Thursday, July 30, 2009

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.

Wednesday, July 29, 2009

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.

Monday, July 27, 2009

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.

Saturday, July 25, 2009

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.

Wednesday, July 22, 2009

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.

Sunday, July 19, 2009

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.

Saturday, July 18, 2009

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...

Friday, July 17, 2009

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.