Monthly Archives: January 2007

My new computer

Tempted as I may be to start this post with apologies to my loyal readers (I know you’re out there, E.K. and M.G.!!!) for writing so infrequently this January, I will instead begin with praise for my new computer which arrived today.

It’s a Dell Inspiron E1505 notebook. The sleek Intel Core Duo processor and a full gigabyte of RAM mean the computer easily laps my nearly 6-year-old Dell Inspiron. Indeed, as I’m writing this post, iTunes is serenading me and Windows is installing 21 updates in the background, and the clip is still Barbaroic.

Why not Apple? Perhaps I identify too much with the PC guy in the commercials. Perhaps I stick with a PC since I’ve always used a PC. But even more significantly, the one-button mouse found on Apples has left a permanent bitter taste in my mouth. I can’t stand those dumb one button mice, and iPods and iTunes notwithstanding, I hate the company that came up with them. So there. Realistically I probably should switch. Fewer bugs. More managable software, a streamlined operating system. Maybe next time around.

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My favorite rotation

This is my second week of neuroanesthesia. So far, this has proven to be my favorite rotation of the year. The cases are long and interesting, and I usually get to start an arterial line at the beginning of the case. (I’ve had a good streak; right now I’m 8 out of 9 on arterial lines, and a few of them have been on awake patients.) I even got to do another fiberoptic intubation last week.

Maybe the biggest factor, however, is the surgeons. Residents and attendings have made the effort to know my name (imagine that, like I’m part of the team!). It’s a very pleasant work environment, and the neurosugeons at this institution seem extremely skilled at what they do.

Of note, yesterday I did my first “awake craniotomy.” Imagine, if you will, the skin on someone’s head sliced open and pulled back, a section of skull removed, dura cut away, and brain exposed for the surgeons to muck around in. And then imagine that the patient–whose head is pinned in place–is awake and talking to you! Pretty crazy! I gave enough sedation at the beginning, and the surgeons used plenty of local anesthesia, but its still weird that the part of the body where pain is “felt” and interpreted doesn’t really feel pain of its own.

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A new feeling inside

I was standing in the line at the cafeteria today when I experienced something unexpected. One of the senior orthopedic surgery residents was in the cashier line ahead of me, and he was eating his sandwich as he waited. I commented that if he finished the sandwich before he got to the front of the line, perhaps he wouldn’t have to pay. He laughed, and then remarked that he usually finished his sandwich before he got to the front.

Given the length of the line some days, and the slowness of the cashiers other days, this didn’t entirely surprise me. What caught me off guard was that I felt just a twinge of pity for him–that he has to eat his lunch as he waits to pay for it. Okay, so I am far enough out from my regional anesthesia rotation that I no longer resent any and all things orthopedic, and this was was one of the nicer orthopedic residents I’d worked with, but it reminded me not to take my 30-minute lunch break for granted.

To you surgeon residents out there–including my friends in Cleveland–I know you have a busy life. Of course no one made you choose surgery, but it’s still a tough residency, and it’s a hugely important part of the world of medicine. Hang in there.

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Comments from a surgeon

I received a few comments on recent posts which I thought I’d comment on in a new post.

From Score 1, Anesthesia! (December, 2006)
“[Y]et another instance of anesthesia trying to get more sleep while the surgeons try to do more work… “

Well, yes, this is precisely the case. The part of the story, however, that it doesn’t tell is what was in this patient’s best interests. Either I could lobby for 1) More sleep and doing the safest thing for this patient, or 2) Doing a purely elective case in the middle of the night and potentially putting this patient’s life in danger. I and every anesthesiologist I know are going to pick option one. I would think most surgeons would too…I’m sure my friends in Cleveland would!

Now I’ll grant that the danger for this patient is an anesthesia/airway risk–one the surgeons wouldn’t necessarily have realized. However, what irked me about this situation was that these particular surgeons were not honest in describing the case in order to get it posted as an emergency. A strangulated hernia needs operated on in the middle of the night. A little fatty omentum trapped in the abdominal wall does not.

From 420 (November, 2006)
“yes thank goodness we have the warm wonderful anesthesiologists to protect us from the evil surgeons. If only the world knew that while they are asleep on the OR table, their surgeon reads the newspaper and does crosswords and drinks coffee/tea/soft drinks while the anesthesiologist removes the malignant tumor or stops a bleeding aorta or meticulously pieces together a shattered bone or removes a piece of necrotic bowel. If only the anesthesiologist rounded every morning at 5:30a.m. to make sure all the patients were OK. Perhaps they should scrub and help out with the surgery…after all, how hard can it be to manage an anesthetized patient…”

I’d like to think that this sarcasm is good-natured ribbing. Let me start by saying that surgeons do a lot of good in this world, including–but not limited to–fixing bleeding aortas, removing malignancies, and repairing broken bones. When I said in the post that I found some surgeons’ mindsets irritating, I was referring to unwise decisions in medical management. A NONEMERGENT SURGERY DOES NOT NEED TO BE RUSHED TO THE OPERATING ROOM. I would want my mother or grandmother optimized for semi-elective surgery. This case illustrates that point well: we could have had less blood loss and fewer transfusions (with their associated risks) in this 105 year old had her coagulation status been managed in a more appropriate manner. Pushing I.V. vitamin K so we can squeeze a century-old patient on today’s schedule is not appropriate in my book.

This comment also suggests an awareness of anesthesiologists who drink and read in the operating room. I would agree that it’s unprofessional to eat and drink in the operating room. I know of no studies showing adverse risks to patients, but JCAHO of course would frown on beverages in patient-care areas.

However, reading in the operating room is a bit more complex. Some might make a distinction between reading the newspaper and reading medical literature. From the standpoint of patient safety, however, I see no difference. Is it categorically less safe for an anesthesiologist to do anything other than monitor the patient 100% of the time? I don’t claim to have an answer to this. But from my 6 months of training in anesthesia, I will say that I notice at an instant (from the change in the pulse oximeter’s tone) when the patient’s oxygen stauration drops from 100% to 99%. I also hear premature contractions and other irregularities in the beat. Other than that, for a simple case, there’s not a lot more information to be gained on a second-by-second basis. In fact, if I look at the blood pressure every 5 minutes and check the patient’s paralysis & the progress of the surgery every 15, there’s not much to do in some cases.

“How hard can it be to manage an anesthetized patient?” Perhaps this comment fails to do justice to changing nature of the acuity of anesthesia care, from very high (induction, emergence, and key times during the surgery) to very low (the middle of a low-risk procedure in a healthy patient who’s been stable). There’s a night and day difference between providing anesthesia for open heart surgery or a liver transplant, and anesthetizing a relatively healthy patient for a cataract operation. Either way, crosswords and all, anesthesia is very safe these days. Nobody wants to go back to the days (and mortality rates) of when surgeons managed patients’ anesthesia. (Consider the concept of “six sigma”, mentioned in this article, and this one.)

“If only the anesthesiologist rounded every morning at 5:30a.m. to make sure all the patients were OK.” To this, I don’t have much to say. I get to the hospital around 0630 for a regular day in the operating room. Some people (internists, surgeons) get there earlier, some (dermatologists, pathologists) get there later. Just remember, my friend, that it’s not too late to switch to anesthesia if you’d like an extra hour of sleep!

From Surgeons can sure be annoying… (November, 2006)
…or you could understand the the surgical resident is a 100 times busier than you are and is not being rude but trying to get some work done before he starts the case. See, unlike anesthesiologists who can go for coffee breaks and bathroom breaks anytime they want, surgeons actually have to stay for the whole case. That’s right America, your anesthesiologist gets a coffee break and lunch break even if you’re still asleep with your abdomen open and the surgeons still working. Understand that there are other residents who have to do more work in less time and there’s nothing rude about it. If i could go grab a donut, void, then come back and see the pt when you’re finished, believe me, I would.

Again, I’m going to interpret this comment as hyperbole. If I have two things to do in the morning (1. Set up a room = 30 minutes, and 2. Pre-op a patient = 20 minutes) and a surgery resident had 10 things to do that take 50 minutes, then who is busier?

Now after an e-mail from my friend DL, I can appreciate the surgeons’ perspective of being busy and trying to get work done, but I stand by my initial criticism. It is unquestionably rude to interrupt another person. The instances that really got to me were when the surgeon broke in and began speaking to the patient without even acknowledging my presence. On the other hand, it doesn’t bother me at all when a surgeon waits for a pause and breaks in, “Excuse me, could I just have Mrs Jones sign this consent? It’ll just take a minute.”

Incontinence notwithstanding, I do not get to go for a coffee or bathroom break anytime I want. I get a 15 minute morning break and a 30 minute lunch break. The times between cases are the busiest for me, whereas that’s when many surgery residents grab a bite to eat or empty their bladders.

“Understand that there are other residents who have to do more work in less time and there’s nothing rude about it.” More work in less time, as I’ve already suggested, is a matter of perspective. Perhaps “more items of work” would be more appropriate, and the amount of time you have to do it in depends on how early you get to the hospital! Even if the surgeons did have more work to do in less time, we all learned in grade school it’s rude to interrupt.

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