Juggling

Logo of the 6th Swiss Juggling Convention, in Zürich 1992, used without permission

So I feel like I'm not getting enough done.

I'm trying to buy a house, do a good job at work, study for boards, read to prepare for talks, plan a vacation with some college friends... all while trying to get enough sleep and also not go insane, which means decompression time.

Mortgage insurance, home inspection, radon, homeowners insurance, down payment, closing costs, argh!

They say life events are very stressful. Several are going on now. I don't even have kids or a wife or girlfriend to distract me. I've been neglect the cat. I don't know how some people do it. They are amazing.

Damn, I need a haircut too.

Board Review

Image used without permission from USGS via Wikipedia.org

Just got back from an intensive 3 1/2 day Board Review Course in Chicago. It kicked my butt. I hope I'm ready in 10 weeks. I've gotten great traning in anesthesia, but I still don't feel ready to take the boards (again). The course was worth the extensive fee though. We'll see if it was really worth it when I get my scores.

Trick Daddy

I may be the only anesthesiologist that listens to rap. It's good stuff. It's amusing though... occasionally they throw in that random medical term in.

Lately on the radio they've been playing (Gimme Some) Sugar(remix) by Trick Daddy, featuring Ludacris, Lil' Kim, and Cee-Lo. It's a great song. They have some amazing rhymes.

One verse by Lil' Kim goes "I give ya high blood pressure like a diabetic". I know they're trying to relate the diabetes theme in as the title is Gimme Some Sugar, but I don't know that diabetes cause hypertension. They are associated however it seems. I guess she's saying she's so hot she raises your blood pressure.

Oh well, I can't hold it against them. I still like the genre. I still like the song.

Litigation

Today we heard about a case where something had been done that had litigation potential.

There are several things that would have to occur to make this a successful suit.
First of all, it requires a bad relationship with the patient. In this case, it was fully explained to the patient, and the procedure to correct the problem was immediately arranged. The patient seemed very understanding. For the second reason we need to go to my lawyer buddies.

A tort is a wrongful act other than a breach of contract that injures another and for which the law imposes civil liability. There are four elements of a tort as I understand it

1. Duty
   
2. Breach of Duty
   
3. Damages/Harm
   
4. Causation
   
   

If all four are not present a tort should not be successful. In this case, there was a duty, and that duty was definitely breached. Most of the time, the act in question does not involve arguing breach of duty, it is assumed to have happened. There also needs to be damages or harm associated with the breach of duty, and the damages must be caused by the breach of duty. If there is no damages, there is no tort. If there are damages, but no causation, there is no tort. In this case, there were no damages to the patient other than having to go through the corrective procedure. So there should no sucesful tort possible.

PS. Hmmm...

looking through my visitor statistics, apparently I'm the 27th choice for a google search of the movie SuperSize Me. Interesting.

Grand Rounds XXIX

Grand Rounds XXIX available at GruntDOc

Difficult Airway

So as a fellow I usually just help out where I can. I'm at the point in the fellowship where I staff rooms as the attending about twice a week. So today I'm helping out this morning and then this afternoon I figure I can sit in the library and work on a lecture I'm giving to the medical students later this week (another responsibility of my increasing faculty duties).

I'm sort of sleepy there looking at my laptop screen in the anesthesia library... and I hear "Anesthesia Staff Stat to ER!" This is not normal. This is usually our safety system in the OR, if something crazy is happening in the OR and you need emergency help or an extra hand, anyone can call overhead to get someone into the room. Residents, CRNAs, or even faculty anesthesiologists can call out and get help. i.e. "Anesthesia staff stat to OR 12." So to hear this page at all means something isn't going well. This is the first time I've heard this call to somewhere other than the OR. Usually that is reserved for the Anesthesia group pager or the code Blue pager. So I figure I'd better get off my butt and see if they need a hand. I walk quickly down the hall (I never run, because 1.If I fall on my face they'll be two patients instead of one 2.I'm out of shape ) A couple of other staff are headed the same way. One of them is relatively new and she doesn't even know where the ER is so she joins us. We cruise down the stairs, swipe our IDs through the security door and head toward the trauma bays. Quite a few others are there already in addition to the ER people, some various nurses and other doctors.

I look at the patient and you know they're in trouble. In medical circles it's sometimes referred to as FLK... funny looking kid... A small really tiny kid with small receding jaw with a massive overbite. Almost Pierre-Robin like in look (GIS for Pierre-Robin) I know immediately that he's going to be difficult to intubate. Now as misunderstood as I usually claim anesthesiology is, most would agree that in addition to the ENT surgeons, we are airway specialists. I see them take a look with a laryngoscope and they see nothing. They look with a fiberoptic scope and they see nothing... by now they've called ENT and peds ENT for a possible emergent tracheostomy. Peds anesthesia has been called to bring their code box and airway equipment. Lucky they are barely able to mask ventilate the patient. I also notice the scar on the patient's neck indicating a previous tracheostomy. They're still having no luck with using a fiberoptic scope for intubation. Incidentally someone mentions that this "kid" is 28 years old.... something like 60 pounds and change.
He's starting to breathe now. He had stopped breathing earlier for some still unknown reason. Seizures and sleep apnea are mentioned. Since he's breathing now and still maintaining his oxygen saturation we decide to get up to the OR where more instruments (and a more controlled setting) are available.

So we run up and this patient recieves and awake tracheostomy, which is the ultimate in secure airways. Ends up that this "kid" as an unknown syndrome and some history of autism (though lives on his own) and has been trached in the past for losing his airway during a seizure eight months ago.

This is an anesthesiologist's nightmare. We have all sorts of tricks and techniques to control the airway. But sometimes we fail. The trick is knowing when to call for help as a good senior anesthesiology resident did, and when you've tried things and they aren't working to call for a definitive surgical airway when necessary. It's hard to ask for help. In this case I think we saved this guy's life. Now someone just needs to figure out why he's having seizures (already on two anti-seizure medications)

Garage?

Taken without permission from an email I received today at work.

Yesterday, a patient remarked as we rolled him into OR 6, "This is the operating room?? It looks like a garage!

Dedication

I wasn't there Monday. Apparently one of the cardiac surgeons almost passed out during surgery. He said he felt weak and they rushed to get him a chair. He sat down and asked them to call one of his partners down to help until he was feeling better. Evidently they wheeled the patient's transport stretcher in the room and he laid down for a bit. And they used the blood pressure cuff to check his pressure. The other surgeon came down and helped for a bit at which point the surgeon got up, scrubbed again and finished the surgery. I doubt he even went to see his doctor.

Now I don't know if this is all true. I'm hearing it second hand. But i heard it from two people.

(BTW, he's a great surgeon)

Rounds

Grand rounds XXVIII is available at Polite Dissent

It's my first submission and post there...

If you're not familiar with term Grand Rounds... it's basically a conference where people talk about a particular subject or recent events in the department. Often there's a guest speaker or something. Evidently it's taken from John Hopkins hospital back in the day. The patient's rooms were in the rotunda and to see them you went "a round" Everything medical has to have "rounds" after it it seems


Seeing patients with your team before the attending arrives is "work rounds"
Seeing patients by yourself before work rounds is "pre-rounding"
Seeing patients with your attending is just "rounds"
Seeing patients with special attending for education purposes is "teaching rounds"
"Grand Rounds" is usually the department's weekly conference.
Eating is "p.o. (per ora) rounds"

Staffing friends

Today I staffed 2 rooms with residents in it. Basically that means being in charge of what happens in both rooms. Also that means I need to try to teach residents. It means that I need to watch them perform procedures that are sometimes tricky. It's very stressful watching someone do something you could do yourself.

Also it it means staffing friends. I've become friends with a lot of the residents because we were in the same program before I was an attending, and we've remained friends. I try to be laid back about the whole process. This morning we bring the patient back into the room after the resident puts in an arterial line and thoracic epidural in the pre-op area. I look at the top of his cart. Now there's supposed to be a bunch of medications available for me to help put the patient asleep. And in addition there's supposed to be some emergency drugs there 'just in case' something happens. I look and there's a couple of syringes of paralytic sitting there. Nothing there to put the patient asleep, nothing to use in case of emergency. He turns and says he forgot the induction agent so we send our medical student running to the pharmacy while we put the patient on monitors. I didn't want to make a big deal of everything so I draw up some emergency drugs while he's fiddling with things. The student comes back and we put the patient asleep. We're getting things worked out and just comment to him that even though we're friends we need to be a little more prepared to do these cases. He gives me a funny look and chuckles. He points to his pocket and the emergency drugs are there ready to go. He says he was wondering why I drew up the other stuff. Ha ha.. now don't I look silly. SO STRESSFUL... people need to tell me things

Plane trouble

So guess where i'm supposed to be... Madison. Guess where I'm not... Madison. So I'm on my way to the airport to give some short presentations at a conference in Madison. On the way to the airport I get a call saying my flight is cancelled... So obviously I think it's a prank. So in actuality, my flight is cancelled. In the next 5 minutes I get about 4 calls from people who were also supposed to be on that flight and they have heard the same thing. Apparently there's some sort of crew shortage and we've been rebooked on a flight tomorrow morning after the conference starts. We go to the airport figuring we can work something out there to get to Madison. We get there, to find some very unhelpful staff... I'm on my phone the whole way there trying to get alternative travel arrangements made. Ends up being that the people on the flight have been put on about 6 different flights, mine being one of the later ones. In the midst of trying to get stuff squared away I'm trying to adjust my car rental so I can pick it up in the morning rather than this evening. The man at the car rental place tells me I need to call the website I booked the car with. I call them and they say I need to call the car place. I explain that I've already done that and they assure me that I just need to make another reservation and the other will just go away. Go away? I question this so I don't get a charge on my credit card and she accuses me of not listening. ARGH!!!! At this point i feel like vomitting. This is the first problem i've had with an airline in the past that I can remember. So instead I'll arrive at the conference just before one of my presentations. hopefully the flight in the morning will go well. At least my cat won't be lonely tonight.

Eww!

I learned yesterday though a convoluted conversation that there is such a thing as "defecography". Don't ask how we got to it... Don't even ask what it is...

Defecography is a test used to evaluate the disorders of the lower bowel that are not evident by direct visualization. Radiologic liquid is instilled into the rectum. Then the patient is instructed to empty the rectum while a fluoroscopic exam of the pelvis is carried out. This radiologic test allows the doctor to evaluate the pelvic floor muscles and rectum during defecation. This type of test, although awkward, provides valuable information that will aide your doctor in diagnosing your problem.

The following is a list of conditions for which Defecography can be used to gather more information and/or confirm a diagnosis.

-Rectal prolapse, irritable bowel syndrome, obstructed defecation
-Solitary rectal ulcer, proctalgia, fugax,a rectocele/enterocele
-Fecal incontinence, internal prolapse, constipation
-Rectal/anal intussusception anismus (inappropriate spasm of the anal sphincter)
(UMHS website)

Apparently the "liquid" they use for this test is the consistency of mashed potatoes.
Thank god I'm an anesthesiologist. I'm glad on the other end of the patient.

Death

I'm watching a documentary filmed at my hospital a few months ago. I've written about it a few times in the past. I've critizized it for being a bit melodramatic and ignoring anesthesiology. That's all okay. Today the showed someone who almost got a liver transplant twice and had it unable to be done for various reasons. Then they showed him dying after having life support withdrawn at somepoint after that. I think they did a great job actually showing that not everything turns out well in the hospital. Not the usual perfect outcome that's usually portrayed. Even though I've seen death in the hospital before it still hits you. Rest in peace.

Supersize Me

Just watched "Supersize Me". As good as people say it is, even though I did doze off a bit in the middle. I can't say it was completely objective or scientific in nature, but it did make a good point. From now on, my Big Mac is eaten with a DIET coke.

(Really I'm just kidding. I haven't drank sugar soda in years.)

Extra room

So today I was on cardiac call (as faculty) usually that means you do cardiac cases during the day and then you take over the other cardiac rooms as your cases finish up, then you relieve others and you end up being 3rd from last to leave for the day.

Today was a bit different. The case that was scheduled in our room was cancelled so that a case that had been cancelled because of emergencies, scheduling, etc had been cancelled two days in a row could go. Unfortunately the original surgeon wasn't available so his colleague agreed to do the case for him. The patient wanted her surgeon to do the case, so she didn't want the case done today. So instead of one or two cases as usual, we had none. This you would think is a good thing. It's not. That means ANY case can be put in your room.

The day starts off with a page while I'm driving in that a cardiac case from yesterday needs to come down emergently for bleeding (well he's been bleeding all night) so I take over from the night staff. Usually in cardiac you are staffing one case/one resident at a time. Apparently there's some sort of flu going around (which I think I have, by the way) because two staff anesthesiologists call in sick (which never happens). We end up giving a bunch of clotting factors during the case, plasma, platelets, recombinant factor seven even (something like $5000 a dose) before the guy quits bleeding. As we're finishing up. I get a page. "Would you mind covering another room because we're short staffed?" I say sure no problem figuring they'd give me an easy room because 1) I'm a fairly new faculty and 2) I'm already covering a cardiac case (not a pump case but still) "So we have a ruptured aortic aneurysm coming in and by the way it's a relative of one of our nurse anesthetists" No pressure right? Yikes. If you don't know, a ruptured abdominal aortic aneurysm (AAA) is an anesthesiologist's (and surgeon's) nightmare. Only fifty percent of these patients even reach of the hospital. Another fifty percent of these never leave the OR, a fraction of those leave the hospital (alive that is) Luckily it ends up being a contained rupture of a previous endovascular AAA repair so it's much more stable than you'd think (which is good)

By this time. There are add-on's in my cardiac room. Not cardiac cases, but ENT cases instead followed by a neurosurgery case. bleah. PLUS i'm doing the to-follow vascular case in the other room. That's the breaks. Not bad for a day's work. I did get to leave fairly early for a call day despite the liver transplant added onto the schedule.

Television

I just saw the side of my head on TV.

Cool eh? I'm famous!

Well not really. The Discovery Channel was at my hospital a few months ago filming stories about residents. I help in part of a heart transplant, so you can see the side of my head over the surgical drapes. Not that I want to be on TV, but they seem to gloss over the anesthesia portion of these cases a lot. Oh well. Surgery makes better television.

Trust

Now that I'm more often than before taking the role of an attending anesthesiologist I've decided it's not about your skills, but more about your trust in others. First of all, for those who aren't familiar with the structure of how academic anesthesia works (most private practices I guess also) -- there is an attending anesthesiologist. He/she is "in charge" if the anesthetic. Usually she/he makes the plan and is there for the "critical" potions of the case. In academic anesthesia, usually there is also a resident involved. This is someone who is a licensed doctor, in the midst of her/his training to be a specialist, in this case anesthesia. That person is present for the entire case, and follows the plan of anesthesia set out by the attending. In private practice most places, and some academic centers too, there are also nurse anesthetists. They are nurses that go to special school to perform anesthesia also, usually under the supervision of an attending anesthesiologist. They would perform the same function as a resident -- being present for the entire case and performing the primary anesthetic. (For the rest of this, when I say "resident" I mean "resident or nurse anesthetist") The attending is usually responsible for one to four cases in total depending on the time of day and what type of cases are being performed. Now here are where trust issues come in to play. If the attending was present for the whole case, he/she could perform all the necessary functions and deal with any crises that arise without problem (most of time) because of their previous training. When you are supervising fours rooms, unfortunately you can't be four places at once so you rely on the residents to call you when there are problems. Most of the time, patients receive excellent care from residents -- sometimes even better than if the attending was performing the anesthesia him/herself. Occasionally because of the level of training there is a lapse in judgement, or a delay in calling for help. This is where you can get into trouble. If the resident doesn't call you... and there is a problem still... you are still responsible for the outcome. I trust most of the residents I work with, and I want to give them some space to learn and make their own decisions, but it's hard when i'm responsible for everything they do. So you need to trust their judgement and hope they have a low threshold for notifying you of a problem. I find myself walking from room to room checking things out from the doorway, even though I know everything should be fine. I'm told this nervousness gets better with time. I'm not sure I want it to. A healthy dose of doubt...

why?

Why do doctors talk about work when they meet outside of work. Usually complaining of some sort, or occasionally something freaky or interesting. Maybe it's only residents that do it.

British rotators

Last night was the 2nd annual "Go back to your own country party". It's where we celebrate the leaving of the rotators that come through our department. For some reason, our department has had a history of foreign anesthetists (as they are called at home) come and spend a year or so here as a part of their training. Most are from the UK. Their training is much longer then it is here, so they act as attending anesthesiologists when they arrive here because of their experience. Anyway for the most part they are well trained, relatively young, and very enthusiastic. They are part of the strength of our program in my opinion. It's nice that the department is willing to pay for such a celebration. It's a good boost to morale, especially since it's March already and there's still snow on the ground. Lots of fun was had by all. Even me, though I couldn't drink on the boss's (sp?) dime because I was on call. bleah. Still I had a good time hanging out.

Discovery Health

I'm watching Discovery Health Channel. I try not to watch medical problems when I'm at home since it's all I see at work. But the hospital I work at is featured. I remember the camera crews walking around a few months ago and it's interesting to see how things are portrayed. Seems like most of the things focused on are surgical procedures. I guess that makes good TV. Being an anesthesiologist I see that they gloss over much of what we do. Oh well. It's also all very melodramatic too. Not that the situations aren't critical, but things are so black and white on TV. I remember speaking to one of the camera women. She said to me, that it's a few hundred hours of footage for every hour of television. I guess you can tell any story when you can edit so much out.