Class 2 trauma man vs cow???

Dental care

Per patient chart "He has no recent dental evaluation but reports that he regularly cleans his teeth with a paperclip"

Loves being in on a Saturday doing an "urgent" case especially since I
heard about it Wednesday

A patient's family in the waiting room wearing "I <3 Team [surgeon's
name]" tshirts. I can't imagine them wearing "I <3 Team Anesthesia".
Not that I mind really

It's going to be a banner day when the anesthesiologist is the most
qualified person in the room to put in the Foley catheter.

Trapped in cath doing aortic procedures. Resident referred to it as
'fat camp'. You don't get to eat all day. And you have to run up and
down the stairs wearing 15 pounds of lead.

Never a good day when you get blood on your shoes

Newspaper

I was explaining the risks of anesthesia to a patient before cardiac surgery... the patient said "no problem, I'm not going any where". I said I just wanted to make sure we were on the same page. The patient said "As long as I'm not on the front page, nor on the back page (obituaries), we're in good shape"

Saw woman in recovery drinking coffee from a mug she brought in herself

Physical exam

Most daily progress notes include a physical exam portion to say how the patient looks, how the heart and lungs sound etc, this was the best exerpt today I found while looking through my patients

"HEEN: WNL, could use a shave"
(HEEN=Head,Ears, Eyes,Nose; WNL=Within Normal Limits)

Surgical Plan

The cardiac surgeon today announced the plan for today's cardiac case:

Out of the room by noon, without a balloon

(Referring to the Intra-Aortic Balloon Pump - a device inserted through the femoral artery into the descending thoracic aorta, used to augment cardiac output and help a person with poor heart function come off of the cardiopulmonary bypass pump)

The hard part about leaving early is avoiding the family members of patients you've just put to sleep

Paging system down

You don't realize how much we rely on the paging system until it goes down. We've turned into the hospital you see on TV, with "stat" pages overhead every 30 seconds.

heart trouble/car trouble

Sorry ma'am, the ambulance that your new heart was travelling in has broken down


(it's going to be a long day)

Monday Morning

You know a cardiac case is going badly when you walk in Monday morning and there's a case to take over in your room from last night - and that case has already been going for 15 hours!

Truth from patients

A patient said to me today - "There are two places you can't lie about your weight - when you're having anesthesia and when you're bungee jumping"

weekend call

Saturday cardiac call... doing an abdominal case for the cardiac service and an abdominal case for the thoracic service... weird.

Gall bladder

I was doing non-cardiac cases the other day... thought I might have a straight forward day for the first time in a while. Things seemed in order looking at the patient's history for a cholecystectomy (Gall bladder removal). I said hi to the patient asked a few questions and then moved along to see my other patient that morning.

The resident came up to me a few minutes later and told me there was an "issue". The history has looked unremarkable and was wondering what I had missed.

Apparently the patient wanted to take her gallbladder home with her as was getting visibly upset when the surgery resident told her that wasn't the usual procedure.

Now I'm wondering why someone would want to take a nasty old gallbladder home...yuk.

I think the gallbladder usually gets sent to pathology after these surgeries. I can only guess what they're looking for but 1)they're checking that you actually took out a gallbladder and not something else 2)possibly looking for cancer in the gallbladder... i'm not sure but that seems reasonable to me.

"I think she's gonna walk" said the surgery resident after 10 minutes of talking to the patient "I need to talk to the attending surgeon"

Apparently the patient wanted to bury the gallbladder in the backyard as some sort of spiritual closure from having it removed from her body... not too unreasonable if that's what you believe in.

The attending surgeon came down and sorted it all out.... She was not going home with her gallbladder... and she wasn't walking out.

Busy morning

It's a busy morning for me... I've got two cases to start... one of them is a Left Ventricular Assist Device (LVAD) in a really sick patient with bad heart failure.

She's in the intensive care unit and will be a transport to the OR. I'm there a few minutes early (as I try to do, but don't always succeed) I meet my resident in the ICU and he tells me the case is on hold.

"Why?" I ask.

Apparently there are two LVADs scheduled for that day, which is pretty rare. They do have two sets of surgical instruments, but there's a particular wrench which they use to tighten certain components of the device. They only have one of those wrenches. They don't want to start the case unless they make sure they have everything they need for the surgery. Of course the OTHER room has already started.

I'm more than a little annoyed... both cases have the potential for lasting most of the day... so a delayed start is less than optimal. Both cases had been scheduled since the day before, so you think that it would have occurred to someone to deal with the problem before it was an issue.

The charge nurse was in the process of contacting the representative from the device manufacturer to see if he could bring the extra wrench.

A few minutes later, they said we could go ahead. The two surgeons agreed that whomever was to the stage that needed the wrench first would get to use it first. Then they would quickly clean and resterilize it so the other could use it.

Not the best solution, but workable I guess.

In the meantime, the representative from the company was able to get there in time with extra tools so that there was actually no issue. Still much unnecessary stress for me though.

are you busy?

I'm standing the preop area in the morning talking to some of the residents before cases get started for the day. One of the preop nurses comes over...

"Are you busy?" Fateful last words "Are you covering the recovery room?"

No cases have come out into recovery room yet, "I'm not covering, but you need help with something?"

"Can you come over and look at one of our perioperative techs? She's having some chest pain? We're going to hook her up to the monitors... could you look at her EKG?"

They bring her over to a recovery slot, hook her up to monitors, everything looks okay, vital signs stable.... I take one of the residents over with me... we start getting some history.

Family history of vascular disease... pain started this morning while she was moving things around in the OR... yes I've had his before... not as bad as this time... it's always gone away.... just a little short of breath... just a little sweaty....

She looks fine to me, but the story is a little suspicious for having heart disease... soon my resident and I are wheeling her over to the ER... just to be sure.

Of course she qualifies for chest pain protocol.... they want to "rule her out" (2 sets of EKGs and blood tests 8 hours apart to see if there's heart damage) and probably watch her overnight maybe a stress test in the morning...

Never a dull moment.

consent

All surgical procedures must have a consent form signed by the patient before we go back to the OR. Most of the time this is done in clinic before surgery. The doctors describe the risks of the procedure, and weigh them against the benefits. (Sometimes glossing over the risks, in my opinion, but that's a different discussion) With some surgical services this is done the morning of the procedure before they go to the OR. (Usually with the more straight-forward procedures).

To assure that we don't miss this there are brightly colored signs at the patient bedside that scream "NO CONSENT"

I walk up to the patient and there are these NO CONSENT signs everywhere, so I start flipping through the paperwork after I introduce myself. I see a signed consent form..,

I'm surprised a bit, because the surgeons are still in the OR as far as I know someone else from the team would have had to come out to take care of the it.

The Preop nurse is starting an IV, "I see someone came down and consented the patient"

"No, she filled it out herself."

???

Apparently the patient is a recovery room nurse at another medical facility, saw the paperwork and just started filling it out herself.

Not necessarily great in a medicolegal sense, but mildly amusing to me.

platelet shortage

Interesting email this week:

This is a reminder that Thanksgiving is next week. We anticipate severe platelet shortages for the first week of December. Platelet availability will be VERY tight December 1-4. Monday and Tuesday will be the worst days since there will be virtually no blood donations Thursday-Sunday. If you have elective surgeries with high anticipated platelet needs, I would recommend rescheduling for the following week.

I guess I never thought of that, but it makes sense.

Platelet availability is dependent on recent (last 4-5 day) platelet donations. The week immediately after Thanksgiving and the Christmas-New Year holidays are always characterized by platelet shortages due to low whole blood donations in the preceding week.

morning surprise

You think you're going to have a relatively quiet day...

2 thoracic rooms, only 2 cases

one room is a late start, so no having to try to start two rooms at the same time.

Come in... pull up the computer to double check the patient's histories...

Hmmm... double lung transplant.

*sigh* it's a living

Dirty Car

Image from Wikimedia Commons Original Batmobile copyright ABC-TV and DC comics

One of the cardiac surgeons always has the dirtiest car in the lot (He must live on a dirt road or something. We were there on the weekend and he mentioned that he's going to have to find out who wrote something in the dirty back window with their finger.

What did they write on the window of the surgeon who does the most tranpslants/VADs(ventricular assist devices) at our hospital?

VADMOBILE

Hilarious... (to me anyway)

Web logs

Occasionally I go through my counter logs to see how people get to my blog.
I try to add links to blogs that link to mine, etc.
I use the free version so it doesn't tell me much.

But there's some interesting stuff.

• Links from several other medical blogs
  
• Many google searches for things:
  
  
  
  • Some medically related stuff, especially related to anesthesia
    "abdominal surgery" "cooling down on pressors medication" "scar tissue sternum" "difficult airway box"
    
    
  • "what does it mean when a doctor says a pt is a very poor historian"
    see 7/16/2007 Poor historian
    
    
  • People who are sleepy
    "i'm sleepy" "I'm sleepy the entire day" "How not to be so sleepy" "at work so sleepy" "I'm at work and so sleepy" "Why am I so sleepy" "I'm sleepy what to do" "why am i so sleepy all of the time" "im so sleepy all the time why is this" "so so sleepy"
    
    So some of these people may be looking for my blog (I don't know why they would) but I'm guessing there are lots of people out there who don't sleep well. There are many medical reasons for this. You should look on the web (which you are trying to do I know...)
    
    Here's a short list from my limited experience in the field (I'm not a sleep expert. This is not a medical diagnosis. Go see your doctor.):
    
    
    
    • Not enough sleep (at least 8 hours a day)
      
    • Poor sleep environment (Not dark enough, too loud, pets, children etc...)
      
    • Sleep apnea (A medical condition where you stop breathing when you sleep. The body wakes itself so you will breathe. Can be treated. Makes a huge difference. I know!)
      
    • Excessive caffeine and stimulant ingestion (including nicotine. I know someone who if they drink caffeine after 2-3pm can't sleep at all)
      
    • Thyroid hormone deficiency
      
    • Other medical conditions
      
    • Medication side effects
      
    
    
    
  • Always some links to some of my random images that I've "borrowed" from the rest of the net.
    "necktie.jpg" "ferret.jpg" "gastroscope.jpg" "heartvessels.gif"
    
    
  • "book called shock of your life"
    I have no idea, but here you go... Shock of your life by Adrian Holloway Go for it, it's only 11 bucks.
    
  
  

Gah!

Don't want to talk about the exact incident.

When I supervise residents or CRNAs I am responsible for their actions...

...regardless of whether or not I am aware of them.

The case was managed correctly.

I didn't know about significant blood loss until I was informed by another anesthesia provider.

Wouldn't have done anything different, would have liked to know about it.

Helpless

On Saturday I was at a popular nationwide-chain arcade/restaurant/bar and playing around trying to win enough tickets to get a stupid little trinket.

I heard a bit of a commotion. Apparently a young girl fell to the ground off a seat and her mom and little brother were screaming and crying (respectively). I rushed over because it didn't look like anyone was really helping (though there was a small crowd gathered). The girl seemed unresponsive.... I felt for a pulse and put my ear to her back to see if she was breathing... she was. I asked the mother what happened... she said it looked like she had a seizure, though she was a healthy kid and never been sick in her life. I made sure someone had called 911 and really didn't know what to do next. I'm pretty used to dealing with rough situations in the operating rooms, but in a restaurant I have no equipment, no IV, no drugs, not even any monitors other than my own senses....

The bartender came over and said he was also an EMT (Emergency Medical Technician) I let him take over, some other doctor came over, but I didn't catch what kind of doctor she was. I let him step in because I figured he was used to those situations, and besides she was breathing and had a pulse so I really didn't think i would do anything different otherwise.

I hovered a bit until the ambulance arrived and she seemed to be waking up a bit.

The rest of the evening was uneventful, but I couldn't help but wonder if she was okay, and also knowing my own weaknesses outside my usual work environment.

Time Out Day

Image taken without permission from Benches.com

Apparently it's National Time Out Day...

No we don't have a bunch of rowdy 6-year-olds in the hospital (though it seems that way sometimes)

It's a partnership of the Council on Surgical and Perioperative Saftey and the Joint Commision, and other organizations such as the American Society of Anesthesiologists and the Association of periOperative Registered Nurses, among other groups to improve safety in the operating rooms and prevent wrong site and wrong side surgery. (There have been several tragic cases of the wrong limb being amputated... etc. gah!)


For some reason National Time Out Day was June 25th in 2004, June 22 in 2005, June 21 in 2006 and June 20 in 2007. Really it's National Time Out Day-somewhere-in-middle-to-end-of-June. Guess you couldn't really have it fall on the weekend, the effect would be lost.

Anyway the chocolate bars with a timeout card and whistle were an odd touch... but who doesn't like chocolate.

Epidural testing

I put in a thoracic epidural with a resident yesterday.

Epidurals are small catheters that go into the space right outside the spinal cord. We give local anesthetic solution through them and it numbs up portions of the body. They are useful for controlling surgical and labor pain. We test them to make sure they are working well. One way is to use a piece of ice and see if the patient can feel the coolness. The other is to use a "sophisticated testing device" called a toothpick to see if they can feel pain sensation.

We finished putting in the epidural and I asked the resident to test the patient. She was testing areas and the patient was amazed that she could not feel the toothpick at all...

"Give me that..." she grabbed the toothpick and started jabbing herself in the side. "Wow" Somehow she believed that we weren't actually poking her with the toothpick.

It's the first time I had a patient test themselves.

The epidural was working.

The patient decided to take the toothpick home. She gave it to her husband. "Don't throw that away... and don't use it."

Helicopter

I hear helicopters in the background. Not so long ago, as a child, I often looked up in excitement at the incredible speed, power and agility of such magnificent machines. Now more often than not (even when I'm not at work) I hear that engine noise and I think... work

soaked to the skin III

Now to help the patient you have to relieve the pressure around the heart.
Usually this is (relatively) easy. You use a sternal saw and cut through the sternum. (middle of the chest where the ribs come together).

In this case it was more difficult. He's had cardiac surgery before. Which means they've already sawn (sawed?) through his sternum in the past. This is problematic because there's sometimes lots of scar tissue there now, so if you try to get in through the sternum quickly, you make have to go through scar tissue. And in that scar the patient's aorta, which is the biggest artery in the body, may be scarred together. The other option is to go in through the side of the rib cage. Since he hadn't had any surgery on his chest from the side, there's less chance of scar tissue and bleeding.

Now, the next scene is as close as you may see to a medical drama on TV. Usually as a medical professional you say "Naw that never happens!" and you criticize the accuracy of things on TV. But, now they tilt him to the side, the surgeon throws on sterile gloves, no gown, and starts cutting though the side of the chest to get to the sac around the heart. He's got blood all over his arms, he's calling to have someone page one of his partners to help him out. In the meantime, I'm giving him lots of medication to keep his heart pumping(pressors), because now it's squeezed down from the blood on the outside of it.

His partner shows up. also throws on sterile gloves, no gown. The nurses are checking blood and giving it. All of a sudden, the blood pressure shoots up to 3 times normal.... They've relieved the pressure around the heart by opening up the pericardium. Now the heart has no more pressure around it and all the medication that we're giving to help the heart squeeze is working too....

But now there's bleeding all around the heart... they need to look for the hole that caused the blood to escape the heart and fill up the pericardial sac in the first place. It's dark in the EP lab, because most of the procedures are done looking at video monitors. Even with all the lights on it's dark in there. At this point they've fillup a whole suction container with blood (1.5 liters) we're giving blood. they're a good way towards filling a second. He asks for a certain kind of stitch... of course they don't have it in EP lab. Why would they need a cardiac surgery stitch. he puts his finger over what he thinks is the hole and yells to have them call up to the OR and get the stitches he needs. I yell to have them call up also and have them get a cardiac OR ready. I assume we'll need to go up there eventually, if we make it.

He finally gets the stitch he needs... puts in a couple more.... still bleeding from around the heart, now there's some bleeding from there entry into the chest too. "I don't know how we're gonna get this guy upstairs" he says. A couple of more stitches, some more blood given, more pressors given. he finally decides that he's got some marginal control of the bleeding and to pack some pads around the heart, to hopefully place pressure on the hole and give us a chance to get up to the OR where the proper equipment and help can be used. The pads go in, 2 stitches to hold the rib cage closed, and a big sheet of sticky plastic (think medical grade iodine impregnated contact paper) to keep the area, marginally clean. I'm a bit surprised we've managed to keep him alive this far.

We roll the patient over to get him over to a stretcher. This is what starts the soaking of my clothes. we get him moved over. we rush to the elevator and up to the OR. It takes several minutes to get up there, we're giving blood and pressors like crazy. we need to position the patient on the side more properly so he has better access to the side of the chest than he did downstairs.

I help roll the patient again, i'm leaning over the wound and it's starting to well up around the plastic sheet. now it's leaking over me, warm. I can't stop, because I know this guy's going to die, and I can't let it be my fault. We finally get organized and they're prepping the patient to go back into the chest.

we're sort of stable now on lots of pressors, but giving a little less blood... until they open up the plastic.... blood starts gushing out again. we scramble a bit. One of the other cardiac anesthesiologists shows up, asks if I need a hand. I ask him if he can help the residents out so I can change.

I scurry down the hall, my belly and crotch covered mostly in blood. I must be a sight. I go to my office, take my scrubs off, my underwear is bloody too. yuk. Luckily I have a clean pair if my office (for call nights) I go wash my hands and I'm back in the OR.

Twenty minutes later, the surgeons can't find the hole, and they're bleeding from all around the heart and incision and multiple transfusions and medications later the man's 80+ year old heart gives up.

I ask the resident if she's okay to tidy on her own and we all walk out of the operating room defeated.

Unfortunately we can't win them all.

soaked to the skin II

anyway, sorry for the delay.. where was I...

So they're doing CPR on the patient. I went up to the anesthesiologist and asked what was going on. Apparently they were doing an ablation in the ventricle and they had starting getting low blood pressure during the case, then a cardiac arrest.

Now you see some people have irregular rhythms in their hearts. Usually these are cause for little areas of abnormal tissue in the heart, they can burn these areas and usually the irregular rhythms will go away. This is called an ablation. Sometimes they burn through too much and they can get into trouble. It's known to happen, but usually rare.

The problem they have here is now they have a hole in the heart and it starts to bleed. That in and of itself isn't great, but the main problem is that the heart sits in a little sac of tissue called the pericardium (literally "around the heart"). Once it's full of blood, if you have continued bleeding it starts to compress the heart and the compressed heart can no longer fill and pump blood. This causes low blood pressure and eventally cardiac arrest. This is called cardiac tamponade. The way to fix this is to open up the pericardial sac and let the blood from around the heart out, then it can again fill and pump blood. The problem with this is that you still have bleeding and now it's not just limited to the pericardium, but can continue to bleed.


More later...

soaked the skin

As an anesthesiologist you shouldn't need to go to your office and change your scrubs in the middle of a case.

No I didn't soil myself because the case scared the heck out of me because it did, but I was covered in blood from moving the patient on to the bed.

I'm on call today and I was headed down to the Electropysiology (EP) lab to relieve the anesthesiologist down there so he could go home. I'm poking around looking to find out which room he's in. I pop my head in one room, I see a CRNA... have you seen Dr. X? Oh he was just here but he's probably next door... they're having trouble.

Hmm... that's not a good sign. I go into the room and usually the room is dark and quiet, the patient is on the bed under light sedation... they're usually pretty sick, but generally unexciting. Anyway... I go into the room, there's a ton on noise and they're doing chest compressions (CPR) A cardiac surgeon is standing near the bedside and they're pulling out surgical equipment.

(More later)

Stat!

"Staff Stat to OR Z"

Hmm.... not good. usually.

This is an alarm system we have so if there's anesthesia emergency and the staff is not in the room, the resident or a nurse can call overhead on the speakers and everyone available can come to the room to help whomever is in there.

Sometimes it's only a false alarm, the patient's oxygen level is reading a little low and the resident gets a little worried.

Sometimes it's much worse.

"Staff stat to OR Z"

I shuffle quickly over there.

I walk in, they are doing chest compressions. Apparently the patient "crashed" about 10 minutes after the start of the case.... low blood pressure of uncertain origin, didn't improve with treatment at all so they started CPR (Cardio Pulmonary Rescusitation). Emergency drugs were given.... epinephrine, atropine, all the good stuff.

After about 15 more minutes after I arrived, they called it, meaning they pronounced the patient dead, all attempts unsuccessful to resuscitate failed. The anesthesia staff in charge of the case don't know what the issue was... the patient was "relatively" healthy. Definitely will need an autopsy to see if anything obvious shows up.

Anyway, we all shuffle out, mostly feeling defeated a little.

Ten minutes later,

"Staff stat to OR 10"

Weren't we just in there?

I head back over there. They're doing chest compressions again.... apparently they were cleaning up the room and filling out the death packet and they saw some rhythm on the monitor so they felt they should give it another shot. Although in the meantime, they hadn't been ventilating the patient or watching the patient since she were pronounced dead. (why would they?)

We persisted a few minutes and then we all decided that it was probably futile... some sort of agonal near death heart reflex (which often happens).

We all left the room again... though not before I disconnected the monitor.

Sadly we can't win them all.

Computers down!

Went to a doctors appointment today. I usually go at 8am. The doctors tend to run behind and if I'm the 1st patient of the day they can't be behind. Anyway, the doors are usually unlocked at 7:45 or so. I pull up and there are three or four people milling around the door. At about 8 they open the door. I walk in and try to check in. Apparently the computers and phones were down. They couldn't check me in, they couldn't put me in a room. Fifteen minutes later, they put me in a room and found some forms to manually check me in. The doctor comes in a few minutes later, he's obviously flustered.

How are you doing? Did they check your sugar today? No of course not, the computer would have told them to do that. Sorry we have no chart, we're all paperless now. What was your last Hgb A1C? your memory is better than mine... an altogether unsettling visit. He's a really good doctor and actually remembered a lot off the top of his head.

Funny how relient we are on computers in the medical field these days. I know I couldn't do my job very well without a computer

Oh, Happy New Year

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.)

Working too hard?

Imagine my suprise to get my schedule this month to find that I have 3 random vacation days this week. Apparently I'm not using my vacation fast enough. I got some Christmas shopping done, and put up some decorations.

Brr.

Sexily dressed doctors may be dangerous

My resident in clinic showed me this article today from the ABC news web site
Sexily dressed doctors may be dangerous

First of all, it must be a slow news day. Second of all the first paragraph mentions Grey's anatomy. And we know that all hospitals are like the hospitals on TV.

Sad.

A day

Been gone for a while, busy at work, vacation (wasted nothing too fun), then busy at work sorry there's been not much posting.

Put in a LVAD (left ventricular assist device) in a patient, which is an assist device to help the left side of the heart. Another patient had an RVAD which was a device to help the right side of the heart which we took out. Stressful day though... now doing some general cases while the overnight guy does a heart... what a way to make a living.

high glucose

my fasting glucose this am was high, 167 usually it's been running high but only in the one-teens to 120s 3 confounding factors.
1)I was up all night teeing up a heart transplant
2)I'm using a different glucometer, the one at work, rather than my usual at home
3)I had Chinese takeout for dinner.

Sadly i suspect It's number three.

Being a patient

So apparently I have diabetes. I went innocently enough to the doctor's office to ask about getting a sleep study for sleep apnea (which I probably have). So he's asking all these questions and running all these tests because it's the first time I've gone to the doctor's in years. My Hemoglobin A1c was through the roof. The hemoglobin A1c measures the average blood sugar over the last 120 days or so in your blood. Also I had a pretty high blood pressure in the office.

Now I'm checking my glucose (almost) every morning, supposed to be checking my blood pressure regularly so he can decide if I need an anti-hypertensive medication. My sleep study is scheduled, and I'm making calls to the insurance company to see if things are covered.

I guess I'm a set up for this. Even though I'm in my early 30s, I'm overweight, I eat poorly, diabetes and hypertension run in the family ... let me continue.

I don't think I'll like being a patient.

Black Cloud

(Sorry that postings have been so sparse. I'll fit in more time)

Some say that I have a black cloud. They're wrong. I have a storm cloud following me.

Let me clarify. In the medical profession, (I don't know if this concept exists in other fields) if you attract all the worst, bad, complicated cases, or when you're on call everyone and their mother has to come to the hospital, then you have a black cloud. It's possible to have a white cloud. And sometimes the white cloud cancels out the black cloud.

Anyway, I think the origin of my black cloud was my first day of residency. To sum it up... out of the 2 patients I took care of that day, half of them did not live to see the next day. Not that I was responsible, but it was still traumatic nonetheless. I had patients die the first two times I was on call as an attending physician.

Friday night, this continued. When I came in during the afternoon, here's a partial list of what was left to start -- 3 liver transplants, a heart transplant, and 2 endovascular thoracoabdomical aortic aneurysm repairs in addition to a myriad of other smaller cases. Also on the table was a facial reconstruction that had been going 8 hours so far, an open thoracoabominal aortic aneurysm repair, and liver resection that had lost six liters of blood.

Needless to say I was up all night. Two liver transplants had been finished (I was not responsible for this) the heart transplant also (not me as well, yay) The thoracoabdominal aneurysm finished after 15 hours of work, the facial reconstruction had been going 24 hours with no end in sight, and another ENT reconstruction case had not only finished, but had gone back to the OR 3 times in addition because things didn't look well. At least I was working with good residents and colleagues. It makes things a bit more manageable.

TEE?

Sorry it's been a while. I've been on vacation for three weeks... but it's not really a vacation because I've been studying for anesthesia boards (third time around.. yikes, wish me luck)

Anyway I was watching Discovery Health (flipping past really... I rarely WATCH it) and there was a cardiologist talking about a test they "rarely" do in the ER. A TEE. A TEE stands for TransEsophageal Echocardiogram. Break it down -- basically a picture of the heart using soundwaves with the probe being in the esophagus (your feeding tube) Then they have the patient talking about it and him being scared and they show a picture of a medical instrument and you're supposed to assume it's a TEE.

BUT IT'S NOT!!!

They show what is probably a gastroscope -- a camera used to see into your stomach. And I can guess why they used that instead. It's kinda like a TEE, almost the same shape, put down the same tube, but more melodramatic because it's got a light at the end of it and they pointed the light into the camera and it faded out to the next scene and ooooh.... aaaaahhhh....

Anyway NOT the same

Tip of gastroscope probe	Tip of TEE probe
Images used without permission fromFujinon Singapore and St. Michaels Hospital respectively

Sixteen Kids?

Just got done watching a bit(most) of a show on Discovery Health called "On the road with 16 children." It's about a family vacation of a family with 16 children.... that's a lot of kids! It's interesting, but I'm uncertain of why it's on the "Health" channel.

Can't sleep

Ugh. I'm on overnight call in the hospital. As staff it's only about once an month or so... which I can't complain about. What I can complain about is how it screws up my sleep schedule. All the cases finished about an hour ago (Ugh... so much neuro) and now I have the oppurtunity to sleep and of course I am taking advantage of this by being -- completely awake! By the time I'm sleepy, I'll either be paged to start some non-emergent "emergency" case, or it'll be time to go home where I have to sleep on my own time. Yuk. Whatever... my sleep hygiene is horrible anyway.

Memorial day weekend

Of course I was on call memorial day weekend. Luckily because it was a long weekend and they split up the call between two people so I had to endure a mere 48 hours on call.

For the first part of it, I worked a full day on Friday... an old lady with three valves that needed to be replaced. Uncharacteristically I got to leave at a reasonable hour... There had been rumors abound about a case to go Saturday morning... in fact I had first heard about "the emergent case for Saturday" on Thursday... so i waited all day on Friday for the surgeons to book it so I could plan my day better for Saturday. All day long... no case booked... everyone from the surgeon's secretary to the surgical PA to the perfusionist had heard that the case was going Saturday "for sure" Still it hadn't been booked by the time I left. I guessed they would page me when it was booked so I could set my alarm etc... imagine my surprise when I woke up Sat morning to no pages. Yipee...

I got about halfway through the day and then decided I would go grocery shopping and buy some food to grill out... steaks, pasta salad, corn, the works... no sooner than I get home from the store. [beepity beep beep] I call the OR front desk. "Type A dissection to arrive at the hosiptal in 30 minutes, Dr. *namedeleted* wanted everyone in" Fine. A Type A dissection is a tear in the first part of the aorta after it leaves the heart. This is an emergency because in that portion of the aorta is the blood vessels that supply the heart itself, and the beginnings of the blood vessels to the head. If this rips further then the heart or brain (respectively) will have no blood supply. Steaks in the fridge... hop in the car. I get the the hospital... perfusion is there, the cardiac nurses are getting there. "Where's the patient?" asks the perfusionist, "Lets get the show on the road" I don't know I think they're being flown in. Okay. Quick call. "They say they're not flying anyone in, but I could be another helicopter service". I find out that the ER doesnt know about the patient, the cardiothoracic resident if fact is at home on the couch because he hadn't heard, and no one knows about the patient. Yikes...

So we're sitting around for 45 minutes waiting for the word, when the surgeon calls in to the room. "She's in the ER, we need to go now". I grab the resident and we head downstairs, I find a woman in her late 20s, slightly tearful. I go through my history with her quickly and explain what's going to happen, she's no longer slightly tearful, but very tearful now. I reassure her and we start wheeling her back.

*time warp*

12 hours later it's 6am and we've just finished her operation. Lots of bleeding, but she's doing fine, I'm exhausted from being up all night. Luckily I get to go home, the resident needs to start an "emergency LVAD that we heard about 2 days ago" Hopefully his staff will let him out for a nap.

I know I need one

death in the or

Somehow as morbidly ill someone is when you are in charge of their case, as little chance as they had of surviving.... you can't help but take it a little personal when they expire in the OR.

More later... maybe.

Administrative Professional's day

So today is Secretary's day... I mean administrative professionals day so I decided to go pick up some pastries and bagels at Panera for the office staff. Amazing how far $40 bucks worth of carbohydrates gets ya. Anyway, I went there last night and gave them my last name. This morning I went in and asked to pick up my order... "Here you are Dr. [name omitted]" Now I don't remember telling them I was a doctor. Usually I look pretty scrubby in the morning... today I had a shirt and tie on because of clinic. Maybe I look doctorly? maybe the only people ordering large amounts of pastries are doctors? anyway. weird.

ugh... clinic

so you see. i'm an anesthesiologist. and I'm wearing a tie. how awful.

no really I don't mind that much, but I never expected to wearing a tie much in anesthiology... maybe a tie made out of scrub material (Hmm that might be funny)

anyway. i'm in pre-op anesthesia clinic. surgeons send us patients so we won't cancel them the day of surgery... so we look at the problems they've overlooked in favor of the surgical repair and we make sure they have nothing that will kill them.(oversimplification... sorry)

anyway for some strange reason the phone has been ringing off the hook today. Really it NEVER rings. Today it's so-and-so from Oto "Have you seen Mr. X yet?" or whoever from Urology "Does Mrs. Y need to come down and see you?"

Argh... I'm busy surfing the net. And seeing the five other patients you just sent down here.

I'll just let resident see them all... it's lunchtime isn't it?

Awareness followup

Sorry I haven't posted in a while, I've been busy at work. I got the following email from someone who came across this blog. I asked her if I could post it so others could share her experiences. Here it is edited (minimally) and posted with her permission.

Hi there,

I stumbled across your blog today and enjoyed reading your post about BIS monitors. I agree -- they DO NOT always work. I experienced awareness during anesthesia just last month, and my doctor was using the monitor.

I lost my baby during my pregnancy and needed a D&C. Unfortunately, my uterus was perforated during the D&C, and so the surgeon performed an emergency laparoscopy to repair the tear. I "woke up" feeling like I couldn't breathe, experiencing intense pain in my naval from the scope, and hearing parts of conversation in the OR around me. I was paralyzed, so I couldn't tell anyone what was happening. But I knew that if my belly was cut, something serious had gone wrong. I honestly thought that I was going to die. I eventually blacked out again for the remainder of the surgery, but have memories from pretty early after extubation (while still in the OR), and have much more recall of the recovery room than seems typical.

It had never occurred to me that something might go wrong with the anesthesia on top of everything else. (I figure that in the "Bizarro universe," my double has just won the lottery.) The only bright spot in this is that I ended up writing the anesthesiologist a letter describing what I experienced. He called me right away and said he was sorry, which was surprisingly helpful for me. He also said that when the perforation occurred, he'd had to quickly switch from using a mask to intubating me. From the details I described, he felt I woke up during that process. He said the BIS monitor lags real-time by at least a minute, and that while they are helpful, they obviously can't prevent all problems.

I do have a question for you: In future surgeries, how detailed does my description of what happend need to be to ensure I don't have awareness while under general anesthesia again? Any tips would be helpful.

My reply:

Sorry about your awful experience, and sorry about the loss of your child. From what I know, the experience you had was one that is typical of people that suffer recall. Generally an emergency happens and anesthetic techniques need to be changed in a hurry, or things are so tenuous, that the risk of recall is weighed against keeping a patient alive. Trauma situations and obstetric situations are classic. I'm glad you had a positive conversation about this with your anesthesiologist. Still must have been a traumatic experience.

As for future surgeries, I think the mention that you had awareness during a D&C converted to a general anesthetic for a laparoscopy, (Just the description you gave me) should be sufficient to avoid any problems. They will probably have you go through your experience so that they can be a better picture of what happened. Some may request a copy of the previous anesthesia record to see exactly what medications you received, but I'm guessing most won't.

I cannot of course promise that this won't ever happen again(you may be resistant to some of our medications) but I'm guessing the urgency of the situation was the main cause of your period of awareness.

Hopefully your future experiences will be more pleasant.

I hate to ask this, but would you mind terribly if I posted an edited redition of your experience on my blog, so that I can post the advice.

Good luck with everything. I'm happy to answer any other questions, sorry for my delay in reply.

Her response:

Hi again,

Thanks for the extra information. And yes, you can post my email(s) to your blog, in whatever edited version you want. I just request that you leave out my name.

The anesthesiologist for my surgery called me back again since I emailed you. He pulled my chart, and what he said matches up closely with what you surmised: Shortly after the lap began, my BP dropped. He administered ephedrine and lightened the anesthesia (propofol, I think he said?) to stabilize me. He believes this is when I initially became aware. He said that BIS readings remained in the 60s throughout the incident, which meant that I should have been out. I guess it just shows how hard it is to categorize levels of consciousness, even with a monitor. As a secondary
issue, he also wonders if I might metabolize Versed faster than normal, which would allow me to remember what happened.

It was a God-awful experience. I honestly thought I was dying, and you don't just immediately shrug off that sort of event afterwards. But, I don't really see how it could have been avoided. After doing some research and talking to both the surgeon and the anesthesiologist about what happened, I'm satisfied I got good care, despite my complications. So I am choosing to lump everything that happened to me -- the baby having trisomy 18 and dying, the uterine perf, and the anesthesia problems -- into the same category, which can be summed up as "sometimes you're lucky in life, and sometimes you are probability's bitch." I wish I'd been lucky.

Anyway, I'm hoping that this was a one-time bad event for me. For any planned surgeries, I'll follow your advice and explain my history as best I can.

Thanks again

This woman has had an awful experience, and has had the heart to share it with us. I think it illustrates that good communication between patients and physicians is of critical importance. It is especially important when "bad" things happen, though it should exist when things go well also.

sorry

Really i'm not ignoring you all. I've got some interesting stuff to post, but I just haven't had time to do it justice. It's coming!

On call

It's not quite 5 am, it's been quiet tonight. I'm on in-house call and the ORs finished really early. No pages since 9:30p or so. Thought it was turning into a great night. Of course I couldn't sleep. I usually can't sleep well at the hospital, but tonight's particularly bad, not even tired. Anyway started an exploratory laparotomy... we'll see what comes of it. I think the resident's happy to be doing the case since the resident that shares the call room snores.

Ludacris

I've blogged about medical lyrics in rap before... it's pretty interesting actually how medical words are thrown around.

Heard on the radio yesterday:
Jamie Foxx featuring Ludacris -- Unpredictable (luda's verse)

I'll be your Tylenol just take me till you doze off

So Tylenol is acetaminophen whis is a mild analgesic(pain reliever) and an anti-pyretic (fever reducer). So while not actually a sedative... it can relieve your pain enough so you can sleep, or reduce your fever, so you're more comfortable and thus can sleep. I guess Luda's right still.

heart trouble follow up

negative heart cath.

This means the stents he got last year are still open. Doesn't really explain his minor chest pains. And we learned that I inherit my stubbornness from my dad

Heart Trouble part Deux

So about a year ago when I started this blog, my father had just had a cath and seven stents... Tonight my mom called me and apparently a routine followup stress test was positive again. He's going in on Friday for another heart cath. Likely a restenosis of a stent from what my dad says. So I'm talking to him about he feels... and being the retired physician he is he notes that he only got a little chest pain when he exercised but was otherwise okay. I could have killed him. That's denial for you.

Anyway. Last year I was all about lifestyle change... exercise, diet modification, etc. Well i'm not exercising, though I do have an exercise machine, my diet is pretty much the same (off and on) we'll see what friday has to show.

Questions

Lately I've gotten some questions from readers and I thought I'd take the chance to answer some of them. I've been rather delinquent.

Some questions from some one beginning premed studies...

1)Any opinions regarding DO vs MD training particularly as it applies to anesthesiology?

Hmmm... interesting question. I think both avenues are good approaches to medicine, and they don't differ as much as you would thing, allopathic and osteopathic classes are almost the same with a few exceptions. I think in general MD programs give you more choices when you are choosing a what type speciality you want to practice in. I've trained with DOs and done a fellowship with a DO and find so generalities applicable. I will say in particular reference to anethesiology is that it seems to be becoming more competitive as a residency. Thus we are seeing less DO physicians meet the rigorous requirements for interview selection in my facility, but those we do see are amazing candidates. So I would have to say that doing well in school and getting high board scores are the most important requirements.

2) What is your experience with physicians who were non-traditional students (i.e. older -- I am already 30), again with particular reference to anesthesiology?

First of all, I do suggest to all my friends who are considering medicine as a career to reconsider it. It is a tough road with long hours of work and study. It is physically as well as mentally taxing. There are better ways to earn money, influence, and/or respect. Saying all that, if you are one that really wants to be a medical professional, who am I to stop you? I do love my job, but the road to where I am now has been a rough one. I would however do it again.

Next, I don't think being a non-traditional/older student necessarily puts you ate any sort of disadvantage in being selected for a residency program. I think it provides an interesting perspective in the field of medicine. Being older, I think the physical demands of medical training may be more difficult. Also there is more likely to be a family involved. And that has needs of its own. All that is fine though, many people train in the medical field with large families. It just requires more juggling.

Just think though if you're considering anesthesiology at age 30 and start medical school in the next few years you may be 40 or older before even starting to have the opportunity to practice on your own. That time is valuable and it is quite a commitment. In reference to anesthesiology, there are plenty of older residents, some have completed all or a significant portion of another medical residency (anesthesia is a field that is highly switched into), some have just gotten a late start as you have. Also anesthesia is demanding, but may require less time commitment in residency some places, then say other residencies such as surgery (although there are wide spread work hour limitations)


Another question from an electrical engineer.
3) How accurate are the new monitors that are supposed to indicate depth of anesthesia in a patient?

That also is an interesting question. The device you're most likely referring to is the Bis monitor. It's gotten quite a lot of press lately. It's basically a transcutaneous monitor that picks up electric activity from the brain (EEG), performs a complicated "black box" calculation and spits out a number ranging from 100 (awake) to 0(No electrical activity). We do not use this device at our institution. There are several problems that I see. First of all there are plenty of other ways to measure consciousness clinically. The device and disposables are not inexpensive. Also what bothers me the most is that the calculations that are performed by the devices are a proprietary formula, and we are not privy to those aspects. I'm not sure how accurate thes e devices are, but regardless I'm not sure they're necessary. (just one man's opinion)

Picture taken without permission from Aspect Medical Systems, Inc. website

If I missed your question, let me know I'm trying to keep up.

IV starts

Bit of a strange couple of days for IV starts for me.

Two nights ago one of my roomies went on a bit of bender and thus couldn't keep any food or water down yesterday. I started an IV on her at home, instead of her going to the ER and waiting for hours and having the same thing done, except with a large bill.

Today near the end of the day one of my residents requested I put an IV in her because she wasn't feeling well and had some sort of flu bug... I was going to put in for her to go home early, but she was relieved by a late resident anyway. What a trooper.

Anyway, wonders that a couple liters of fluid will do to help with how you're feeling.

More anniversary stats from the last year

Shortest time between posts: 3 minutes
Longest time between posts: 17 days

Anniversary

Three days ago this blog turned one year old... It's been a slow year and a fast year at the same time.

I've finished a cardiothoracic anesthesiology fellowship. Started a full time job as a cardiothoracic anesthesiologist. Bought a house.

On the other hand... I am working today on a sunday, doing a semi-emergent (as in booked two days ago) coronary bypass. (well supervising a resident anyway). This after doing a Heartmate II and a heart transplant on Friday, two chest closures yesterday (see friday's cases). At least I have tomorrow off.

Some stats:
365 days.
72 posts.
Avg. 1 post every 5.07 days.
5006 vistors by counter since March 7, 2005 (when I started counting) some of those are me however.

I hope for many more years.

cargo pants

heh. Wore cargo pants to clinic... realized no one can stop me.

Readily available

I'm trying to be a good anesthesia attending today... but failing. I flew back late last night from being out of town for the New Year. The anticipated late arrival after the weather delay and the walk through baggage and the shuttle bus to the parking lot and the drive home became the ridiculously late arrival. Got settled at home and slept for only an hour before coming in to work. Good thing I slept on the plane. I am working with 2 senior residents today. Both very good. Both rooms I'm supervising have long cases, so not much to do after getting started. Instead of teaching I've been hanging out in my office. Being "readily available" for crises from my chair.

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.