Category Archives: Work

A weekend of work

After Thanksgiving Day off, cousin Steve dropped me off at the Wallingford train station where I caught the SEPTA train in to Market East Station and crossed the street to the bus station to catch my Greyhound Coach d’Elegance back to Manhattan.  As fellow passengers were boarding, the Indian woman behind me complained when I reclined my seat back a few inches.  “Oh, oh, please raise your seat, my knees are hurting!”  Irritated that a woman who couldn’t be taller than 5’4″ was complaining about her knees to someone a full foot taller than her, and resisting the urge to suggest she could pick out a different seat on the bus–preferably behind an unoccupied seat–I raised my seat a couple inches and rode the rest of the trip with this semi-comfortable compromise.

I took my first pediatric anesthesia long call on Friday.  I went in expecting to anesthetize a three-day-old neonate for a Norwood procedure (palliative surgery for hypoplastic left heart syndrome), only to find out the case was cancelled.  Instead I did a central line on a 1 year old and a pyloromyotomy on a 3 week-old, before helping with sedation for a 7 year-old in the MRI.  This child had “single ventricle physiology” having a hypoplastic left heart as well, now having undergone the Norwood, bidirectional Glenn, and Fontan procedures.

I then did brief afternoon rounds with the pediatric pain attending, as I was covering the “OUCH” pager that night.  Circling through the list before I left the hospital, everyone seemed comfortable enough, and I went home.  This is one of the few rotations where we can take home call, or “pager call.”

I was awakened by my pager at 0100.  There was a 7 year old with a ruptured eyeball, and the ophthalmologists wanted to take him to the operating room within the hour.  I quickly paged my attending to notify her of the case, dressed, and caught a cab to the hospital.  No telling how long I would have waited for the subway at that hour, and ten dollars seemed like a small price to pay to avoid the cold and get there quickly.

I was in scrubs and had the room set up by 0150. but the patient didn’t show up till nearly 0300 from the emergency room!  Somebody felt the need to order a CT scan before sending him up to the operating room.  Anesthetic concerns include the following:

  • This is a trauma, and thus may put the child at risk for aspiration of stomach contents during induction of anesthesia.  Pain and increased tone from the sympathetic nervous system delays gastric emptying, and aspiration can occur as a patient is anesthetized and loses protective airway reflexes.  Aspiration, though rare, has a high fatality.  In order to minimize the risk of aspiration, anesthesiologists frequently employ the “rapid sequence induction” technique.  This involves ample preoxygenation of the patient to build up as large a reserve of oxygen as possible in the lungs, and a quick administration of a sedative and a paralytic–usually succinylcholine because of its rapid onset.  As the medications are pushed, pressure is applied to the round cricoid cartilage in the neck to help close off the esophagus.  This pressure is continued until the placement of the breathing tube is confirmed.  The breathing tube with its inflatable cuff protects the lungs from aspiration.  In this case, the child had not eaten for more than 12 hours, so this risk was probably lower.
  • The eyeball (or “globe” in medical terms) is ruptured.  Succinylcholine can increase intraocular pressure, which could lead to greater extrusion of contents from the eye.  Most anesthesiologists get the willies when we think about jelly-like substances squirting out of an eye wound, so we prefer to avoid this.  Additionally, succinylcholine is avoided in children because of the risk of malignant hyperthermia (serious adverse reaction) in a child with an undiagnosed myopathy (muscle disorder).  Hence, we used rocuronium for our paralytic agent with an onset nearly as fast.
  • General anesthesia, and eyeball surgery in particular, can cause nausea, and wretching can increase pressures in the eye.  We would like to avoid this post-operatively as it could damage the surgical repair, so administering ondansetron (a powerful anti-emetic commonly used for severe gestational nausea or chemotherapy-related nausea) is a must.
  • Coughing and bucking on the endotracheal tube as a patient emerges from anesthesia is also suboptimal for the same reason.  We can treat patients with intravenous opioids and lidocaine to blunt airway reflexes, and we could topicalize the vocal cords with lidocaine, but in this case we opted for “deep extubation.”  This is a technique in which the patient is allowed to resume spontaneous ventilation, and the endotracheal tube is removed while the the patient is still anesthetized.  The airway is then supported and supplemental oxygen provided.  This provides for smoother wake-ups.

It was around 0600 when I dropped off the patient in the recovery room, leaving me enought time to check e-mail and change into street clothes before heading uptown for my moonlighting shift which began at 0700.  Thankfully, the day was as slow as it could be (not a single operating room case, epidural, cesarian section, or stat intubation) which meant I didn’t do much other than sleep, eat, and read.

2 Comments

Filed under Work

“A soft answer turneth away wrath…

…but a witty one can silence a fool.”

Living in New York City means living in close quarters with people who are at times cocky, arrogant, brusque, dismissive, and overbearing.  People do not sit on the front porch sipping lemonade here; they do not bring casseroles to new neighbors.  No, they run over others who happen to get in their way, they insult those in proximity who happen to annoy them, and they often have no regard for others they may be inconveniencing.

Thankfully, the hospital atmosphere usually smooths out the rough edges.  Usually.  I remember vividly when I was interviewing for residency at NYU, I stopped at the security desk and asked politely for a visitor name-badge.  That simple request at 7:30 in the morning apparently ruined that security officer’s day.

The other day, I was going to bring a patient back to the operating room.  One of the nursing assistants had already started an IV on the patient–a bit of a luxury at my institution.  I usually will just carry the bag of intravenous fluids as I escort the patient, but this time, without thinking, I started to push the IV pole with the patient as we headed toward the door of the preoperative holding area.

“I knowyou’re not taking that pole!” one of the nursing assistants said in a condescending tone.  I stopped, instantly feeling annoyed.  I usually don’t think about the medical hierarchy, but there definitely is one.  Attendings > Fellows > Residents > Interns > Medical Students.  Nurses have a bit of a different ladder, but I would generally place an average nurse somewhere between an intern and a medical student.  Interns write orders that nurses follow, but they are still credentialed professionals; medical students are not.  Otherwise, the nursing hierarchy is something like Nurse Manager > Charge Nurse > Nurse > Nursing Assistant.

As a senior resident (a chief resident at that) I intuitively feel I’m perhaps a couple rungs higher than this nursing asssistant.  And while rudeness (in the sense of condescension) is never professional, it seems particularly egregious when it’s directed up the ladder.

And so, I turned, and I said in the most neutral tone I could muster, “Are you asking me to leave this IV pole here?  Because if you ask nicely, I would be happy to.”  This was met with absolutely no reply, so I unhooked the bag from the pole, and escorted the patient out of the room.

On a different day, I happened to have a medical student on an anesthesiology rotation assigned to my room.  We were doing a complex case–a resection of a lobe of the liver for a living-related liver transplant.  The surgeons like the patients dry so the liver doesn’t bleed as much, and I was trying to accommodate, though the risk would be hypotension.  Throughout most of the case I was successful in walking the fine line of hemodynamics, though at one point the patient seemed a bit bradycardic (heart rate of 46, baseline of 60, running most of the case in the 50’s) and hypotensive.  I gave a dose of ephedrine and a little fluid, and explained to the medical student my rationale as we watched the monitors for the response.

Just then, I heard a voice say, “The patient is bradycardic.”  I turned around.  It was a woman who had been one of the two or three people floating mysteriously on the periphery of the room; she was now standing immediately behind me.

Rather than answering her, I asked, again with a neutral tone, “Excuse me, who are you?” “I’m with the liver transplant team, but I used to be an ICU nurse,” she replied.

I then asked her, “Are you asking me or telling me that the patient is bradycardic?”  She said nothing, so I turned around and went back to my job of taking care of the patient.

I think the thing I found particularly insulting is what this former ICU nurse’s interference with my work implied.  If I’d been sitting there working on a crossword puzzle while the patient was on the brink of death, that is one thing.  But I was clearly monitoring the patient, so this woman’s comment suggested that I was not qualified to recognize a problem.  This I found highly offensive.  This is my job.  I monitor patients.  I keep them alive while the surgeons hack out major organs. Not only did I already knowthe patient was bradycardic (not so worrisome) and hypotensive (more concerning), I had already treated it by the time this woman thrust herself into my area of sanity on my side of the drapes.

I will spare my gentle readers the story from the same day of the animal, er, older man, who resorted to pushing on the subway when people were in his way, rather than walking around or *gasp* saying “excuse me.”

I don’t know…maybe I’m the arrogant, dismissive one.  But better to be clever and arrogant and dismissive, than foolishly arrogant.

Leave a comment

Filed under Musings, Work

Team captain call

Tonight will be my fifth “Team Captain”, or “TC” call.  The standard anesthesiology overnight call team at my training program includes an attending, a senior resident (the TC), a junior resident (the assistant TC, or ATC), and two first-year residents.  There are also six “short call” people who typically go home somewhere between 1800 and 2230.

This call team is distinct from other call teams, which include a cardiac call team (an attending and a resident or fellow who take home call), an ICU call team (an attending who takes home call, two in-house fellows, and a handful of residents/physician assistants/nurse practitioners), the Pain Management night-float resident, the pediatric call team (an attending and a senior resident or fellow who take home call), and the obstetrical anesthesia call team (an attending, a night-float resident, and a 24-hour resident).  There’s also a liver transplant attending who only comes in as needed.

The Team Captain functions as a junior attending.  He is the point person for the OR desk when new cases need to be scheduled.  He delegates responsibility to the various team members, including setting up operating rooms and assigning cases.  He speaks with the surgeons if there are issues that need resolved before a case proceeds.  He is the first person the junior residents call if they have intraoperative problems.  He manages the PACU (Post-Anesthesia Care Unit).  He advocates with the ICU fellow for ICU care for appropriate patients. He resonds to requests for “stat intubations” and medical codes in the hospital wards and sometimes even the emergency department.  On occasion, he assists the pediatric team or advises the pain resident.  He orders food for the team.

When starting a case, the TC generally aims to have a room set up, the patient’s pre-operative evaluation done, the junior resident briefed, and the patient in the room before the attending is called.  This way, the attending can simply swoop in, sit in the corner of the room while the TC induces anesthesia, and then stumble back to bed.  Of course, if there are medical or anesthetic concerns, the attending will be called much earlier at the TC’s discretion.

In sum, this is a multifaceted, interesting, and challenging role.  I think it’s one of the strengths of my training program, since it prepares us not only to be anesthesiologists, but to be managers of the entire perioperative process.  After every one of my team captain calls, I’ve thought, “I should come home and write a post about this.”  Unfortunately, in my sleep-deprived state, I usually collapse on my bed for a good four or five hours and awaken in an afternoon haze, when writing is the last thing I want to do.

Some notable parts of my last TC call:

  • Reintubating a post-operative patient in respiratory distress within fifteen minutes of my arrival and within thirty minutes of his arrival in the recovery room.
  • Getting something on the order of 30 pages between 1600 and 2200.  This averages out to only five pages per hour, but when they come in quick succession, it sure feels like a lot!
  • Managing multiple ICU level patients in the recovery room (PACU) who were there because the ICU was full.  Their problems included mild myocardial infarctions (heart attacks), profound bradycardia (slow heart rate), and hypotension/sepsis (low blood pressure due to a bloodstream infection).
  • Putting in a subclavian central line (a large IV just under the collar-bone) all by myself.  Regrettably, anesthesiologists at my institution are a little paranoid about subclavian lines because of the increased risk of pneumothorax (accidentally puncturing the lung and developing an air leak around the lung, preventing it from inflating fully and requiring  a chest-tube placed between the ribs to help re-inflate the lung).  I’d done nearly 40 of them as an intern, but only 1 or 2 as an anesthesiology resident.  This PACU patient already had a chest tube from his surgery (and he needed a central line), so I figured it was a good time to put in a subclavian, since the treatment for the potential pneumothorax was already there!  It was gratifying to get blood returned from the subclavian vein on the very first try.
  • Bread-and-butter PACU problems like post-operative pain in a shoulder surgery patient requiring massive opioid doses when his nerve block wore off (I nearly asked the attending if he would supervise me placing another nerve block for post-operative pain), managing fussy epidural catheters, taking care of routine post-operative respiratory failure, etc.
  • Starting two “ASA 5E” cases almost simutaneously at 0630.  When I got the calls about these cases within minutes of each other, I paged the entire call team, because I knew I would need everyone’s help.  See next few bullet points…
  • The first case I was evaluating was a 65 year old woman in the medical ICU (MICU) who appeared to have dead intestines and was looking sicker by the minute (with no invasive blood pressure monitoring).  While starting to look at her chart, I got called by the neurosurgery resident…
  • “We have a 35 year old with a subdural hemorrhage who’s dying.  We need to come down [from the neurological ICU] right now.”  When a neurosurgeon says that a patient is dying and they need to come now, I tend to believe him.  I told him to come right away, and I had two of my team members meet me there.
  • Within minutes we had the neuro case underway, and I returned to the MICU to help transport the general surgery patient.  With very little down-time, the patient was intubated and the surgery was underway.  The patient’s femoral (groin) central line was difficult to access, besides not being a very “clean” site, so I slipped in a neck line under the drapes.  Given her short neck and obesity, this was going to be potentially challenging. I had one of the first-year residents retract the patient’s breast under the drape so as to stay out of my field while I quickly prepped with a sterile cleaning solution, draped, and cannulated the internal jugular vein with only one minor redirection of the needle.    By this time, it was 0730, and I turned the case over to the attending and resident who’d come on for the day.

One last side note–because the job of TC is so demanding and because we expect to get no sleep and to be on our feet almost the entire night, the shift begins at 1600 and ends at 0700 the following morning.  In comparison to my ICU calls, TC call doesn’t involve the same level of acuity (since most of the patients I’m dealing with are not ICU-level patients) and it’s more in my comfort zone (dealing with intra-op and post-op issues is what I’ve mainly been doing for two years, compared with only two or three months in the ICU).  However, there’s no “wall” of an intern or junior resident between the TC and the PACU “nonsense”, so I’m the first up to deal with everything from simple issues like low urine output or a patient missing standard post-op orders, to more complicated problems.  Thus, by about midnight, I usually feel a bit like a trampoline which is stretched equally in all directions.  But overall, I’ve found the calls to be challenging, interesting, and often rather fun but exhausting.

3 Comments

Filed under Work

Maybe I should get a desk job…

Editor’s note: I wrote this post some time ago, but waited an unspecified length of time to post it to protect patient privacy.  It should be noted that the post portrays graphic medical situations in raw, unedited detail, so readers with a delicate constitution may wish to stop reading here.

Yesterday afternoon’s code was one of the…shall we say…earthiest I’ve ever been to.  My friend Jen, carrying the code pager for the day, had grabbed the orange “arrest bag” which was stocked with medicines, airway equipment, and gloves and was headed out of the anesthesia workroom.  “Code blue, sixth floor,” she said tersely, “Want to come?”  Given that I find participating in codes strangely rewarding, I tailed her.  It’s satisfying to make a huge difference in the acute trajectory of a patient’s health, and once an endotracheal tube is successfully placed, one can sense the rest of the medical team breathing a collective sigh of relief.  I’ve also noticed that walking into a crowded room, assessing the situation, and taking charge and communicating effectively seem to restore a bit of order to the chaos.  It’s good practice for learning to function well in highly stressful situations.

As Jen and I rounded the corner, we saw a small gaggle of medical students clustered around a door near the nurses’ station.  They talked quietly in intense conversation among themselves, their short white coats’ pockets bulging with reflex hammers, pocket references, and “to do” lists.  We immediately headed toward that door.

We strode into the room that was packed with physicians, nurses, pharmacists, respiratory technicians, and the code cart.  Being nearly 6’4″, I had a decent view of the situation, but rather than seeing a patient, all I saw were white coats clustered around the bed amid a flurry of syringes and beeping.

“Anesthesia,” I announced loudly.  “Who’s the primary team?”

“Anesthesia, get in here and intubate this patient!” one of the surgery seniors commanded me.  A little taken aback by his tone, many thoughts quickly crossed my mind.  Why else were we here?  Tea and crumpets?  Of course we were going to intubate the patient, in the quickest and safest manner possible.  Jen and I were working our way to the head of the bed.

Rather than replying, “Can you communicate with me rather than barking orders at me?” I simply asked in a voice that carried across the crowded room, “Does he have any cardiac history?”  The surgeon didn’t seem to know.  Instead, in a more neutral tone, he said, “He aspirated.  He needs intubated.”  Aspiration is the medical term for when acidic stomach contents enter into the trachea (windpipe) and potentially cause grave damage to the lungs.  Most people who aspirate end up with in the ICU with lung injury; many die.

By this time, through the tight ring of white coats, I was able to see the patient at last.  They were doing chest compressions.  I looked at Jen and said, “Compressions.  We need to intubate.”  A true code–that is, a cardiac arrest–makes our job fairly simple.  No medicines are needed.  Just a laryngoscope and endotracheal tube.  And there’s really nothing worse than being already dead, so we don’t have to worry much about hurting the patient.  I’ve never heard of a patient saying, “Hey Doc, I wanted to thank you for saving my life, but I think you may have cut my lip in the process.”

The “fairly simple” task, however, became a bit more complicated as I got a better view.  The bed was only about two feet off the floor, making it more difficult to get a close view.  The patient had a huge stomach, which is usually associated with a thick neck and a difficult time performing adequate laryngoscopy.  In addition, he had a full beard.

“Move the bed out,” I ordered.  As the bed rolled forward, I noticed not puddles, but small lakes of brown liquid covering the floor at the head of the bed.  The white sheets covering the mattress were saturated with particulate brown fluid.  Donning gloves, I scarcely had time to process it before the respiratory therapist told me, “I’m having trouble moving air.”  With that, she removed the ambu bag and I saw the source of the effluvium.  It was erupting from the patient’s mouth with every compression of his chest.

“This’ll be tough, Jen,” I said, looking at my fellow senior resident.  “Do you want to do this?”  She shook her head no as I removed the head board and grabbed the suction tubing with the Yankauer tip.  This attachment quickly clogged with the particulate matter, so I removed it and placed the larger tubing directly in the patient’s mouth while the internists continued compression and rounds of epinephrine and atropine.

After thirty seconds, I realized that whatever I suctioned out was being replaced with more fluid from deep, deep inside this poor patient.  His mouth was like a storm sewer overflowing after an afternoon deluge.  If we didn’t get oxygen into his lungs soon, there would be no hope of resuscitating him.  I tried to think about my options: a fiberoptic scope would be useless with all the liquid, and it was downstairs anyway.  A laryngeal mask airway might help get oxygen in, but it wouldn’t prevent more fluid from entering the lungs.  I don’t feel qualified to do a slash-tracheotomy, and a needle cricoidotomy would be silly in this setting.  He needed a definitive airway–an endotracheal tube–and our main way of placing it–by direct sight–was impossible with the copious runny stool being forced up by the impossibly large gut.  My sense of smell, taste, and hearing didn’t seem to help me here.  This left me with one obvious answer.

“Jen, could you hand me a bougie?”  This somewhat rigid yet flexible tool saves lives daily in the operating room.  Its curved tip is designed to bounce on the cartilaginous tracheal rings, providing tactile confirmation that the bougie is within the trachea and not the esophagus.  Once in, an endotracheal tube can be slid over the bougie, the cuff inflated, and the bougie removed.

I grabbed the laryngoscope and pried open the patient’s mouth, while brown chunks seeped out the corners of the lips.  Advancing the laryngoscope by feel rather than sight, I knew that it would help me by lifting soft tissue out of the way, rather than providing a line of sight.  I took the bougie in my right hand and plunged it into the small pool in the patient’s mouth.  It met some resistance as I advanced, so I twisted and redirected a couple times before it finally sped forward.  I felt a subtle bump or two, suggesting tracheal rings.

Raising my eyebrows at Jen, I steadied the bougie while she advanced the endotracheal tube over it.  With deft hands, we inflated the cuff, pulled out the bougie, attached the carbon-dioxide sensor, and applied a few breaths with the ambu bag within seconds.  The sensor turned a reassuring yellow, and one of the keen internists called out, “Bilateral breath sounds!”  The tube was miraculously in place.

I called for a soft suction catheter, knowing if the patient stood any chance of survival I’d have to remove as much fluid as possible from the lungs.  As I removed the ambu bag, however, I didn’t anticipate the geyser of fluid pumped from the lungs, up the tube, and out onto Jen’s scrubs and a nearby internist’s white coat as another medicine doc continued forcible compressions.  We quickly suctioned and continued ventilating while rounds of epinephrine, atropine, lidocaine, and calicium were poured into the femoral line.

The story ends, sadly, as many codes do.  We were unable to restore a heart rhythm.  The code was “called” as no pulse was attained.  The room emptied in what seemed like seconds leaving Jen and me, with spinning heads, alone with the patient and our orange bag.  We wandered back downstairs to change scrubs and sit down for a few minutes of peace to restore our sanity.

In retrospect, I cannot think of much we’d do differently.  Attempting mask ventilation can force more fluid into the lungs in a patient with such copious gastrointestinal regurgitation.  We should have put on masks with face shields first thing for our own protection.  But in reality, I knew that our chances of bringing this fellow back were next to nothing with such massive aspiration.  Here is a situation where the patient is clearly objectified, as he should be in that moment.  He becomes a task, a problem, a challenge.  We solved it.  And even if saving his life was practically impossible, by restoring oxygen to the lungs, we at least gave a sense of closure to the medical professionals.  Everything that could be done had been done.

Images of those minutes kept coming into my mind during the remainder of the afternoon and as I tried to go to sleep last night.  Nearly every sense was saturated with input: slippery floors, shouted orders, red blood & brown stool, ringing pages, splatters, needles, cracking ribs.  And I wondered, “What kind of job do I have?  What would it be like to sit behind a desk, sip coffee, and sort through e-mail and messages?”  In medicine, we tweak the inner workings of an amazing machine, our finesse guided by thousands of years of experience, by the scientific method, by love, by art.  But in the crucial times, practicing medicine rams together the raw, animalistic, sloppy, dirt-under-your-nails sort of gritty survival instinct with placid, cerebral, transcendent rationalism.  And I marvel that this is all starting to become normal.

4 Comments

Filed under Musings, Work

Red up, blue up, volume in

Such is the chatter I pick up going on between the cardiac surgeons and the perfusionists.  The simplicity and efficiency of the lingo belie the complexity of the cardiopulmonary bypass machine.

My first month in cardiac anesthesiology nearly a year ago was rather stressful, with often difficult arterial and central venous lines, intense and dynamic physiological perturbations, and a general haze of confusion when it came to knowing exactly what was happening when.  One would think that that a major surgical event like, say, unclamping the aorta, would be heralded with a clear pronouncement, if not a chime, a blast from the trumpeter in the corner of the operating room, the unfurling of a scarlet “Aorta Unclamped” banner, and a few turns of the disco ball above.

Not quite.  In the midst of the rocky course of coaxing an octogenarian’s heart off bypass, dealing with hypothermia, metabolic derangement, coagulopathies, and blood volume shifts, I must pick up on quickly uttered words like, “Pressure down, off.”

As a whole, however, I’m enjoying this month much more than before.  Knowing the basics already of how to do straightforward bypass graft and valve surgery, I feel like I’m able to pick up on more details, like nuances of induction of anesthesia, performing transesophageal echocardiography, how to better communicate with the surgeons and the perfusionists, and pearls and pitfalls when it comes to coming off cardiopulmonary bypass.  Transporting an intubated patient with multiple intravenous infusions in a large ICU bed can still be challenging, but at least now I don’t feel overwhelmed by just setting foot in the cardiothoracic ICU.  Having rotated through six months ago, many of the nurses are friendly faces.

Even medical situations that used to be daunting now seem fairly routine.  The patient’s on 6 mcg/min of norepinephrine and 4 units/hr of vasopressin?  A little nitroglycerin?  No big deal.  Pulmonary pressures a little high? Let’s start some nitric oxide.  And I know it’s bound to come to an end at some point, but my hands have been golden this month.  Bright red arterial blood flashes back in my catheter with no redirection; the catheter slides right into the artery.  Central lines slip into the neck like slipping my fingers between the sofa cushions.  Difficult view on intubation?  I’ll just ease a narrow bougie into the trachea and glide the endotracheal tube over that.  So that’s at least been rewarding.

My biggest difficulty has come consistently toward the end of a run on bypass, when the circulating blood must be reheated in order to bring the patient’s body temperature back closer to a physiologic temperature.  (The patient is cooled during bypass to help decrease the brain’s and heart’s metabolic demands.)  Around this time, I page my attending to announce, “We’re rewarming.”  That’s the hardest thing to say, with all those R’s and W’s.  I’ve even tried coalescing the two R’s into one (“Weereewarming”), but I’m thinking of just shortening the message to “Rewarming.”  Or maybe just “Warming,” since, unlike leftovers, this is only the first time I’ve brought the patient’s temperature up.  I’ll try some of these out, and let you know what works best.

3 Comments

Filed under Work

I’m a fan of methadone

One of the more interesting parts of spending time on the pain management services was getting more comfortable using methadone.  Methadone is a synthetic opioid (mu-receptor agonist) which was developed in Germany in the 1930s since there were predictions of opium shortages.  Methadone has a very long duration of action (making it well-suited for recovering addicts) and it also is a NMDA-receptor antagonist.  This means it may help prevent some tolerance to opioids, and it can quell central nervous system responses to pain.

One of my patients was a young man with sickle cell disease, which leads to painful “vaso-occlusive” crises.  These crises happen when the shape of the red blood cells becomes distorted, leading to obstruction of small vessels.  Patients typically develop pain in their chest, shoulders, hips, and knees.

This particular patient had been in the hospital for nearly two weeks by the time I inherited him (as I came on the Chronic Pain Service on a Tuesday).  He’d been intermittently refusing his long-acting oral morphine and insisted on using his substantial intravenous patient-controlled analgesia (PCA)  pump.  When I asked him why he refused his oral medications, he said they didn’t work for him.  I explained that I believed the oral medicine did work for him, because when he took his medicine consistently, he required less intravenous medicine.  The morphine was long-acting, so it didn’t produce a “rush” or “high”, but I explained that it provided a baseline level of pain control.  He still seemed doubtful.  I also told him that my goal was to get him off intravenous medications by the next day, and I was able to get him to agree to take his oral medicine.

Sure enough, by the next day, he’d refused a couple more doses of morphine.  The cynic found within all pain specialists may interpret this as a sly move to exchange the pain control afforded by long-acting medicines for the euphoria of intravenous medications.  Since one side-effect of opioids is sedation, if a patient is too sedated, he won’t push the pump’s button.  This is the elegant safety feature inherent to PCAs.  If a patient refuses long-acting medicine, that means he can get more intravenous medicine more frequently without becoming sedated.

At this point, I called the pain fellow to make sure he was on the same page as me, and then I lay down the law.  No more intravenous medications.  We’re starting methadone.  The patient would have shorter-acting oral medicines available too, but only if he took his methadone.  With the fellow, I did a multi-step conversion to determine the appropriate starting dose.

I was in for a surprise when I went to see the patient by the next day.  He had received three doses of methadone by that point (one dose every eight hours).  I’d double checked the nursing medication administration record to make sure he hadn’t refused them.  And then I walked into his room.  The patient was sitting in bed, awake, alert, and smiling.  He stated that this was the first day in two weeks that he wasn’t in pain.  Not only that, but since starting the methadone, he had not required any additional doses of shorter-acting oral medication.

Given the long half-life of the medication, it could potentially be building up in his system for days, so I titrated the dose down a tad.  He was still comfortable the next day, so I recommended that he was okay for discharge with close follow-up with his hematologist.

Another satisfying success story for methadone!

10 Comments

Filed under Work

Guilty pleasures

I had an epiphany of sorts on the train today.  I was riding in relative peace–as much as was possible wedged between two strangers in a car whose air-conditioning was a bit like a gentle breeze in Death Valley–when a nearby two-year-old began to cry.  This was no “I’m scared” cry, or “I’m hurt” cry.  No, it was an angry cry, one whose screeching pitch rose and fell like the tides, one whose tantrums crested with piercing squeals as the child arched his back and kicked his legs in convulsive fits.

A pleasant middle-aged black man riding across from me smiled at the struggling father and asked, “How old is he?  Two?”  The father nodded.  In that moment, I could think of no other age that so deserved the modifier “terrible.”

In fact, the cries brought me back to my time doing pediatric anesthesia.  For those rare children whose parents refused oral premedication on their behalf, a trip to the operating room may have well been like checking into a nice stay at Abu Ghraib.  And for these children–a particulary wiry and surprisingly strong eight-year-old getting a questionably medically necessary circumcision comes to mind–gently inducing anesthesia was a two-, or sometimes three-man job.  More than once, I’ve stood behind a child who sat on the operating room table facing his mother and wrapped my boa-long arms around his body, pinning his arms to his side, while the attending held the cherry-flavored mask to the little head which was frantically flinging itself left to right, left to right.  With every deep, visceral shriek, I could just imagine the little molecules of sevoflurane being whisked from lung to capillary to heart to brain.  No child can withstand a compelling inhalational induction of anesthesia.  Grisly, but strangly satisfying.

And so it was, as the cries brought me back to the rattling subway car, I slowly opened my bag and pulled out the pink bubble-gum mask.  The father, seeing this, grimly nodded and handed the child to me.  His dark, confused eyes surveyed the new face before him while his shallow panting afforded our ears a brief reprieve before the fierce wailing resumed, the back arched, the little fists pounding against the orange plastic seats.  As I pressed the mask against the child’s face, the sobs became muffled and shorter, and then, eyes rolling back, blessed, quiet sleep came.  I handed the little one back to his father as the subway ground to a stop and the doors opened.  A last glance at the car before exiting showed every beaming face raised, every mouth upturned in a thankful smile.

Okay, so I made up that last paragraph.  But oh, what I would have given to knock that little kid out (anesthetically, of course).  It was startling, though, to realize that I wouldn’t have done it only for the sake of my hearing.  No, when those situations arise–not that I would ever choose to be in them–there’s also some element of primative power struggle, and it’s gratifying to win…even against a two-year-old.

Addendum–ethical analysis

In my defense, I don’t believe I’m a horrible doctor and a horrible person.  Just reflective.  The same essay could probably be written about law-enforcers, or CEOs, or even a flight attendant dealing with an unruly passenger…  With many (most?) jobs, there’s a difference in power, and when individuals’ goals are in conflict, that power advantage–be it physical, mental, social, or rhetorical–can be, shall we say, compelling.  The intentions and the circumstances may determine the moral and social acceptability.  Anyone remember Rodney King?

What I realized is that unpleasant as it is to put a fighting child to sleep (“Disgusting,” I remember my attending muttering after the aforementioned eight-year-old was anesthetized, referring to our brute force, not the child’s lack of cooperation), it’s generally regarded as necessary in some circumstances, and it accomplishes a greater good, so it’s okay.  But if I’m honest, I have to say that a primitive part of me actually finds it satisfying.

Obviously, the hypothetical scenario I described on the subway would have been a display of power not out of necessity or because it was accomplishing a greater good for the child, but simply because it would have given our ears a rest from the painful cries.  The epiphany was that I would have definitely enjoyed putting that child to sleep for the good of everyone on the subway.  Clearly this is ethically indefensible, and so those motivations were filed away to some hidden part of the consciousness, and I continued reading my magazine in a socially acceptable manner as other nearby riders rolled their eyes and the wheels continued clicking along the steel rails.

2 Comments

Filed under Musings, Work