Reflection on Anesthesiology

Well, today was my last day on the Anesthesiology rotation. Overall, I'd say I had a good time and learned quite a bit, actually. However, the rapidity with which we switch attendings makes the residents and attendings hesitant to let us really perform any procedures, I think, except for simple ones like starting IV lines versus intubation. The more invasive procedures, or at least those with greater risk of harm to the patient (in this case, their teeth), the less comfortable they are with students unless they know them well. If they could somehow improve the continuity between attendings and/or residents, then we might get more opportunities to perform more procedures. Then again, is it really all that necessary for me to learn how to perform intubations? While I'd agree it's an useful skill, potentially life-saving, without proper equipment and frequent practice, I suspect it's more of a liability than aid not unlike instrument flight where while you can certainly become certificated and legal to fly in instrument conditions, lack of experience often kills as pilots fail to recognize their own limitations.

Healthcare (again)

Today I saw my first coronary artery bypass graft surgery. I have to admit - it was very interesting, seeing the beating heart, etc. However, the circumstances surrounding his surgery highlight a lot of the tough questions that I believe lie ahead for healthcare reform. Here is an elderly gentleman, 80+ years old, with multiple medical conditions, depressed including a history of recent attempted suicide, who had a massive heart attack and found to have severe coronary artery disease. Due to an unusual reaction with a common medication used to prevent clots from forming, the patient required special drugs during and after the surgery. These medications costs upwards of $8,000 per vial, and multiple vials had to be used. The patient was also at great risk of bleeding out from the surgery, and his risk of dying right on the operating table was relatively high. The total cost of this marathon 7+ hour surgery will probably be in excess of $200,000. All this for an elderly gentleman who didn't want to live in the first place?!

I'm not advocating that we let people who attempt suicide to die (or to "finish them off"), but if we are to advocate for "healthcare for all", we must be ready to draw the line somewhere. Drawing the line is easy when we don't know the person - most would probably agree that this surgery might represent one of the "horrors" of American Medicare/Medicaid system, but to those who knew this man - who cherished his presence while he was awake and alive, would probably strongly disagree. So who draws the line, and when?

Compensation

Why is it that so many physicians I now meet talk about reimbursement rates, poor salary/pay, etc.? The talk almost always centers about the disparity between what they do and how they are compensated. It bores me to hear such talk - mostly because I care little about it. Work should be what I enjoy - and if I'm paid to do it, so much the better! But how much am I paid, I care not - so long as I'm able to survive. And by survive I don't mean a large house, fancy cars, etc. I'm earning a stipend now of $25,000 per year before taxes, and I'm still able to save $16,000 over the past 10 years. I'm not poverty stricken - I'm living well, having gone through flight school and financed the purchase of many computers and computer-related hardware (I tend to upgrade nearly annually). So my point of view is rather simple - anything more than $25,000 per year is simply icing on the cake. Put in that perspective, I can get just about any job - even working at a fast food restaurant, and I'd be paid sufficiently.

What really bothers me about all this talk, however, is clearly how hypocritical so many physicians are. On one hand, they all claim that they enjoy this job no matter how poorly they are paid. But then on the very next breath they go ahead and complain about the pay! If they really didn't care, then it wouldn't be an issue, would it?

What's my role?

There we were - 45 minutes into the procedure, multiple puncture sites in her large back, and still no success. A large, obese lady (BMI>40) just came out of surgery and was in pain. Acute pain service, my rotation for the day, was called to evaluate and possibly place an epidural catheter to deliver analgesics and narcotics into her spinal area directly. Due to her large size, we had to try multiple times and use ultrasound guidance but none of it was working. The poor lady was in pain, but worse of all was the nurse on the other side of the patient. For the procedure, it's best if the patient is leaning forward, sitting up on bed with her leg hanging off the side. As this patient was still a little dopey due to pain medications, she needed help in staying upright. The nurse practionner on the acute pain service was helping position the patient and this included holding her shoulders and propping the patient up - in essence having the patient lean against her. Remember - this is a large, 300 pound lady resting against a small, short, nurse who can't weigh more than 120 pounds. I could clearly see that she was struggling, and I was not alone. Another nurse asked if she needed help, and she said no the first time. I was observing the whole procedure on the opposite side of the patient.

Normally, I would offer to help - and believe me, the thought came across many a time while we stood there for the 45 minutes (which became closer to an hour). I was torn - on one hand I felt awful having the poor nurse prop up this beheomoth, yet on the other hand I wanted to observe the procedure and see how they handled this difficult case. It struck me then - my role was to learn, not help. We later called a clinical assistant who came over and helped. All this time while I was on the floors I tried to be helpful, do something productive. I never minded the "scut" routines. Yet in doing this I've clearly interferred with my learning opportunities. This particular example was simply an exaggeration where I had to choose between helping or learning. In the end, I chose to learn and stayed put. I was uncomfortable with my decision, but ultimately, I think I made the right choice.

Am I ready?

As the fourth year of medicine comes to a close, I cannot help but feel woefully unprepared for the practice of medicine. A lab mate tripped and fell on the escalators. At first I pretty much ignored his injuries - the mechanism of the fall didn't sound serious at all. The other first year medical student in our lab started to do all sorts of things to the wound. Finally I spoke up and suggested that they use gauze as opposed to bandages being a much more efficient manner to cover a large area without too much adhesive (perhaps the most painful component of small cuts/bruises). It was at this point that I noticed his cut appeared rather deep. It looked like a 3-4cm long laceration about 5mm deep with separated edges about 5-7mm apart when he flexed his knees along the patellar region. I thought stitches might help close up the wound and help it heal faster. I accompanied my friend down to the emergency room - tried to "fast track" him but was turned down and had to go through the entire registration process. Finally we arrived back where we started and the resident came in to examine the wound. He took a look at it, manipulated it somewhat, and then said there's nothing to stitch, all the needed was a bandage and he's done. I felt like an idiot - here I am, 4th year, about to graduate, and I cannot distinguish between a serious wound and one that merely needs a dressing?! I think I was mislead by the appearance of the wound, and that further manipulation would have (hopefully) suggested to me the same course of action - bandage and leave it alone. Nevertheless, it does make me wonder whether or not I have what it takes to become a true practicing physician.

Anesthesiologists

Spent my day at the chronic pain center where patients with debilitating, chronic pain are treated. Many of these patients are clearly suffering - they arrive at the clinic only after "failing" standard medical therapy for the most part. There are always the sob stories of patients who get bounced from doc to doc with their pain complaints ignored or untrusted, only to finally get vindication when the doctors at the pain clinic find something, diagnose them, and treat them with pain medications.

The problem is, pain is not visible, palpable, nor detectable by any person other than the one feeling pain. The feeling/perception of pain itself is not really all that well understood. Yet, the pain medications do work at blocking pain reception/perception. So it's not really all that surprising to find a story of a patient who suffers from intractable pain that nobody can really confirm, find some sort of radiological or physical exam abnormality that appears to explain the source of the pain, and then treat them with pain medications with relief. Truth be told - the findings could be completely incidental and not the true cause of pain. By now my attitude on chronic pain clinic is probably apparent - I'm not a believer.

The experience in the clinic did not change my opinion on chronic pain management but did alter my perception of anesthesiologists. I know that the statistics show that they are frequently abusing drugs, especially narcotics. It has often been blamed on their knowledge of medications, side-effects, and what I'm going to call hubris in believing that they themselves know how to administer the medication safely to avoid addiction/withdrawal. My observation of their behavior, however, suggests another far more human reason why they are more likely to become drug seekers/abusers.

As anesthesiologists in chronic pain management, they encounter people suffering from tremendous pain all day long - pain that again is invisible. It's hard to imagine someone else's pain, and more often than not we tend to over- or under-estimate the severity. The gratitude that comes with relief when a patient receives a pain-blocking medication is rather clear and obvious, however, despite again a lack of objective measurement. I believe these encounters result in the development of extremely low tolerance of pain/discomfort for these anesthesiologists. While on one hand this is extremely beneficial for the patients, and these doctors will appear compassionate and caring, it's a disaster for the physician himself. The low pain/discomfort threshold makes these doctors turn to pain-blocking procedures/medications and often perform it on themselves also with relief. It's then only a matter of time before they become psychologically, if not physically, addicted to pain-blocking medications as the most human instinct takes over - avoid pain.

I don't think this will ever change - and I believe this to be an occupational hazard, not a self-selection of drug-seeking/abusing people into the field/specialty of anesthesiology.

Medical education

I guess as students as will, inevitably, have to practice at some point. In the OR, while the patient is under anesthesia, it is remarkably easy to practice without causing undue pain to the patient. This is not to endorse senseless extraneous procedures on an anesthetized patient, but students must learn somehow. I guess I'm trying to rationalize my experience today in the OR. It all began innocently enough, with a very nice attending who went on to demonstrate and then permit me to practice insertion of a peripheral IV and then a laryngeal mask airway. These went rather well, although my initial attempts at mask ventilation was a bit difficult. Hopefully the patient didn't become hypoxic during my "practice session".

Then, we had a patient who required endotracheal intubation. An elderly, frail lady who also required large bore peripheral IVs. Mask ventilation went much easier with her, although there was some air leaking at some point. The trouble began when I attempted to insert the large bore IV. I had trouble, and then the anesthesiologist also had trouble. In the end we ended up poking quite a few times at the patient. While it's not entirely my fault, I feel that my presence is what started the whole thing. The anesthesiologist, trying to be nice and teach, also felt tremendous pressure to perform while the surgeon rushed ahead with the surgery. The delays incurred in trying to teach me as well as permit me to practice left the anesthesiologist behind the curve, so to speak. As a result of the pressure, the patient had to endure additional pokes - thankfully all under anesthesia, but I'm sure when she awakes and sees all the bruises my lesson will have cost quite a pretty penny (figuratively speaking, of course).

Consent

Heard an interesting comment today while on my first day in Anesthesia rotation. A few residents were just sitting around chatting, and got to discussing Spanish-speaking patients. In general, they tended to prefer them despite the language barrier because the residents felt that the Spanish-speaking patients were usually more relaxed and more compliant compared to American patients whom they felt were extremely anxious, in general. That got me thinking - is it that the Spanish-speaking patients are simply more trusting of physicians in general, or is it that they are simply more relaxed? I think it might be cultural - perhaps in European culture the notion that the physician knows best still remains. Here, in the United States, expectations have become so high that short of a perfect outcome, patients demand some sort of retribution/compensation, usually through a legal recourse. Perhaps the American patients are more knowledgeable, more read-up via the Internet, but then many will probably also scare themselves into imagining the worst possible diagnoses much as medical students often do. What's better - a well informed albeit potentially arrogant/litigious/anxiety-prone patient or a relaxed, compliant yet naive/ignorant patient?

Patient autonomy

If a patient has been declared to be unable to make medicine decisions for himself, and thus is not consentable - what happens if the patient has occasional periods of lucidity? We were assisting in the lumbar puncture of a rather severely demented elderly patient, yet at times I thought his words made some sense. The procedure was rather lengthy due to the presence of large, venous stasis ulcers on his legs making it difficult to turn and position him. At first he was cooperative but clearly not quite understanding what we were about to do. When we finally began with the local anesthetic, he started to complain and wanted us to stop.

Should we stop? It sounds like a reasonable request - in fact, if he had been any other patient who had been deemed competent we would have been forced to stop. But I guess since it was also rather clear he didn't really understand the rationale and the need for the procedure, it would be unethical to listen to him and stop since that's not really an informed decision, is it?

Yet, it seems rather incongruous, to say the least, when he has some semblance of rationality, to completely disregard his demands. We tried to make him more comfortable, including keeping him informed as to the progress, but it was a slow output tap and collecting those 4 tubes took much longer than I had anticipated (note to self - never say, "almost done" to the patient - it just makes them much more anxious). In the meantime, the patient had began to threaten us verbally - saying he's calling the police and will "see [us] in court!". Wow - the first time I've ever been threatened by a lawsuit!

I've dealt with patients with dementia/delirum before, and it was rather easy - you kind of just ignore they non-sensical babble or talk along with them but not really listening to the content. In Winthrop, I've had many an alcoholic hepatic encephalopathic patient who had to be strapped down to the bed, but they were, for the most part, benign. They would obviously request that the restraints be removed, but that decision was not mine to make so that made interactions with them so much the easier.

Being an active participant, however, in this invasive procedure, made matters rather different/difficult. I'm now personally, actively, restraining the patient, in a way (more for his own safety given that he's got a nice sized needle sticking out his back) despite his protests. It's uncomfortable, and goes against the doctrines of medicine: Primum, non nocere (First, do no harm).

Harm whom? Clearly, the patient. By whose standards? Ah - that's the tricky part, no? Is the decision made by the omnipotent/omniscent physcians? As a collaborative agreement between the patient and the doctor? Or, in this case, between the healthcare proxy and the physcians? Where then does the patient fit into all this?

I guess one would argue that as the patient had, previously in his right mind, appointed a healthcare proxy for situations just like this, he is represented virtually through the proxy. Yet how often is it that the health care proxy is a close loved one of the patient? Don't you see a conflict of interest there?! Just look at the past cases involving persistent vegetative state patients and the conflicting interests of familys/spouses/etc.

Perhaps it's time to re-examine the idea of a health care proxy...or perhaps it's time to educate the public that sometimes, choosing your own spouse/close family as a proxy isn't the best idea...