Tag Archives: Epidural

A new Mulberry feature

Saturday finds me realizing this has been a week comprising mainly two things: work and opera.  In a first for me, I made two trips to Lincoln Center this week to enjoy complimentary tickets to the Metropolitan Opera.  I’ve come to the realization that if I don’t plan to live in New York City forever, I should take advantage of things the city offers, and one of those things is a world-class opera house.  And when the tickets are free–courtesy of my roommate Jordan–that much the better.

 Learning to enjoy the opera more has been a side-benefit of living in Manhattan.  Having strongly favored orchestral music in the past, playing in the pit in a few operas in college helped me to appreciate the genre a bit more, but it wasn’t until I moved here and made friends with several vocalists that the world began to open up to me.  That being said, I hope never to become that sort of freakish opera buff I overheard in Patelson’s the other week.  The kind that says things like, “Bartoli is to mezzo as Pavarotti is to tenor.  That woman is a machine, but a machine with feeling.”  Or, “The Zeffirelli production is creative, but it lacks the raw power and nuance of the staging I saw in the 70s.”

In between the opera, I’ve been working on the Labor and Delivery floor, placing epidurals for labor and doing anesthesia for cesarian sections.  This is my third call in a six-day period.  When I don’t get home before midnight from the opera, needless to say it’s been a tiring week.

The shows this week included Puccini’s Madama Butterfly and Verdi’s La Traviata.  Good, solid Italian opera.  Given that I have a few remarks for each, and given that I’d like to avoid a monstrously long post, I think I’ll post retroactively on each of those.

The new feature the title of this post alludes to is the tab at the top in which I offer a short review of the various cultural experiences I take in.  A bit indulgent and supercilious, I know, but the obsessive-compulsive part of me likes to make lists.

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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.

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Beware, the interns have arrived…

The last couple nights on pain night float have been complicated by the fact that the new interns have apparently begun taking call.  It doesn’t seem like that long ago I was beginning internship, but it’s already been three years.

As I look back at some of the earlier entries in this blog, I see some rather indignant posts describing my calling consultants who seemed to think we hadn’t done an appropriate work-up.  Even last year, I remember calling a cardiology consult for a stat echocardiogram in the ICU for a crumping patient (because the fellow wanted one), and the cardiology fellow was still a jerk about it.

Alas, I am now that consultant.  Last night found me returning a page from an intern who told me that his patient with a thoracic epidural catheter was having pain.  This was a very reasonable consult, but the intern couldn’t tell me much about the patient’s medical history, couldn’t give me more details about the patient’s pain, couldn’t tell me where the catheter was, how deeply it was placed, which medicine was being infused through it, and at which rate.  He stammered, “This is my first night on cardiothoracic, and I’m just cross-covering that patient.”

I responded, “You are that patient’s primary physician for the night, and you should know more about the patient than anyone else in the hospital.  You should know all these things before you call a consultant.  I wouldn’t dream of calling a cardiology consult if I couldn’t recite a brief history, and if I didn’t know what the last troponin was and what the EKG showed.”  Of course, I said it all in a nice–but firm–tone of voice, and the chastened intern apologized to me when I showed up on the floor.  I told him I wasn’t upset, but that it was important for him to learn sooner rather than later how to appropriately ask for help from a consultant.

This morning I received yet another page.  “This patient had back surgery and is having pain.  Could you come write a PCA?”  Again, I asked for more details, and at first the intern couldn’t tell me the patient’s medical record number, when the surgery was, and what pain regimen the patient was on.  For him, I simply said, “It sounds to me you know very little about this patient.  Please go look up the information and then you can call me back.”

In this case, I was busy and I didn’t have time to wait while the intern looked up every detail I asked for.  Sure, I could easily look up all the information, but it’s inappropriate not to be able to tell a consultant pertinent details.  I felt like this intern just hadn’t really bothered, and that conveyed the message that he felt like his time was more valuable than mine.

Ironically, I’m sure he did have a lot more than me I to do that morning, but I think he still got the idea that he needs to know his patient before calling the consultant.  I think of it as tough love.  You can’t coddle these interns who just spent the last six months skipping through an easy end to fourth year and being told how bright they are.  Better to work hard and to be prepared than to be bright.

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Enjoying New York in the spring

I’ve realized that there are many ways Pain Clinic could run smoother.  Having an additional exam room would facilitate patient flow.  Stocking reflex hammers in every room would also help.  But most notably, having a fifth of Jameson Irish Whiskey in the back room would greatly lubricate the process.  Made from fine ripe barley, flavor-rich malt, and crystal clear water from the green mountains surrounding Dublin, a sip of that smooth drink between patient encounters (or even stepping out during a patient encounter) would greatly improve one’s outlook on the day.

Such was the morning yesterday.  In the afternoon, I got to see several pain procedures, including epidural steroid injection, cryoablation of the occipital nerve, and medial branch blocks of cervical nerves.  Lecture in the afternoon with all the other CA-2s focused ostensibly on reviewing the medical literature, but the real take-home message was secrets to advancing one’s career in an academic instutition.  (“What I’m telling you does not leave this room…”)

In the afternoon, I planned to meet up with Gloria to check out the free museums along Fifth Avenue.  I rode the subway to 103rd Street, and as I realized there was no crosstown bus nearby, the words of a very wise New Yorker flitted through my head.  “Living in New York City is all about being separated from your time or your money.  You can have your time, or you can have your money, but not both.”  This sage advice has proven true on countless occasions.  Generally I err on the side of saving money, but to successfully cope with life here, one must be prepared to part with either in certain circumstances.  With my dress shoes, slacks, tie, tired feet, and shoulder bag, this was one such occasion.  $10 and 10 minutes later, the cab deposited me on the Upper East Side in the shadow of the stately buildings that line Fifth Avenue…

…however, not before nearly running over a woman with her stroller crossing 96th Street at Central Park West.  True, we did have a protected left turn, but it’s understandable that pedestrians instinctively start to cross when traffic comes to a stop the opposite direction.  My driver seemed to make no effort to slow down, and as we whizzed by within feet of the stroller, he rolled down the window and shouted at the woman!  To that woman who was crossing 96th Street at Central Park West at 6:15 PM on Tuesday, June 3, 2008, and to her now traumatized infant in the green stroller: I am sorry.

Nine museums along Fifth Avenue offered free admission that evening, and the avenue was closed off to give a festival sort of feel.  We checked out the Museum of the City of New York, which had fascinating displays featuring New York City homes’ interiors through the centuries and the role of the Port and waterfront in commerce, trade, industry, and leisure.  We finished the tour in front of the museum, watching a choir from Harlem called Impact perform songs and dance.  The group had been featured in last year’s movie August Rush.

All in all, not a bad day.

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Filed under Around town, Musings, Work