures? It's the type of seizures most think about as seizures, with unconsciousness and violent jerking movements.

I'm in clinic today. On her history form she has written "mini mall seizures".

I usually shop at mini-malls, but I think she means petit-mal seizures. These are also known as absence seizures and not associated with jerking motions.

Poor historian

I'm in clinic again... the bane of the non-pain anesthesiologist. A 60-some year old woman is here for surgery. She's had a history of heart failure. (Her heart is damaged so it doesn't pump very efficiently) She's a terrible historian.

Now for non-medical types, this doesn't mean she didn't know that Washington crossed the Delaware. It means that she's a terrible reporter of her own medical history. For different patients it means different things. To some it means that they can't remember what they've had done in the past or what medical conditions they have. To others it means that they ramble on so much it's hard to separate the medical information from random stories about their puppy. And my favorite group is the group where they're so vague about things that it takes 14 follow-up questions to get what you want from them.

"So how bad has your heart failure been" (Looking at the chart with 6 heart failure meds on.)
"Oh I don't really have heart failure"
"Hmm... really. Can you climb a flight of stairs?" (I don't care if she has stairs in her house, I just want to know if she can tolerate minor exercise)
"Oh I don't really climb stairs with my back and all" (Meaning she can't do it)
"How about walking, how far can you walk?" (Easier than stairs)
"Oh not far..."
"Do you ever get chest pain or shortness of breath?"
"Well not really.... well only if I walk too far." (Meaning yes all the time)
(inside) *sigh*

So I look again through the notes. There's a note from the Primary care provider (PCP) "Will stress before surgery." Now someone there has a good idea. Good to know if this lack of function is due to her heart or her back before we possibly kill her in the operating room.

I flip to the studies. I see a non-stress echocardiogram (essentially a heart ultrasound picture) from five months ago showing diastolic dysfunction. And a stress echocardiogram (same pictures, but while giving a chemical to stress the heart) from last month. "Indeterminate. Study cancelled due to hypertensive response." So they cancelled the stress in the middle because her blood pressure got too high. Fine. What did they do about that. I see another non-stress echocardiogram from two weeks ago. Hmm.... curious. So the stress was unable to be done, so they repeated a test that DIDN'T stress the heart, and had results we ALREADY knew about.

So it's six days til her surgery, I have a patient with known heart failure, maybe shortness of breath, maybe chest pain, two non-stress tests, and an indeterminate stress test. Someone also has decided before me that a stress would be a good idea, but never really followed through. So I have six days (including two weekend days) to get her stressed (a different type of stress test) or cancel the surgery. Luckily the ladies out front (the wonderful office staff) are able to get her scheduled for early next week. I cross my fingers and let her go.

The intern asks me what happens if the stress is positive next week. Good question. If it's negative, then I'm just a worry-wort and paranoid about nothing but she should get her back fixed. If not, then they need to evaluate her to see if anything can be done to optimize her heart before her elective surgery. This may mean changing her medications, or performing a heart catheterization, or more.

Did I tell you I love clinic?

Study Says Chatty Doctors Forget Patients

Study Says Chatty Doctors Forget Patients

Funny... except for the patients. Published in the Archives of Internal Medicine via the New York Times

Playing Doctor

I got to play "real" doctor this weekend.

Not that an anesthesiologist isn't a real doctor, but it's not immediately what comes to mind when you say doctor.

My friend volunteers at a free county medical clinic run by medical students some weekends. The medical students see patients and are staffed by physicians from the community. They were running short of physicians this week so I offered my services.

It was a little different than my usual Saturday morning, but a little fun nonetheless. I only had to ask a few questions to the "real" doctors.

A lot of me saying to medical students "just warning you... I'm an anesthesiologist."

Staffing shortage

This week we opened a new building... brand new operating rooms, new offices, etc. beautiful place. Still some growing pains as we are somewhat short staffed.

Yesterday, we had an urgent case to start. No residents or CRNAs were available since it was a lecture day and the available people were giving breaks so other people could go to their lectures.

Anyway they had an available OR, and I myself was giving lunch breaks....

So I just went ahead a did the case myself.

I know this doesn't sound too strange to most of you. It's probably the norm in most places. But being at an academic institution I haven't done a case by myself, well ever. In the few years I've been staffing, I always work with a resident or CRNA. Before then I was a resident so I worked with a faculty member supervising me.

It's nice knowing you have your stuff together well enough that you can do a case by yourself at a moments notice.

Yay me.

Preop Hijinks

So I'm in clinic today and I'm talking to a patient about his health problems for some surgery or another. All of a sudden he stands up, unbuckles his belt buckle, unzips his pants and starts tucking his shirt in.

Now I've done this before too, but usually it's in my bedroom before I go to work or if I'm in the bathroom or if I'm alone somewhere with no hope of someone walking in.

Weird and unsettling.

I just acted like nothing was happening and averted my gaze.

Condolences

As you no doubt have heard by now. A plane with an organ transplant team crashed into Lake Michigan on Monday. All six aboard were lost.

Condolences to the families of the two doctors, two organ donation specialists, and two pilots.

They perished in the quest to save the life of another.

Tragedy

I don't really want to talk about it now but do me a favor.

Go home, kiss your wife or husband, boyfriend or girlfriend, hug your children.
You never know when it's the last time.

More later... maybe

Tuberculosis

Everyone knows the name of Andrew Speaker. If you don't he's the person carrying the multidrug resistant tuberculosis(TB) stain all over the world.

First, Tuberculosis. It's a difficult disease to treat... months of antibiotics are required in most instances, and usually more than one type of antibiotic. Because people generally feel fine when they have this diagnosis they often quit taking the medication. This leads to more drug resistance.

I find a few things very funny about the case.

1. He's a personal injury lawyer. If someone else had done this I bet he'd be on TV advertising for people to call him to get their "rightful settlement"

2. His new father-in-law... works for the Centers for Disease Control. Speciality -- tuberculosis. You can't make this stuff up.

3. His name came up when he crossed the border from Canada. "including instructions to hold the traveler, don a protective mask in dealing with him, and telephone health authorities." The border inspector ignored these warnings because they appeared discretionary and the man appeared healthy. Good to know the system works. Good thing he's wasn't a terrorist. I imagine if he had been of middle eastern ethnicity he would have been face down handcuffed in a ditch in twelve seconds.

I'll give the guy some credit. He's probably not extremely infective from what I know about TB. He wasn't coughing, he probably didn't have an acute infection. He also picked it up somewhere long ago. And it was just recently found on an xray for something unrelated.

But also some problems.

1. He states he didn't know the risk of what he was doing, but when he was told not to come home he went to extreme pains to get home. He flew from Atlanta to Greece for his wedding, warned not to travel. Then flew to Rome, Italy. Warned again not travel. Then got to Prague, Hungary flew to Montreal, Canada then drove across the border to avoid authorities. Sounds like someone deliberately trying to skirt the system.

2. I'd hate to miss my wedding and honeymoon. But questions are now arising to whether a wedding took place. One article states "There was no wedding. They came for a marriage but they did not have the required papers." Good planning on his part. If I was the prospective bride I'd be pissed off.

Keywords

So I've realized for the last few posts that you can add keywords to each post and people can read those posts with those keywords only.

I'm anal enough that I'm going back and adding keywords to all my old posts. Hope this makes reading more enjoyable.

(I'm assuming people are reading)

Random walls

Image from freefoto.com

I'm walking out of work late yesterday. I'm tired. I'm on cardiac call i've been here for 12 hours. Not bad hour-wise but i've had to work with one of the stressful surgeons and just finished helping code a patient in the operating room.

I just want to go home and put up my feet...

All of a sudden there's a wall along the corridor where I usually walk out. It was open this morning

"Detour -->" I guess they're finally connecting the new building to the old one.
Now I wander through the basement and finally get to my car.

Perfect ending to a long day. Hope I don't get called back in.

Yay!

I got a page from a friend today saying oral board results were posted.

I passed!

It's about a week and half earlier then they said scores would be up, but I'm glad.
Relief.

Oral Boards - Done

I've been back from DC. Oral boards are done.
Yay!

Topics were anticipated. Did I study enough, hard to say... would studying more been more helpful... doubtful.

I think I did okay... but who knows for sure. I'll find out at the end of May.

At least it's over, for now.

Transvaginal Cholecystecytomy

In a word -- Yuk!

These words together mean removal of the gallbladder through the vagina.

Yuk yuk yuk.
If I had a vagina, you're not removing my gallbladder through it.

And to boot there's a Natural Orifice Surgery Consortium for Assessment and Research.

You can leave my natural orifices alone... I mean look what great scientific advances there are in this decade.

New York Times online via Book of Joe

DC in the spring

Ah to be in Washington DC in the spring.



Blossoms on the trees.

Spring is in the air...

NO!

I'm in DC for anesthesia oral board exams

Its 40 degrees outside.

There's a wind advisory...
The plane was shaking like a laundry dryer as we were landing... and I swear we were going sideways for several seconds.

AND I'm taking oral boards tomorrow.

I'm a little stressed

I'm back to the books for last minute cramming... maybe a short nap.

More later.

Drug interactions

A friend called and asked me: "Are there any drug interactions between Darvocet and albuterol?" Her friend had just had surgery and was on pain killers (Darvocet - acetominophen/proproxyphene) and wanted to take a puff on her inhaler (Ventolin- albuterol).

I said I didn't think so. The narcotic has lots of interations, but not likely with albuterol. "Why?" I asked.

"Well she saw this Law and Order where this girl poisoned her mom with darvocet and albuterol."

Hmm... Law and order? "You sure that wasn't darvocet and ALCOHol not ALBUTERol?"

"Hmm... yeah probably, see ya bye!"

I guess it's all in the details.

Clinic

Been in clinic a lot the last few weeks. Almost half my work time. By now i'm almost suicidal... I didn't go into anesthesia to do so much clinic

(no offense to those who are actually suicidal)

Room temperature

It's important to keep the patient in warm in most cases. Most cardiac cases this is not an issue much because the heart-lung bypass machine has a heat exchanger on it which allows the perfusionist to warm or cool the (patient's) blood as it goes through it.

We were doing a big cardiac case under left heart bypass -- where part of the blood is taken after it gets passed through the lungs, and rerouted to the femoral artery in the groin so that work can be done to the descending aorta with most of the blood flow being perserved. This is nice so that damage to important organs like the kidneys and intestines can be limited.

Since we have less control over temperature because it's only partial bypass, we had the room temperature way up. It was warm for me, but must have been killer for the surgeons who were wearing waterproof gowns, etc.

On of the attending surgeons was scrubbed in and asked for temperature to be turned down. He's generally very expressive. "Turn down the temperature or I'll vomit in the wound and the patient will get septic and die!" I just about died laughing...

(For those not in the know... sepsis in a severe systemic infection caused by bacteria. If you vomited into a patient surely this would happen but it's not a scenario you contemplate ... well ever.)