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.