Saturday, December 8, 2012

Want To Be An Anesthesiologist? Only Perfectionists Need To Apply.

One of the toughest things about being an anesthesiologist is that we are always striving to give the perfect anesthesia. I guess you could call us the Goldilocks of the operating room. You never want to do too little or too much for the patient. If your practice deviates to either extreme, you will be doing your patients a disservice. Let me give you some examples.

First, let's take general anesthesia. It is considered one of the most important developments in the history of medicine. Yet despite over a century of use, its application can still be extremely challenging. While modern anesthesia machines are leaps ahead of the old copper kettle, it still harder to use than a toaster. It still takes years of training and experience to judge just the right level of anesthesia to give. If you allow too little anesthesia, you'll be hearing from the patient's lawyers about how the patient suffered surgical recall and remembered feeling every slice of the scalpel on her body while she was totally paralyzed. Give too much anesthesia and the patient's blood pressure could bottom out, causing a heart attack or a stroke. It is not an easy balance to maintain during the course of an operation.

How about pain control? We anesthesiologists are considered experts at relieving pain since, well, we invented the field way back when. But it is no easier now than a hundred years ago to give just the right dose of analgesics to make the patient comfortable. Every patient has a unique level of pain tolerance that no computer model can replicate. We have all experienced the anxiety of having a patient screaming in pain in the recovery room despite having been given twelve milligrams of hydromorphone in the past one hour. At the opposite extreme you might give a patient half a milligram of hydromorphone and suddenly the patient goes apneic and you're calling for the Ambu bag and a bolus of naloxone. Pain management is tricky as hell to do perfectly but that is often what is required of anesthesiologists.

Let's not forget the complex business of blood transfusions. In this age of scarce blood supplies and possible viral transmissions, it is vital that just the right amount of blood be given to a patient. We are always trying to keep the patient's hematocrit around thirty for the best combination of oxygen carrying capacity and blood viscosity. We do this even though we may be giving the patient liters of crystalloid fluids while the surgeon is losing hundreds of cc's of blood at the same time. If we transfuse too little blood the patient could die from hemorrhage or end organ failure. Give too much blood and the hospital starts questioning you on the waste of this precious resource. Transfusing blood products is not to be taken lightly.

These are just a few examples of why anesthesiologists need to be perfectionists. There is little room in this field for approximations. Unlike internists who can keep adding antihypertensives to a patient until the blood pressure is just right, we usually have only one shot at doing right by the patient. We don't have days or weeks to fine tune our treatment plan. Surprisingly we are successful more often than not. It is not often that I go home at night and worry myself sick over what I could have done differently. Of course there are always cases where I ruminate for hours on the what ifs of a particular case. But these are the exceptions, not the rule.

So if your idea of practicing medicine is to sit in the doctor's lounge, drink coffee, and munch on a Krispy Kreme while discussing patient histories with your fellow physicians for hours on end, anesthesiology is probably not for you. We like our colleague fast thinking, resolute, and faultless. Because our patients demand nothing less than that from us.

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