Just When You Thought It Was Safe to Go Back in the Water...

Okay, surgery isn't Jaws II. But what I mean to say is that it's often shocking how complacent you can get around things when everything goes well for a while.

It's been a long time since I've been away from the academic centre... or to borrow a phrase from The Flea, TBFTHITW.* Things in the community are... well, nice. Patients come into hospital with usual things, like urosepsis and COPD exacerbations. Some are palliative, and pass away quietly with adequate pain control. Surgery happens, people recuperate and rehab. Births happen, very rarely by c-section, and require nothing more in the way of intervention than a few absorbable sutures for mom and some blow-by oxygen for the baby. It's easy to fall into the complacency trap.

Last weekend I was on call for my preceptor's call group. Now that his call group no longer accepts the care of orphaned patients, rounding on the group's patients in the hospital rarely takes longer than 3-4 hours. Mercifully short, and I can often salvage at least enough of the weekend to go for a long run while there is still daylight left.

On Saturday, one patient on our list stood out like a sore thumb among the usual band of CVAs, ACSs and 'gastro+dehyrations'-- a kid in the ICU. Hmm. Don't see that everyday, particularly not in our sleepy community hospital.

So the story is this-- healthy kid sustains a fracture. Not a serious fracture, but it is slightly displaced and may not heal correctly without intervention. Enter surgeon who arranged for an ORIF of said relatively minor fracture (Open Reduction and Internal Fixation-- basically, we cut you open and put your bones back together, then make sure they stay that way).

It should be routine. Instead, as the kid was emerging from anaesthetic he bit down on the tube. The details are sketchy-- I wasn't there, just read the notes from anaesthesia in the chart. The patient was intubated with an LMA (as an aside, does anyone else think that those things resemble female genitalia?) and when he bit down, it obstructed the flow of oxygen through the tube. When someone is in this state-- emergence-- you can yell in their ear to stop biting down all you want and it won't make a difference. They have little to no control over their actions, but are no longer under the effects of the muscle paralytic. So as this guy's oxygen went down-- and it went WAY down, to about 50% O2 sat as evidenced by the OR record-- he continued to bite down reflexively. And then, likely secondary to hypoxia... his heart stopped.

Holy crap. At this point I was sitting at the ICU nursing station, reading the kids chart like a bestselling novel. A full 10 seconds of asystole. Basically, the kid was dead. Compressions were started, and eventually the anesthesiologist got another dose of sux into him which re-paralyzed him. The situation improved from here.

The result of all this was non-cardiogenic pulmonary edema-- basically, a heckuvalotta fluid in the lungs. Not so good for the breathing. And more fluid third-spacing... going to places it shouldn't. The poor kid looked like the Stay-Puft marshmellow man on a CPAP. After 18 hours or so on CPAP, the intensivist managed to wean him down to O2 by nasal prongs, but attempts to wean him beyond that resulting in rapid desats.

The poor kid and his parents were stunned. Thankfully, the story had a happy ending... he hung out in the ICU for a couple of days until he was able to be successfully weaned from supplemental O2 and went home, none the worse for wear.

Still... scary story. Serves me right for starting to think of surgery on healthy people as 'routine'.


* The Best Fucking Teaching Hospital In The World, a phrase intended to illustrate the view of the staff/clinicians/trainees at said hospital that everything done there must be the right way to do things, because we're TBFTHITW.

The Scutmonkey Rules

Okay, I rarely do this-- post passages directly from another blogger. But rarely does another blog actually make me laugh out loud. Which isn't so great if I'm working on my laptop, say, in the middle of Starbucks. People think I'm crazy. But this recent exchange, ever-so-wonderfully captured by Michelle over at The Underwear Drawer, was worth risking a Form 1.

(That 'Form 1' comment was a medical joke. And jokes like that are why I will never be cool.)

So for context, Michelle is an anesthesiology resident in NYC. And this recent OR exchange illustrates what is wrong with the traditional medical mentality:

So of course Joe and I had to work this last week, but thankfully the OR schedule has been somewhat light, with the exception of the orthopedic rooms, because those orthopods just don't know when to stop. Yes, they love doing surgery, and I respect that, but at some point, don't you think that stopping the smell the roses or having outside pursuits is a sign of a fully realized life? Or am I just a lazy turd?

Apparently the latter, according to the neurosurgeons. I was in a neuro case just the other day when the following conversation transpired between the surgical team and myself. They were discussing interdepartmental rivalries between our institution and [Upper East Side Affiliate Hospital]. You know, the surgeons down there talking smack about the surgeons up here and vice versa. The attending surgeons then posed this question.


NEUROSURG ATTENDING
How about Anesthesia? Did the anesthesiologists down there have some sort of big rivalry with the group up here?

SCRUB NURSE
[Who has worked at both hospitals]
No, the anesthesiologists were pretty laid-back.

NEUROSURG RESIDENT
Anesthesia doesn't have rivalries because anesthesiologists have no ego.

MICHELLE
I'm trying to figure out if you said that as a compliment or an insult.

NEUROSURG RESIDENT
(Bitterly)
All Anesthesia wants to do is go home! You know they leave at 4pm some days? 4pm!

MICHELLE
Um, it's 7pm now, and I'm right here.

NEUROSURG RESIDENT
(Starting to froth)
I get into work at 4am and leave at 10pm! They get six extra hours in their day! Six hours! That's a whole life!

MICHELLE
That's exactly right. That is a whole life. My whole life outside of the hospital.

NEUROSURG ATTENDING
If all you want to do is go home, why be a doctor at all?

MICHELLE
I don't think that wanting regular hours means that you shouldn't be a doctor. I think that having regular hours enables me to be a doctor and something else too.

MICHELLE'S INNER MONOLOGUE
Like a human being.

NEUROSURG ATTENDING
Ignore us, we're just jealous.

NEUROSURG RESIDENT
(Mumbling angrily to self)


It's this strange attitude in medicine, this macho thing, that in order to be the best, most committed, most self-sacrificing, most punk rock doctor, you have to basically sell your soul to the hospital. LOOK AT ME IN AWE AND WONDER, FOR I HAVE NO OTHER LIFE. I just don't really get that attitude. I mean, I'm glad there are people like that out there, I suppose. I mean, when it comes down to it, most of us will do what we need to do to take care of a patient in trouble, regardless of what time of day it is. But on the other hand, doesn't it make you a better doctor to, I don't know, take a break once in a while? Or think of it another way--do you want to be operated on at 8pm, the fourth elective CABG of the day, after your surgeon has been awake for the past 30 hours?

("No" and "Hells, no" are both acceptable answers.)

Thank God I'm not the only one that thinks that medicine and having a life are not incompatible life goals.

If you want to read more of Michelle's wicked and warped sense of humour, check out her blog at The Underwear Drawer. I only recently discovered that she is also the force behind Scutmonkey, who was the originator of the Twelve Types of Med Students that circulated around my med school class way back when. Check her out. Seriously.

Pimp of the Week, Volume II

Today I was pimped on greek mythology. My staff anesthesiologist wanted to know the origins of the words Morphine and Atropine (two commonly used drugs in anaesthesia). When I looked appropriately confused, he hinted that they came from the words Morphea and Atropius (or something like that). I was incredulous... he seriously wanted me to research greek mythology and get back to him? Yup. But at least he was impressed that I knew they were based in greek mythology.

I can only hope that this means I know everything I need to know about medicine and the staff guys are running out of things to ask me.

Anaesthesia-- From the Latin Word for "This Rotation is Putting Me to Sleep"

Okay, I'm determined to say something positive about anesthesia. Today was a good day. Part of that might be because it was the first day I worked this week, and part because it only lasted three hours. Sigh. On Monday I went into work only to find that the ONE operating room that was doing general anaesthetics had already been claimed by a respiratory therapy student. Okay. I went around to the other rooms, but all there was going on that day were a couple of ortho rooms doing spinals and a couple of eye rooms doing neuroleptics (i.e. happy drugs that relax you but don't put you to sleep). So, I went home.

That was the second time in the space of a week that I'd gone in and ended up turning around and going home. This is getting ridiculous. After being told by a staff anaesthesiologist that 'it's expected that residents step down to let the medical students have the good rooms' I had enough. I checked the list for the next day, saw that there was a similarly small number of OR's running, and made the executive decision to stay home.

I'm being paid for this. Yes folks, this is where your health-care dollars are going. To fund a doctor with 11 years of university education to go on a hike with her visiting sister and her dog. To break up the monotony of this post, here's a picture of the dog:



So here is my effort to say something positive about anaesthesia: I may have learned something this month. Today, I did a successful nasal intubation. Pretty cool. It's a tricky thing, so I'm proud of myself. Then, I got to see an 'awake intubation'. Which, unfortunately for the patient involved, is exactly what it sounds like. If you're expecting someone to be SUCH a difficult intubation that you can't risk sedating and paralyzing them, you stick a tube down their throat while they're awake, then put them out once you've confirmed correct tube placement. Another tricky thing... I left that particular trick to the staff guy! It was unfortunate to watch, but the guy had a tumor in his throat that obscured all of his laryngeal anatomy. Calling him a difficult intubation would be an understatement.

Okay, so here's where I learned something. I'm sure this is going to be one of those stories that you really had to be there to appreciate, but I'll try it anyway. So during the last case, the anesthesiologist got called back to the recovery room to deal with the patient we had done previously. I was left alone with the patient. Suddenly, lights and alarms started going off on the big, intimidating anaesthesia machine...



That's not good. All I could figure out was that the bellows weren't filling and he wasn't breathing... this guy was a heavy smoker and didn't have much in the way of reserve, so his oxygen saturation fell pretty quickly. I panicked at first and asked the circulating nurse to call the recovery room and get the anesthesiologist back ASAP. He wasn't there. I tried manually filling the bellows, I tried increasing the flow of oxygen, I tried bagging him manually... nothing. Finally I got my head on straight enough to think the problem through. And I found the problem... the surgeon had inadvertently knocked the tube, and the circuit had come apart from the tube. Phew. Crisis averted.

So there ya go... anaesthesia isn't always boring.

Pimp of the Week

In case I haven't adequately explained the term "pimping", it is the process by which anyone senior to you in the medical hierarchy (an attending, a senior resident or hell... anyone from the janitorial staff) asks you a series of questions getting consecutively harder until you get one (or many) wrong. At this point you are likely mocked and the very basis of your medical qualification is called into question. At my medical school we also called this process "shame-based learning", as it was often done in front of a group of your peers who were likely to watch with barely disguised glee because hey... it's not being directed at them.

So this week the Pimp of the Week award goes to the staff anesthesiologist (haven't I complained about this rotation enough?) with whom I worked on Tuesday. He was older than dirt, and was likely around when anaesthesia still consisted of hitting people on the head with a blunt object. Suitably, he spent the entire day pimping me on medical history. Yes, you heard me right folks. The freaking HISTORY of medicine. When was the first anesthetic given? When was the first laparotomy performed successfully? What was the first local anaesthetic used? What country successfully pioneered the gas induction method? It was like Jeopardy if Alex Trebek suddenly decided to don OR greens and a funny surgical cap.

Of course, since my knowledge of medical history is somewhat lacking (read: nonexistant) not only did I not deserve my medical degree, but it was undoubtably due to bribery that I managed to pass my board exams. I didn't have the heart to tell this guy that not only is there no medical history on the board exams, but that it isn't really taught in med schools anymore.

For now, I'm a little more concerned with learning the medicine that will allow me to not kill people TODAY. I'll worry about the historical stuff some other time.

Anaesthesia Continues to Suck...

There is so much I hate about anesthesia, I'm really going to have a rough time keeping this brief. Here's what I'm particularly hating today, though.

Anaesthesia is an art masquerading as a science. Sure, it's all based in hard-core physiology and pharmacology (which, of course, is what I get pimped on incessantly)... but every anesthesiologist does it a bit differently. There's a general recipe for induction of anaesthesia-- One part narcotic, one part sedative-hypnotic and in most cases, one part paralytic. There are different choices for each, the most common cocktail being Sufentanyl, Propofol and Rocuronium (isn't that a cool name for a drug?). But some use Fentanyl instead of Suf, some use Succinylcholine instead of Roc... I won't bore you with any more details, but you get the gist. But this goes WAY too far.

Monday with Staff Anesthesiologist #1:
Dr. Couz secures breathing tube to the patient's upper jaw with paper tape.
SA#1: What the hell are you doing? That stuff is crap! Who the hell told you to use paper tape?
Dr. Couz: Um, sorry. What would you like me to use?
SA#1: The pink tape, obviously. Where did YOU go to medical school?

Tuesday with Staff Anesthesiologist #2:
Dr. Couz secures breathing tube to the patient's upper jaw with the pink tape.
SA#2: What the hell are you doing? Are you trying to rip off ALL of the patient's skin? And who the hell told you to tape to the upper jaw? The tube moves with the LOWER jaw!
Dr. Couz: Um, sorry. I'll use the paper tape.
SA#2: That stuff is crap too. Use this. (SA#2 inexplicably produces a roll of seemingly identical tape from his pocket and secures the tube to the lower jaw)

Wednesday with Staff Anesthesiologist #3:
Dr. Couz secures breathing tube to patient's lower jaw with used chewing gum.
SA#3: What the hell are you doing?

You can see where this is going.

I don't entirely understand why people are motivated to go into anaesthesia. You draw up some drugs, shoot them into people, and sit around for the rest of the surgery doing a crossword puzzle and hoping to hell that nothing goes wrong. I'm amazed that more anesthesiologists aren't raving drug addicts. Three weeks of anaesthesia and I'M tempted to stick a random syringe into my vein just to keep myself awake. Sigh.

Can I do some emergency medicine now? My short attention span can't take much more of this.

Random Thought for the Day

When women come into hospital to have babies, I never cease to be amazed at how many of them have the presence of mind to engage in meticulous pubic hair grooming even when unable to see their own genitals. Not everyone, mind you, but enough that after a couple of weeks of obstetrics I asked one of the attendings if they asked their patients to shave at least partially before coming in to hospital (her answer was no, and a puzzled shake of her head-- it's okay, I'm now used to asking stupid questions).

Men, on the other hand... not so much. I spent one day in a urology OR, where it was apparently vasectomy day for men unable to have anyone handle their delicate members without general anaesthetic (can you SEE me rolling my eyes out here?). Not ONE of them even thought to trim their giant bush of pubes. Lovely. So instead, the nurse does it and they end up with a half trimmed wang.

Are men just lazy, or are women just more conscious of personal grooming?

Discuss.

Mr. Jekyll becomes Dr. Hyde

I don't think anyone will argue with the fact that a disproportionate number of physicians out there are pompous assholes. When I say disproportionate, I mean that when you compare the number of assholes per hundred physicians, it seems to be much higher than the per capita number of assholes in any other profession. Way back when, some of my medical friends discussed this topic at length. Does medicine select people with pompous tendancies, or does the pursuit of a career in medicine make us this way?

I am currently doing a month of anaesthesia. In theory, anaesthesia is an incredible learning opportunity. (Newbie note: anaesthesia is the area of medicine responsible for the patient's vital signs-- breathing, blood pressure, heart rate, etc.-- during surgery. Basically, it's the doctor who puts you to sleep.) You have an entire day of what basically amounts to one-on-one mentorship from an anaesthesia attending. You're there for every step of the patient's operative care from the pre-operative assessment to the post-anaesthetic care unit. It's a great opportunity for someone in emergency medicine to learn about pharmacology (they have all the best drugs), fluid balances and ventilation, and a great chance to learn and practice skills like intubating, starting central lines, starting IV's, lumbar punctures and other crazy things that I still can't believe they let me do on real people.

Instead, I'm hating every minute of it. Every anesthesiologist I've worked with is an ass. Instead of taking the time to teach me things, they humiliate me for not already knowing what I'm doing (in my first week, natch). On my second day, I asked the staff guy I was with why he used Sufentanyl when the guy I'd worked with the day before had used Fentanyl and here is what he told me: "I'm not here to answer your questions". I shit you not. Dude! You work in a freaking ACADEMIC CENTRE. You are employed not only by the hospital, but by the university. IT IS YOUR FREAKING JOB TO ANSWER MY QUESTIONS. What an ass.

The guy I worked with the next day was no better. He basically went about his day and completely ignored my existence. It wasn't the best room... long surgeries. This isn't as much fun for me since the only time I really do anything is during induction (putting people to sleep at the beginning of surgery). But two of the three patients needed everything for their surgery... epidural, arterial line, central line, intubation and general anaesthetic. A gold mine of procedures for a rookie... particularly one in emergency medicine who needs to become proficient in them (except epidurals... that's strictly an anaesthesia thing). But what does this guy do? He does every single thing himself, silently. Doesn't even explain what he's doing as he goes along. Here I was, trying to get close enough to see without contaminating his sterile field, and he was just going about his business like I wasn't even there.

Sometimes I hate the "culture" of medicine. The rigid hierarchy, the unfriendly rivalry between specialties (not to mention the way all specialties seem to look down on family doctors), the pompous asses that seem to be everywhere you look...

I'm hoping to God that this is just a tertiary care/academic centre thing. I'm really counting on the fact that when I get the hell out of here and start practicing in a smaller town away from the academic bullshit that this will all go away. For now, although I love my job, I'm really dreading going to work in the mornings. Sigh.