Monday, December 21, 2009
The Slow-Mo Game
We are in the middle of a procedure when the OR phone rings. The nurse on the other end says they are ready for the surgeon to come assist in their room. The surgeon promptly announces that he is needed for assistance in the other room and he will be back to finish his line up in an hour or so. WTF! How inconsiderate to the OR staff for the surgeon to schedule himself in two rooms at the same time without letting anybody know. I was beyond pissed. This called for the Slow-Mo Game.
In the Slow-Mo Game, the idea is to slow down the OR proceedings as much as possible without being obvious about delaying the case. Because if there is one thing surgeons hate, it is to sit around the OR lounge with nothing to do, wondering when he can get his case started. This is a very passive-aggressive maneuver. I only do it to surgeons I don't like. And you can't do it often or you'll get a reputation for being a "slow" anesthesiologist. But it gives me some level of personal satisfaction when I see the aggravation it causes the surgeon.
When the surgeon returns from the other room, he immediately wants to get his next case started. Normally I would have seen the patient already but in this case I announce I'll go preop the patient now. This is where Slow-Mo works the best. If there is one thing you can't be faulted on, it is taking your time to conduct a thorough history on a patient. The time between a patient and his physician is sacred. No one, not even the surgeon will dare to intervene in your interview. I introduce myself to the patient and start my exam. Does she speak English? Damn, she does. Can't slow down the preop to wait for a translator. I review the chart page by page. Consent? Check. H+P? Check. Labs? Check. EKG? Oh, oh. The EKG is over 6 months old. Call for another EKG stat.
Now let's go over the review of systems. Remember the H+P's you used to take as a medical student, the ones that took about two hours to perform? You can do something similar here. Any CP, SOB? What's your exercise tolerance? Uh huh. Any productive cough, fevers, chills? Abdominal pain? Rectal bleeding? Melena? N/V? How about PONV? What has worked for you in the past for PONV? Allergies? What reactions do get with these meds? And please be specific. This can go on and on. Out of the corner of my eye I can see the surgeon starting to pace.
Now let's do the physical exam. PERRLA? Jaundice? Open your mouth and say aaah. Any dentures or loose teeth? Filling? Where. Oh back there? It's not loose or will fall out right? No neck rigidity? Flex and rotate your neck for me. Any neck pain or stiffness? Good. Let's listen to your heart. Hmm. You have a slight murmur. Has anybody every talked to you about it? Yes? Did you see a cardiologist? Yes? And? No intervention necessary? Did you ever get an echo or stress test? Yes? Do you know the results? No but the doctor said everything was okay? Now let's listen to the lungs. Listen to all four quadrants. Front and back. Big breath in and out. Good. Abdominal exam. No pain. No masses. Extremities without edema? Any radiculopathy, neuropathy, or weakness? Good. Good.
It is time to start the IV. I need to go to the IV cart to assemble my IV bag. Walk slowly to the IV cart. Put together the line. Come back and exam for arm veins. Ooh, you've got small veins. Have you been a difficult stick in the past? Yes? Okay we'll give it our best shot. You know it doesn't help that you're dehydrated because you've been NPO all day. Tourniquet up. Pat pat pat. No, let's try here. Pat pat pat. Don't actually stick the needle in the patient multiple times to Slow-Mo because that is cruel and unfair to the patient. Get the IV on the first shot. Thank you doctor, that was great. I didn't feel a thing. That's what I'm trained to do ma'am. Now let's go over the anesthesia consent. Explain in great detail what will happen under anesthesia. Don't forget to discuss ALL the potential complications. That's informed consent right? But reassure the patient that the chance of a serious complication with anesthesia is miniscule.
By now this could be going on for 20 to 30 minutes. The surgeon is tearing his hair out. Don't push your luck too much. If you think you can get away with it, finish writing up your H+P before letting the nurse bring the patient into the room. Once in the room take your time putting on the monitors. Do a lot of chit chat with the patient while doing this. Once the monitors are in place, start drawing up your drugs. I normally draw up the drugs between cases but in the Slow-Mo game I draw it up now. Can't be accused of delaying a case by drawing up my anesthetics, right? Now do a nice gentle slow induction. Don't want any sudden adverse changes in the vitals now, do we? The surgeon at this point is ready to pour on the skin prep by himself. Tube the patient in your usual competent way, sit back, and watch the surgeon's frustration in silent amusement.
There you have it. The Slow-Mo Game. Use it sparingly and you will get great satisfaction out of annoying the hell out of the inconsiderate surgeon.