Violent patients in the OR

This blog article in the LA Times about violence against ER nurses reminded me of the times that violent patients have come into the operating room. I've had some swings and misses against me. Most of the time the patients were agitated because they were under the influence of drugs or alcohol. But one particular incident is still vivid in my memory.

I think I was in my second year of practice after residency. A patient was transferred from the psychiatric hospital next door to ours for emergency surgery. When he came he would not allow anybody to touch him. Of course he had no IV. Any attempts to touch him produced loud screaming and yelling and violent flailing against his restraints. His disruptive behavior caused great anxiety to the other patients in preop holding to the point we had to move him into another room that normally wasn't used for patient care. Naturally I was the one who had to put in the IV as the preop nurse said she couldn't do it. Even with several people holding him down it was impossible to hold him steady to start the intravenous. Everybody stood around looking at me for directions.

So I made the decision to mask him down. We wheeled him into the OR. No monitors could be placed on him. Again using several strong men we held him down tightly. I cranked up the Sevo and nitrous and slapped that mask on his face as tight as I could. Once his motions slowed down, the circulating nurse placed the monitors on him. I had her hold the mask while I went around and started the IV, just like how they trained us for pediatric inductions. Once started, I intubated the patient and the case started. I was afraid of how he would act in postop. But surprisingly he did very well. No more screaming or punching. Go figure.

Afterwards I asked a senior partner what I could have done differently. He said casually he would have given him IM succinylcholine with intubating supplies on hand. I asked wouldn't that be very traumatic as the patient would be fully aware of his intubation? His reply was that it didn't matter as long as it got the job done. This is an anesthesiologist know for his swagger and doing a lot of complicated cases. Others later on said I should have given IM ketamine. That sounded more reasonable but any IM injections in this patient would have been terrifying. So now I've learned another lesson. Some things they just don't teach in medical school and residency.

Medical Blog Surfing

I'm sitting here on call, with nothing going on, so I decided to explore the world of medical blogs. I am new to blogging so it is fascinating to see all the conversations that are out there. First of all, there are LOTS of medical blogs. After reading for a few hours, it seems like there is a preponderence of blogs by surgeons and emergency physicians. There are surprisingly few blogs by anesthesiologists. Is that in keeping with the OR dictum that anesthesiologists are best seen and not heard? Or is it surgeons just enjoy bloviating, like in the OR?

Medical blogging seems to be a temporary hobby for physicians. Looking at the archives, many blogs start exuberantly, logging dozens of entries in the beginning. Then it tapers off. After a few months (or years for the tenacious), the entries dwindle. It gets to the point where new subjects are written only every few months. And there is a distressing number of blog links that have broken. Not going to happen to me. No Sir. There are exceptions of course. Some of the more astonishing examples I've found include the Dr. Wes blog. He is a cardiologist/cardiac electrophysiologist who logs in dozens of entries a month and hundreds per year. Impressive. There is also the Happy Hospitalist. There are already almost 1000 entries for this year alone.

The subject of most blogs is predictable; they are about what they know--medicine. There are case reports, discussions about the latest health care debates, complaints about medical inefficiencies. Some talk about their favorite hobbies, like photography or music. Many are made by physicians in the armed forces, active or retired. One in particular caught my eye: White Coat's Call Room. It is a blog composed of several emergency physicians. One of the docs details the agony of a malpractice trial he suffered through a few years ago. It is a multi-part series and goes into great detail about all the aspects of the trial, including the psychological exhaustion it caused. Great stuff.

I've found the best way to find these blogs is to look at blog links on established and well-read blogs. Some that I've used liberally for this include Anesthesioboist, Surgeonsblog, and Aggravated DocSurg. But this is by no means comprehensive. I couldn't possibly read all the hundreds of medical blogs out there. But as a way to pass the time, to me it is more interesting and thought provoking than watching another YouTube video.

Murder by propofol

The outlook for propofol just became more tenuous. Today the news agencies are saying that Michael Jackson's personal physician, Dr. Conrad Murray, is being investigated for possibly injecting the propofol that killed the singer, manslaughter by propofol. Propofol was found in the closet of the doctor's bedroom in the house, along with IV supplies. MJ had needle tracks in his arm and even in his neck (which partially explains why he was always covered up, even in broad daylight). And the toxicology studies reportedly show propofol in his system.

In the April 2009 issue of Anesthesia & Analgesia, there is an article about possibly the first murder by propofol ever recorded (here is the abstract). It details how an SICU nurse in Florida took propofol from the hospital and gave a lethal injection to his female friend. He not so carefully took the empty bottles of propofol out to the garbage then flew overseas. The coroners found the needle stick in the antecubital fossa and the police traced the propofol bottles to the hospital where this nurse worked. At this hospital the propofol had to be checked out, which is how the police tracked down the nurse as the culprit. He is eventually extradited and sentenced to life without parole.

At this rate, the DEA will soon be making propofol a controlled substance, just like narcotics, benzos and the new fospropofol that was just approved. In the case of the Florida murder, controlling the dispensation of propofol proved the link between the killer and the murder. At the end of that article, it lists several case reports of nurses and physicians dying from overdosing on propofol. They also cite a study saying 18% of anesthesiology residencies in the United States have found evidence of propofol abuse. In a ten year stretch, 25 abusers were reported and seven died (28%). In all these cases, the dispensing of propofol was not controlled. Even with this, the authors still insist locking up propofol will be detrimental to the practice of anesthesia. While I agree with them that making propofol a controlled substance will substantially hinder our practice, I think the DEA will be under enormous pressure to make propofol less accessible. And as always, anesthesiologists will just have to be creative and work with the new rules as best as we can. Remember pentathol was a controlled substance too.

All quiet on the OR front

Everybody likes to work with the Mellow Surgeon, the Thoughtful Surgeon, and especially the Funny Surgeon. But in every hospital, there is the Angry Surgeon, the one that makes working in the OR that day a long and thankless task. The day begins with its usual buzz of activities--the anesthesiologist drawing up his meds, the scrub nurse counting the instruments. But under this calm, there is a quiet sense of foreboding. The circulating nurse is just a bit more careful to make sure everything on the surgeon's case card is in the room. The anesthesiologist arrives just a bit earlier to make sure everything is ready to go on time, interviewing the patient, starting the IV. And then the wait.

Usually the Angry Surgeon is also the Tardy Surgeon. Though he'll blow his top if anybody delays his case, he thinks nothing of arriving thirty minutes late for his scheduled case. Once he arrives, everybody jumps to attention. He inquires loudly why his cases are always late starting, as if he is innocent of the situation. The OR team quickly moves the patient into the operating room. The patient is quickly induced, the nurse gowns up the impatient surgeon, and the case begins. With other surgeons, the OR can be a happy and fun place to work. Jokes fly across the room. Gossip is exchanged. Current events about sports or politics are discussed. But with the Angry Surgeon, the room is deathly quiet. People talk only when necessary. The iPod is kept off.

And soon enough, as surely as the sun rises in the east, something displeases the Angry Surgeon. The scrub nurse, who keeps track of hundreds of pieces of equipment, is unable to find a particular instrument. The case cannot proceed without that vital tool, yells the Angry Surgeon. He demands to talk to the OR supervisor, who is called into the room. He tries to defuse the situation, looking vainly into the instrument tray for the missing piece. The only other tray for this kind of case is dirty and unavailable. The surgeon demands that an incident report be made out and ready for him to sign by the end of the case. Even without that crucial instrument, the Angry Surgeon improvises and moves on. Now his fuse has been lit. The cautery is not working properly. The OR lights are not to his liking. In the old days, surgeons used to throw instruments in this situation, but luckily generational changes and stricter OR conduct rules have made that nasty habit a thing of the past, mostly. As the case proceeds, the scrub nurse seems unfamiliar with this particular case. The Angry Surgeon gets impatient. The nurse says she is new to this procedure. Of course the OR supervisor gets called in again. The Angry Surgeon wants to know who scheduled a scrub nurse not familiar with this case to work with him. He wants to talk to the Nursing Supervisor and the Hospital Administrator at the end of the case. And he wants a second incident report written up and ready for him to sign. The case continues as planned, despite the missing vital instrument and the rookie nurse.

Cases never go smoothly for the Angry Surgeon. At the end of the case, a needle is missing. As people scramble to find the missing needle, a call is made to take an X-ray of the patient to make sure the needle is not inside the patient. The Angry Surgeon is livid that this is delaying the finish of his case. He insists the needle couldn't possibly be inside the patient. He decries the mindless hospital policy of taking X-rays even if he KNOWS the foreign body is not within the patient. Fortunately, the needle is soon found and no X-ray is needed. The case finishes, the patient is extubated and wheeled to the PACU. The Angry Surgeon perfunctorily thanks everybody in the OR and leaves. Everybody relaxes and the iPod gets turned back on. Time to prepare for the next case.

Anesthesia in space

With all the talk about significant events in space recently, I thought I'd look into some of the research into space medicine and anesthesia. There is a large body of work studying surgery in a zero gravity environment. As human space flight lasts into months and years duration, inevitably a traumatic event will occur and surgery will have to be performed in outer space to resuscitate the patient.

I didn't know this, but surgery has been performed in space on animals. If you do a Google search, you will see a list of interesting journal articles. Did you know bleeding isn't really a big problem in zero gravity surgeries? The high surface tension of blood keeps them clumped to the surface of the wound. Only arterial bleeding can cause drops of blood to float away from the body. So just like earth-bound surgeries, avoid arterial bleeding. Laparoscopy apparently isn't a problem in space either. It was feared that bowel and other organs would float inside the abdominal cavity, obscuring the surgeon's view. Apparently the mesentery keeps everything tethered down so laparoscopy can be performed.

But what about anesthesia specific research? Our number one priority in anesthesia, airway management, has been extensively researched. Most of the studies involve mannequins in a parabolic flight pattern that yields about 23 seconds of weightlessness, more than enough time to intubate a patient. Bag masking a patient is not a problem. A study comparing intubating with an endotracheal tube vs. a combitube showed a slight increase in speed with the combitube, but this was performed by non-anesthesiologists. But the most interesting aspect about intubating a patient in weightlessness is shown in this picture. The anesthesiologist would hold the patient's head between the knees so that the patient doesn't float away during laryngoscopy. I would think this will limit the number of anethesiologists who can work in outer space; flexibility is not a trait among many anesthesiologists I know. I better go to the gym to work on my thigh adductors if I want to work in space.

Anesthesiologists are scientists too

What an amazing week this has been for science, and astronomy in particular. First we celebrated the 40th anniversary of the first manned lunar landing. Then there was the longest solar eclipse of this century over India and China yesterday. And late in the day was the amazing discovery by Australian amateur astronomer Anthony Wesley of a collision between Jupiter and a large space object, likely a comet or asteroid, producing a big black spot in the atmosphere.

What does all this have to do with anesthesiology? Well, we anesthesiologists are scientists too. We are not just "gasmen", "tube passers", or just "anesthesia". (That is one of my personal pet peeves, to be addressed as "are you anesthesia?" Anesthesia is a sensory state, not a profession or title. You never hear a nurse or resident ask a surgeon "are you the blade?" or "are you the skin cutter?") We all studied very hard in the sciences to get to where we are. And I bet most of us loved science as kids. You would not mistaken anesthesiology nerds for the jock orthopedic surgeons whose arms are the size of their heads.

I grew up watching all the science shows: Nova, Nature, Wild Kingdom. I saw every episode of Carl Sagan's "Cosmos" twice. I was so engaged and infatuated by that show that my best friend thought I was in the cult of Carl Sagan. I'll never forget the first time I looked at Saturn through a friend's telescope. The rings were even more spectacular than any of the books that I had read. It wasn't until much later that I bought my own telescope. And boy is it a good one, a Meade 8" Schmidt-Cassegrain. It weighs about 50 pounds in its case and that doesn't include the stand or the wedge. And everything was controlled manually, not like today's fancy computer guided scopes.

But as our jobs and lives get more hectic, the opportunity to indulge in our passions becomes more remote. That precious telescope has been stowed in the closet for years now. Last time I took it out was to watch Earth's close encounter with Mars a few years ago. Some of the neighborhood kids came out to watch. They were in awe of the Martian ice cap and the green and red blotches on the surface (alas no canals). I like to think that I instilled the love of science into at least a few of them. And in a few years, when my own children are older, I can share with them the joys of science and discovery that I made all those years ago.

Nitrous oxide, a new addiction

Today the LA Times documents another new addictive substance making the rounds, nitrous oxide. Apparently kids can buy nitrous in little cannisters called "whippets" from any convenience store or even an ice cream truck for as little as 50 cents each. They then go get high between classes. Some have died from what they term sudden sniffing death syndrome. Nitrous is more popular among middle schoolers than marijuana or cocaine and is popular at teen parties. Sounds like the nitrous parties people used to have in the 19th century.

The article shows a picture of the products that contain nitrous that kids are sniffing, such as cans of WD 40 and Reddi Wip. I must be getting old but how the hell do you sniff WD 40 or Reddi Wip? Wouldn't you just get oil or whipped cream in your nose? As far as the whippets go, the article says it is used to make whipped cream. First of all, why would a convenience store sell nitrous for making whipped cream. Sounds like it should be sold in a specialty food or kitchen store. And after watching countless hours of the Food Channel, even I know that you don't need nitrous oxide to make whipped cream. All you need to do is beat whipping cream with a beater for about three minutes and voila! you have whipped cream. Where does the nitrous come in?

So now there is legislation in California to prohibit sale of nitrous to anyone under 18 and make it illegal to possess nitrous unless for use in medical procedures. Sounds reasonable except they can't ban the sale of air fresheners and oven cleaners, which is what teens are sniffing to get their high. This again points out the limitations of legislating lifestyle choices. The government can only do so much to change behavior. Ultimately it is up to the child, his parents, the community to set the proper example. As HRC said, it takes a village to raise a child. If the child is not properly supervised and morally confused no amount of legislation can change his behavior.

Stress of being an anesthesiologist

I published a link below to a wonderful post by the Anesthesioboist blog. It accurately describes the pressure anesthesiologists go through during the day. So many people, and doctors, think anesthesiologists just sit around and read the Wall Street Journal every day. But when a bad situation arises in our field, it is always a life and death event. An adverse outcome in anesthesia usually means the patient has died, has been trached, or has aspirated. It's never as simple as "doctor, my mom has trouble sleeping at night. Can you give her something for that?" Bravo to the Anesthesioboist for saving the patient in a difficult situation. We can hope that all anesthesiologists we work with are as skilled as her.

Notes of an Anesthesioboist: You Know It's Bad When...

Notes of an Anesthesioboist: You Know It's Bad When...

Rationing health care, not an original idea.

Right after I posted my last blog, giving my opinion on the health care debate and the need for rationing in the future, I happened to read in the New York Times a terrific editorial about the very same topic. It was published two days ago but I swear I had no idea it was there until I had posted on my blog.

The editorial by Peter Singer, a professor of bioethics at Princeton University, gives some very pointed arguments about how we must quantify the value of life in order to properly ration health care and bring down its costs. For instance, what is the value of 10 years of life as a quadriplegic versus for a nonquad? Five years? Six years? So is the life of a quadriplegic worth only half the life of a nonquadriplegic? Would a person with quadriplegia agree? Another good example is if you had a life threatening illness how much would you spend for a treatment that extends your life by six months? Would you pay the same amount for a stranger with the same disease to extend his life for six months? Terrific stuff. It's a long article but well worth the effort.

Another administration, another health care debate

Some of you reader(s?) may have wondered why I haven't mentioned anything about the health care debate raging in Congress right now. First of all, it is hard to debate a health bill that changes every day. As soon as you argue one point, the language of the bill changes and the argument is moot, a lot of wasted hot air. Then there is my conflicted opinions about what I want from all this. My doctor brain wants to have universal care, to make sure everybody in this country has health insurance. My taxpayer brain wants to limit how much money I want to spend for other people's health care, especially people who have abused their bodies with alcohol or drugs or people who just refuse to buy insurance just to save money, like people who don't buy car insurance.

And this is where the debate usually bogs down. We want universal health care, which everybody is for. But we don't want to acknowledge that the price will be astronomical. So now we need price controls, which is where the lobbyists take over to protect their turf. It would be much easier to pass into law if we can say we want universal health care and screw the costs or control health care inflation but screw the people.

We can have a socialist system like the Europeans. But nobody seems to want to face the fact that they face far higher tax rates and they don't seem to mind health care rationing. Can anyone imagine telling an American that their 89 year old Alzheimer's grandmother is not allowed to have state paid dialysis three times a week, ICU bed with full code status, while under ventilatory support? They would trot out a 60 Minutes reporter and some media hired gun ethicist to say how cruel this system is to the most vulnerable. Rationing will never work in this country but that is where we are headed.

There are so many facets to this debate and each and every side has a valid point. So somebody will get screwed if and when this passes (most likely doctors and hospitals. No unions, no clout). I will talk more on this subject in the future.

Regulate doctors, not propofol

Today we hear the DEA is considering making propofol a controlled substance, with the same level of scrutiny of distribution as narcs and benzos. Though Michael Jackson's toxicology reports have not been made public, everybody is concentrating on propofol as the culprit. I have a better idea. Why don't we regulate and punish these unethical doctors that led to this tragedy in the first place.

Propofol is a wondrous drug, revolutionizing the practice of surgery and anesthesia with its ease of administration, predictable efficacy, and rapid emergence. Many outpatient surgical procedures would not be possible, or would be more difficult, if it were not for propofol being widely available. Patients wake up quickly after propofol anesthesia, with very little side effects. This property of propofol allows the patients to recover quickly, letting them go home sooner. This lets surgery centers operate more efficiently and lower their costs. They can schedule more cases each day instead of waiting around for a recovery room full of patients to wake up.

If propofol becomes a controlled substance, the process of acquiring and using it becomes more cumbersome, slowing efficiency. Sure we would still have access to propofol, just like we can use morphine and versed now. But having to account for every drop of propofol that is used on a patient, like we do for morphine and versed, will inevitably slow down the operating room. When a vial of narcotics is not accounted for, the whole operating room practically shuts down until it is found. Yes propofol can have addictive properties. But deaths from propofol addiction are very rare. Alcohol kills thousands more people each year than propofol. Alcohol is also a mind altering substance but you don't see the government locking up all the beer in this country.

Instead we should be concentrating on getting rid of these doctors that are giving medicine a bad name. Where do celebrities find these "physicians"? MJ's personal doctor reportedly isn't even board certified in Internal Medicine or Cardiology. Was he the one who brought the propofol into the house? Who was the anesthesiologist that was reportedly travelling with MJ in the 1990's on his concert tour? MJ was supposedly getting propofol every night to help him sleep.Who referred Anna Nicole Smith to her doctors. What about Heath Ledger, or Elvis? Celebrities or their handlers always seem to be able to find these doctors that have no ethical fiber in their being. These so called doctors, if found to have contributed to the deaths of their patients by overprescribing or abusing medications, should be prosecuted to the maximum extent of the law. As a board certified anesthesiologist, I hate to say medicine needs more regulations. But we need to put the fear of God, or the DA's office, into all physicians to help prevent any more wasted lives.

Anesthesia whores

I'm sitting here looking at my schedule tomorrow. It consists of three short cases scheduled to end by 10:00 AM. And I'm thinking to myself, I can't make my house payments or save for my children's college funds with schedules like this. We anesthesiologists are such whores. Follow me here.

Unless the anesthesiologist works as an employee in a university hospital setting or is employed by an HMO, we are all pretty much fee for service. Get my drift? And just like the world's oldest profession, we are at the beck and call of another person (the surgeon). If the surgeon has no cases that day, then we have no work either. If we arrive late for a case, the surgeon immediately demands another anesthesiologist, as we are all pretty much used the same way by him, just another faceless warm body hired to do the task at hand. If the surgeon is late, well we just have to sit around and wait. If we're lucky and the surgeon likes the "job" we do for him, we might be asked to become his private anesthesiologist, his exclusive.

I've seen some of these anesthesiologists that work in surgery centers for their surgeons. They pretty much kiss ass all the time. They learn to tell frat jokes to amuse their surgeon (surgeons like that). If the surgeon wants to start a case at 6:00 AM, well by gosh the anesthesiologist will be there too, even earlier, no matter if the next case is not until 1:00 PM. These anesthesiologists know who is writing their checks and unless the anesthesiologist owns the surgery center, he is going to pucker up until the day he retires.

Unfortunately that is just the nature of our profession. We anesthesiologists are completely dependent on another physician for our well being (pain doctors being an exception but they don't consider themselves anesthesiologists). I can't think of another specialty where there is this strange one way dependency. Radiologists and pathologists are employees of the medical center and everybody has to use them, whether you like them or not. Emergency physicians take care of whoever walks in through the door. Surgeons and internists rely on each other for referrals, but that doesn't necessarily mean they think highly of each other. We've all seen bad surgeons and internists and they still get referrals all the time. But we accommodate our surgeons in the hope we will get more work, and more income, from them. We can be whoever they want us to be. And that, my friends, is a whore.

St. Michael Jackson, savior of anesthesia

How many of you have noticed, like I have, that there is a sudden great interest in anesthesia and propofol since the untimely death of Michael Jackson (RIP MJ)? Some have referred to it as Michael's drug or Michael's milk. I get questions everyday from doctors and patients about how propofol works and how it can kill you. All these questions can be dismissed as a ghoulish interest in anesthesia, just like when Steve Irwin (the Crocodile Hunter) was killed by a stingray and all of a sudden everybody wanted to know about stingrays.

But as I mention on my website www.greatzs.com, any and all questions patients and colleagues have should be welcomed by us. We are no longer just the doctors who push drugs to make patients fall asleep. People have realized that we are dealing with something that is potentially DANGEROUS (no pun intended). A patient can actually die from what we give them. And that feeling is very empowering. I feel like I've achieved a level of respect from my patients that I've never had before. They look at us now as medical professionals, trained in the use of dangerous substances for the good of mankind. So here's to you, St. Michael Jackson, the savior of anesthesia.

Case starting. Time to fire up the laptop.

We tell our medical students, residents, spouses, children how intellectually stimulating and wonderful anesthesiology is. But let's not kid ourselves; practicing anesthesia can be mind-numbingly boring at times. Granted, when it's boring it usually means the patient is doing well. I certainly wouldn't want to work everyday having to constantly stress about whether my patient is about to code on the OR table.

But I've walked into my colleagues' rooms and half the time (most of the time?) they are either reading their Wall Street Journal, surfing the internet on the laptop, or talking on the phone. It's no wonder surgeons do not see us as their medical equals. I saw this acronym from a medical student forum on what anesthesiologists do in the OR.

A--Airway
B--Book
C--Coffee
D--Doughnut
E--Eat
F--Funnies (read)
G--Go
H--Home

This unfortunately is how our behavior is noticed by the future generations of physicians. We then complain about our long hours and difficult working environments, which only sounds whiny to your internist or surgical friends. They are juggling an inpatient census of 20, office full of patients, pages from the floor and ICU nurses, and calls from the ER. The caricature of anesthesiologists is so bad that people believe it. One time I was watching my patient's monitor during a case. Though the patient was doing well, the surgeon kept looking over the drapes at me. I asked him if anything was wrong. He said he was worried because he rarely sees the anesthesiologist pay that much attention to the patient. He thought the patient was doing poorly based on my attention. He usually sees the anesthesiologist checking their email or reading a travel magazine.

I hate to admit it, but the temptation to do something else besides watching your patient is great. Today, I had two loooong cases. Both cases involved healthy patients with minimal bleeding or cardiovascular disturbances. At that point, it's hard not to nod off without doing something else, like surfing my laptop. Is that a crime? Is it better to have half the attention of an alert anesthesiologist than to have an anesthesiologist fall asleep (intermittently)? What's your best idea for staying alert in the OR without eating, drinking, surfing, talking on phone, texting, reading... Do we sabotage our image as medical professionals when we do this in the OR in front of the surgical and nursing staff?

We Changed Domain Name!

If you got here from a Google search, we have changed our domain name. Before, it was www.blogzs.greatzs.com. NOW it is www.blog.greatzs.com. Easier to type and remember. Please bookmark and link to this page if you want to keep reading this blog. Thank you.

What did I get myself into?

My wife took the kids to see the grandparents this summer so I have a lot of free time on my hands for once. I thought I would go to the gym again, catch up on a bunch of movies I've been meaning to see, go out with some friends, yada yada yada. But instead my life has been consumed by the creation of this blog and website http://www.greatzs.com/. I used to wonder why anybody would want a blog. What could make his life so interesting that he thinks other people want to read about it? But now this blog and site have taken over all my time. I'm constantly thinking about what I want to put into these sites next.

I've wanted to start an anesthesia directory like http://www.greatzs.com/ for a long time. I figure that I've seen a lot of crappy anesthesia related web sites and I can do much better. Boy, is this hard work. I am a complete newbie at this. At first I had to get a domain name and find a web host (don't even think I knew what those terms meant before this whole episode). Unfortunately I'm not as orginal as http://www.anesthesioboist.blogspot.com/ and I'm too late to get an obvious name like http://www.theanesthesiablog.com/. After going through dozens of domain name suggestions from Yahoo, I thought I found a great one. Great Z's.com. Get it? Anesthesia? Z's? I jumped on it when I thought of it and found it was available. Now I'm wondering what was I thinking? I should have done a better background check. Who knew that Graetz is such a common name? I certainly have never met anyone named Graetz. Plus greatzs.com is hard to pronounce and type. Those of you who know how to type can understand the difficulty of typing zs. However you can type greatzs with one hand only. So now I'm stuck with this name and will have to do the best with it that I can. After all the work I put into it I don't want to change it. I hope it grows on me, and you, over time.

After a few weeks of this I've now gone knee deep into the world of Adsense, Adword, HTML, XML, JaveScript, Sitemap, sitemap (there is a difference), external links, internal links, back links, PageRank, etc... Bought one of the Dummies books to help me understand all this. Looking at Google's help forums is intimidating. They can be quite arrogant and seem to assume that everyone knows how to insert a robot.txt file into your root directory. Can somebody explain this to me in English please?

There have been moments of triumph. The day Google found my site was pure elation. I've finally got my own property on the web. Then last week Yahoo actually ranked my site for "anesthesia education". I'm number 47, ahead of about 11,600,000 other people! We're moving on up (moving on up). To the sky! Unfortunately Bing hasn't found me yet. Poor Microsoft. When will they ever give up on this search thing.

I've read that every new site gets placed in a Google sandbox, where it sits for a few months until Google figures out it is a legit site. I'm hoping that's why it hasn't come back around to see all the great improvements I've made since it first found my site. In a way this is good because it gives me time to work on it before anybody (hello, anybody here?) sees it. I've also seen a lot of doctor sites not get updated for months or even years. I guess they just keep paying their webhosts every year with their credit cards and not realize it. When the wife and kids get home, I hope I can still reserve some time for this. It is kind of fun. I used to love working on computers in high school and college. Had the original IBM PC with two 5 1/4" floppy drives, upgraded memory to 512K and installed a 10 mb hard drive into one of its slots. Add color monitor and color printer and the whole thing cost my dad $5000. That was real money back then. You could buy a car for that much money then. When I think back, I'm amazed my dad gave in to my whining and pleading. No wonder my brother says I was so spoiled. Now I don't know the difference between MySpace and FaceBook. Twitter vs. RSS.

So I guess in a way this is kind of reliving my childhood. I'm having fun on the computer again, like my old geek self. I'm creating original work and not just doing the same intubate, extubate, intubate, extubate every day. I feel like I've found a purpose this summer, not just vegging in front of the TV like usual. I sincerely hope I can continue this enthusiasm when the family gets back.

When is casual too casual?

Here it is, 3:00 AM and I'm on call at the hospital. I can never sleep here, even on a light night like now. Something about sleeping on a sofa that is not very comfortable. So I guess I'll write a little blog instead.

Earlier this evening, the surgeon booked a case for an I+D of an abscess to start at 8:00 PM. This was not because we were so busy we couldn't get him in earlier. In fact the OR was dead and we were all sitting around waiting for him to show up. When he did, it was immediately clear why he wanted to do this case at this hour, right after sunset. He showed up in a hawaiian shirt and beach shorts under his white lab coat. His messy hair looked like it had just been blown by the ocean breezes. I was quite astonished by his lack of decorum coming into the hospital. True I was a bit jealous that he could be out at the beach all day while I had to stay inside the hospital. But really. Such a lack of professional attire, even if it is on a holiday weekend. It doesn't matter that the surgeon is very pleasant to work with. I wouldn't allow myself to present in that way in front of a patient. But I guess I've always been a bit uptight about my manner of dress, aside from the fact that I wear scrubs nearly every single day.

I once read in a journal that anesthesiologists would get more respect from their patients if they showed up in better attire, instead of schlepping in and out of the hospital every day in scrubs. After all, the internists and (most) surgeons see their patients on the floor in a shirt and tie under their white lab coats while only techs and nurses and residents wore scrubs. It made sense to me so I tried wearing a shirt and tie to work every day for a few months. It certainly got everybody's attention. I was the best dressed anesthesiologist in the department. But it quickly became impractical. First of all, only the first patient of the day saw me in my nice outfit. After that I was not going to put my tie back on just to interview the next patient on the OR schedule. Then all these studies came out saying how dirty and disgusting ties were in hospitals. In fact they're banned in England because of the risk of spreading bacterial infection from one patient to the next. They also don't allow long sleeves; nothing below the elbow. So after awhile I stopped wearing nice clothes to work. Sure lowered my clothing and cleaning bills.

Case Report #1

Last week, I had a 50ish year old male patient who had been in the hospital a few weeks for a liver transplant. He came into the operating room for another procedure. I gave a general anesthetic and the patient was put into a prone position for the procedure. When the procedure was finished, I gave a cocktail of neostigmine and glycopyrrolate to reverse his muscle relaxant. When he woke up, he complained of extreme pressure pain in both eyes. He said he felt like his eyeballs were going to explode. My first reaction was could this be corneal abrasion, as this has happened before in the prone position. But the patient denied any scratchy sensation and had no photophobia or redness. Plus the pain affected both eyes, which is very rare for corneal abrasions. I then asked if the patient had glaucoma. He said he does and was being treated by his ophthalmologist with eyedrops. His ophthalmologist said the pressure in his eyes were high but well controlled with the drops. But since he had been in the hospital, he had not gotten his eye medications. Luckily, the effects of the glycopyrrolate soon wore off and we treated his pain with narcotics.

Whether you're a patient or a physician, my question to you is have you ever seen or experienced this kind of reaction? Yes the textbooks say anticholingergics can cause increased intraocular pressure in narrow angle glaucoma. But after giving thousands of anesthetics with probably hundreds of patients with glaucoma, this is the first time I've seen this reaction. I would think that the combination of neo and glyco would balance each other out to prevent increased IOP.

Could anything have been done differently? His history of glaucoma was not mentioned in the H+P and I didn't bother asking about eye history (c'mon you're kidding yourself if you say you ask all your patients about their eye history every time because that is part of the complete medical workup). If I had known the consequences, next time I would only give succinylcholine to allow intubation then maintain his anesthesia with propofol infusion and volatile gases. Or maybe I wouln't intubate at all next time and just keep the patient very deeply sedated, though this can be tricky in the prone position and his recent transplant operation. This particular procedure did not require the patient to be paralyzed, but if he was having abdominal surgery, I would have to warn the patient he may be on the ventilator after the surgery is finished until his muscle relaxants wear off without reversal. In case you're wondering, he did not receive reversal of his paralytics after his transplant because he was sent immediately postop to the ICU intubated. All helpful thoughts and insights welcome.

Anesthesia, The Great American Contribution To Medicine

On this Independence Day, let's celebrate the great American contribution to the world of medicine: anesthesia. While most medical students are familiar with the names of Michael DeBakey, Denton Cooley, and William Halsted, all great surgeons, how many know the names of William Morton, Virginia Apgar, Ralph Waters, and Arthur Guedel. For the moment, we won't dicuss the great works of the British citizen John Snow, considered by many to be the first anesthesiologist.

William Morton (1819-1868) was a dentist who first successfully demonstrated the use of anesthesia to the public. It is claimed he got the idea from another dentist, Horace Wells. Wells' demonstration in 1845, which Morton witnessed, of a tooth extraction with nitrous oxide failed as the patient screamed in pain. On a Friday, October 16, 1846, Morton applied an ether anesthetic to patient Edward Abbott at the Massachusetts General Hospital so that the patient could have a lesion removed from his neck. Later, Abbott reported that he was aware of the surgery but felt no pain. Thus the term anesthesia, or lack of sensation, was invented by Oliver Wendell Holmes, Sr. who was sitting in the audience.

Virginia Apgar (1909-1974) was an anesthesiologist who invented the Apgar score, a universal method of assessing a newborn baby's health. Measured at one minute and five minutes after birth, it accurately measures the likelihood the baby will need specialized supportive care.

Ralph Waters (1883-1979) is considered one of the founding fathers of academic anesthesiology. He was the first person to hold an academic position in anesthesia, at the University of Wisconsin, Madison medical school. There he helped develop the rigorous training methods of American residency training, including the Morbidity and Mortality conference. This is where physicians discuss their mistakes in patient management so that other physicians can learn from them. Waters later became the first president of the American Society of Anesthesiology in 1945.

Arthur Guedel (1883-1956) invented the cuffed endotracheal tube. This allowed the patient to be placed on a positive pressure ventilator if the patient has repiratory failure or is under anesthesia. Guedel experimented with different types of endotracheal tubes on animal tracheas he received from a local butcher. Later he demonstrated the effectiveness of tracheal intubation on his dog Airway. He would anesthetize Airway then intubate and submerge him in a tank of water. Thus Guedel demonstrated the ability to ventilate and apply anesthesia to the animal.

This is just a short list of great American contributions to anesthesia. We haven't even discussed other distinguished names like Ronald Miller, Lucien Morris, and Humphry Davy. So today, while you're enjoying your day off with friends and family, and toasting America's day of independence, think about the great American inventions that have changed the world, including anesthesia.

Propofol Addiction

Michael Jackson, and celebrities in general, provide endless material for discussions about narcotic and prescription drug abuse. The recent revelation about propofol being found in MJ's house is different. First of all, propofol is not a drug you can find at your local pharmacy. It is supposed to be used only for general or monitored anesthesia by an anesthesiologist or nurse anesthetist. It comes only in an intravenous form. So unless MJ was adept at sticking needles in himself like a heroin addict he would need help giving it to himself. Propofol also has a very short half life; it disappears from the body quickly. That is why it is usually given as a steady infusion in the operating room to maintain anesthesia or as a bolus to induce anesthesia quickly before giving a more sustained drug, like inhalational anesthetics.

Somebody asked me yesterday whether it was possible MJ overdosed on propofol. I suppose anything is possible. But according to the coroner's report that's been released so far, there was no evidence of needle tracks on his body, which would be required to inject propofol. The toxicology reports are still pending but according to the ASA, if MJ used propofol, it will show up in the toxicology tests. If Dr. Conrad Murray, the cardiologist who found MJ's body, was giving him propofol which led to his cardiac arrest, he would have to be extraordinarily quick hiding the evidence, what with all the syringes, needles, and drugs he would have to stash before the police got there.

The questions remain. Why was propofol found inside the house that MJ was renting? Did it belong to him or to the owners of the house? Why was it even inside a private residence? Who brought it there? Was it stolen from a hospital or surgery center by a physician or nurse? When did MJ last use propofol, as he seemed to have a familiarity with its sedative effects.

So many questions still left unanswered. In the meantime, his public funeral was announced this morning. Look for another media circus in L.A. next Tuesday.

For more information about propofol and propofol addiction, visit http://www.greatzs.com/.