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Jonathan’s fed up

Enough formatting problems, text glitches, and software bugs! Mulberry Street is moving…to Mulberry Street.
I’m leaving blogspot (a decision which perhaps I should have at least slept on) and moving my blog to mulberrystreet.wordpress.com.

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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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Depends…

What a delightful tidbit to post as my second year of blogging draws to a close.

I recently notified a charitable organization to which I’ve donated in the past that it appeared I had two separate account numbers, and the address on one account number was wrong. I received a prompt reply that included these sentences:

Thank you for informing us that you have two donor accounts under your name. Please accept our sincere apologies for this error and for the incontinence that this has caused you.

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Niles

Another thing you wouldn’t hear at a NASCAR race, or even at your local hardware store:

Niles: “Frasier, I played the most delightful party game last night with some of Maris’ friends. Tell me, if you were stranded on a desert island, what is the one meal you would want to have, the one aria, and the one bottle of wine?”

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Score 1, Anesthesia!

While I could write about another glorious post-call day, instead I must make record of the amazing victory achieved overnight.

I’d worked nearly continuously from 0700 Wednesday morning until 0200 Thursday morning, with a 30-minute lunch break and a 45 minute dinner break late in the evening. My last case was a laparoscopic appendectomy which began at midnight. The same surgical team was planning to follow that case with another “lap appy”, but it would be done by the other first-year anesthesia resident on call with me. I could potentially sleep from 0230 until 0800. (Our call day ends an hour later on Thursdays to allow the new call team to attend grand rounds.)

To my dismay, just as the junior surgeon was putting on bandages, I heard the surgery attending say to the senior on service, “Why don’t we just go ahead and do that incarcerated hernia tonight, if we’re all here? Just get it done, instead of leaving it for someone else to do.” This meant two things to me: 1) It didn’t seem like a true emergency if the patient could potentially have gone to the floor rather than straight from the E.D. to the O.R. The surgery team seemed to be adding it out of some bizarre sense of convenience. And 2) Unless the anesthesia team captain called the second-year anesthesia resident to do the hernia, I would get a mere 2-hours of sleep. There was also the off chance that my attending or team captain could try to block the case.

I suppose any sleep on call should be appreciated, so sleep I did. At 0415 my pager went off, summoning me to the pre-op holding area. Bother.

The patient was 77, but overall seemed realtively healthy and was not in any distress. I groggily interviewed him in Spanish, and when I examined his airway, I noted he was “Mallampati Class 4”, which meant it might be difficult to place an endotracheal tube.

Turning to my anesthesia team captain (a third-year), I asked if they could do this case under sedation with local anesthesia. She hadn’t thought of that, so we asked the surgery junior. “Oh, maybe so!” she said, further explaining, “We didn’t even see bowel entrapped on the CT scan, so it’s just going to be a little superficial operation…probably just a little omentum that we have to push back in.”

This angered me. This was not a strangulated hernia; not even a real incarcerated hernia. It was a little bit of fat poking through the abdominal wall, and we were about to start this surgery at 0430. The anger had at least two facets. First of all, if the patient were my grandfather (with a difficult airway), I wouldn’t want him operated on at that hour. Converting from local anesthesia to general could be dangerous, especially without support personnel around as they are during the day. The surgery team was essentially suggesting putting this man’s life in danger because it was convenient for them to do the case then and leaving the case for the next day’s on call team could be seen as “weak.” And secondly (on a more personal level), I was losing sleep over the whole ordeal, and neither my attending nor my team captain had raised the questions that should have been asked originally. Time to take matters into into my own hands. The surgeon had given me all the ammunition I needed…

“If this is a ‘little superficial operation’ as you say, and there’s no bowel entrapped,” I asked the surgery resident, “then is this really an emergency? I feel like we could be putting this man’s life in danger by attempting a difficult airway in the middle of the night.” She had nothing to say. She called her attending, and 5 minutes later, the case was cancelled and instead posted on Thursday’s “add-on” list.

As my head sank onto my flimsy, thin pillow at 0500 that morning, I didn’t care about the sub-optimal call-room furnishings, and I didn’t even mind the long, busy day. This was sleep I’d fought for and earned, and in the end we did the best thing for the patient. The sleep came sweetly.

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Bowling night

So I’m on call yet again tonight. I just finished a case about 45 minutes ago, and I hear there are a couple laparoscopic appendectomies on the horizon. 😦 Maybe I’ll get a little sleep afterward.

Last Friday my home fellowship group went bowling at a place called Harlem Lanes in, you guessed it, Harlem. After a strong start with a couple spares, I quickly fell behind the pack. Maybe I should have gone with the 12 lb ball instead of the fourteener.
A couple pictures from the evening…
(From left to right) William, Jan, Katherine, Jonathan, Andy
Dessert afterward at W&K’s. William, Andy, Jonathan, Jan, Ezer, Katherine

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And to think that I saw it…

The day seemed to have an unexciting end. I finished my last case around 5:15, did a couple post-op notes, and then walked out of the hospital at 5:45. The subway station is just a block away from the main hospital building.

Once downstairs beneath the street, however, I noticed a small crowd of people. Their attention seemed focused toward the middle of the crowd…where a woman was lying on the ground and others were performing CPR.

I worked my way into the circle, set down my bag, and said I was a physician and offered to help. Turns out the fellow doing chest compressions was a medicine attending, and there was a GYN fellow there too. The girl giving breaths had witnessed the entire episode: the patient had said she didn’t feel so well before passing out. The girl eased her to the ground, and they weren’t able to find a pulse.

I asked the medicine doctor to hold compressions while I felt for a carotid pulse. No pulse. “Resume compressions,” I said, “no pulse.” I was perplexed, however, when I realized the attending was giving five compressions for every two breaths the girl gave. The basic life-support I learned had ratios of 15:2, whereas the newer guidelines are 30:2. The thought is that since it takes several compressions to even get a blood pressure, it’s better to go for longer stretches. The compressions themselves may also help with air exchange.

I felt like I should say something, but then I thought, “This is a medicine attending. Maybe he knows something I don’t know.” In retrospect, he was probably just rusty on basic CPR. Soon, I noticed the patient was starting to make respiratory efforts, so I reassessed the pulse (which I couldn’t palpate). Soon, the EMS personnel arrived and attached monitors, started an I.V., and gave supplemental oxygen before wheeling her off to the Emergency Department less than a block away.

Thinking about the whole experience, a few things strike me…

  • It all happened very suddenly. I was simply walking to catch my train, minding my own business, when all of the sudden I was caught up in this episode.
  • It was more than an episode. This lady had some form of pulseless cardiac arrest. This was life or death.
  • I felt very helpless without my monitoring equipment. No EKG, no pulse oximeter, no blood pressure cuff, no I.V. access, no cart full of medicines.
  • Despite not having monitors, I was still able to gather a lot of information about the patient, from feeling for a pulse, to watching her respiratory efforts, to assessing her color.
  • I probably should have taken charge, especially when I realized the medicine attending clearly didn’t know what is the standard of care.
  • It’s kinda weird how the whole thing didn’t rock my world more than it did. I would attribute this to the nature of anesthesiology: we take care of potentially life & death situations daily.

For someone whose heart may have stopped (she had regained a slow rhythm by the time the EMS service arrived) she didn’t look too bad. She was breathing, and she didn’t look too cyanotic. I hope she does okay.

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