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).