Monday, October 1, 2012
Anesthesiologists Do More By 8:00 AM Than Most People Do All Day
As I leave the house I wonder if it will be dark again before I get home. Hopefully I'll return before the kids go to bed tonight or it'll be two days that I won't see their smiling faces. I'd like to think that they miss my company but this has happened so often that I think they hardly notice anymore.
The streets are still fairly deserted when I get on my way. Other than the lone exercise fanatic or the dog walker who irritatingly changes my green stoplight to red when he pushes the crosswalk button, there are only a handful of cars sharing the lonely asphalt. The freeway is a whole different story however. It is already starting to get congested. If I leave the house ten minutes later my commute would take twenty minutes longer. Such is the traffic calculus of Los Angeles.
Pulling off the freeway I see all the same usual cars going to the same destination as me. The hospital is like a self-contained city, with hundreds of people with different responsibilities all converging to make sure it runs efficiently and on time. I recognize fellow anesthesiologists, nurses, and various hospital staff all pull into the parking lot ready to start another day.
I go straight to my assigned room to get started. I have a difficult case this morning. No time today to go to the doctors' lounge to chit chat and grab a coffee and bagels. After preparing thousands of cases over the years the basic setup is rote. Do an anesthesia machine check. Make sure there is enough inhalational agents in the vaporizers. I hate it when some fool of an anesthesiologist leaves his last case of the day without turning the vaporizer completely off and the oxygen still gassing out eight liters per minute all night. Check the suction. One of my worst weaknesses is failing to remember to have a proper suction in place. It was a problem during residency and it still dogs me to this day. So suction? Check.
I notice that the anesthesia tech has already set up the arterial and central line transducers. Thank goodness we have such great techs, always thinking ahead to what the patient will need instead of my having to ask them for it.
Now for the drugs. I draw up the induction agent, the paralytics, the antibiotics, the resuscitation drugs. Almost ten syringes in all. Then I mix a couple of bags of pressors and hang them on the IV pole. Taking one last look around I don't think I'm missing anything egregious. Glancing at the clock, it is now 6:45 AM. Time to go meet the patient.
Like an actor about to walk out onto the big stage, I take a deep breath, put on my happy face, and enter preop holding. The room is its usual morning chaos. Patient beds are lines up against the walls. Nurses, residents, medical students, and staff are all trying to talk to the same patients simultaneously. Some patients have compared the din to the aural assault in a too-hip dance club.
If the nurses aren't too busy or they're feeling extremely generous, they may put in the IV for me, or at least have the IV supplies ready. No such luck today. I go into the IV fluids cabinet and assemble my favorite bag of crystalloids, taking up precious minutes. Then I go to the IV supply cart and get the things necessary to start one: tourniquet, local anesthesia, IV catheters, alcohol pads, and tape. More minutes tick by.
Arms fully loaded, I walk over and introduce myself to the patient. In order to save time, I go over the patient's history while simultaneously starting his IV. Sure I had perused his chart the night before but surgeons' H+P's are notorious for being next to worthless when it comes to describing anything about the patient besides the chief complaint. I've been surprised by undocumented cardiac disease, adverse previous surgical experience, or even wrong site surgery on the schedule.
With just minutes to go I rush to the closest computer workstation to enter my H+P. New Joint Commission rules say the patient cannot enter the operating room before the anesthesia note has been written. I then go to the Pyxis and wait in line for my turn to get the narcotics. Luckily the surgeon is late, surprise surprise.
Finally he arrives. He says a quick greeting to the patient then asks why he isn't in the room yet. The patient gets a quick squirt of Versed, which nearly all patients appreciate, and is moved to the OR. The anesthesia tech is already waiting for us. Once the patient is on the table, the tech prepares him for an arterial line. By the time I have put on the usual standard anesthesia monitors, the patient's wrist has been prepped and draped for my a-line insertion. Luck is with me today as I feel a strong radial pulsee and put in the line on the first shot. Few things are worse than holding up the case trying to futilely find a pulse to get an a-line in.
I then walk back to the head of the bed and put the oxygen mask over the patient's face. In my most soothing voice I ask the patient to imagine himself relaxing at his favorite vacation spot as I start the induction. In seconds he is unconscious. Intubation is a cinch. I tape the tube securely along with the eyelids. I make sure the anesthesia gas has been turned on. The patient returned his twitches so I push some muscle relaxants. The tech is now preparing the neck for a central line.
A quick check of the monitor shows the patient is hemodynamically stable. An ultrasound machine is rolled towards my line of sight. To me this contraption still feels novel as I grew up when men were men and anesthesiologists could place central lines by anatomic landmarks alone. But it does make the procedure easier and with more certainty, like today.
Another brief glace at the computer screen shows the patient continues to do well. I quickly give a push of IV antibiotics before I forget. One last review of the patient. Vitals? Check. Anesthetic? Check. Twitches? Check. Fluids? Check. The surgeon calls a timeout. Yeah yeah, we all agree on the procedure. The scrub nurse then hands the surgeon his scalpel and makes the incision. Another life about to be improved at the point of a knife.