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...

Level of vocabulary to use with patients

Here's an interesting dilemma I noticed today. How do you talk with patients? Do you use complex medical jargon so that the patient is completely lost? Or do you tone it down to an eighth-grade educational level (supposedly that's the average reading level in the United States?!) so that they can understand it? On one hand, we are accused to being lost in our own ivory tower speaking techno-babble that the "commoners" don't understand - perhaps in an effort to befuddle them and make them believe that we are doing "important things". On the other hand, when we try to use simpler words some patients might feel insulted and patronized. How to choose the right balance?

A good friend of mine was just recently admitted to the hospital for an acute stroke. I won't dwell on the ethics of having someone I know as a patient, but suffice it to say that luckily, as things turned out, I never did round on him nor follow him as a patient. While fortunate from an ethical point of view, this ended up being a detriment in my later interactions with him. You see, they saw some unusual spots in his MRI and wanted to do a slew of additional tests. It didn't help matters at all that, being a very popular guy, many friends and family members were coming by at all hours visiting him. As it turned out, many different family members got only a piece of what was going on, and in the end the poor guy was confused as to what the plan was or why he was even in the hospital! He became to frustrated he ended up having to call up a friend who's another physician at the hospital to try and find out what's going on.

It was at this point that I discovered he was in the hospital, and I had only a brief conversation with him. But it was clear that he was confused as to what he was being worked up for. I managed to track down the resident and told her the issue, and she re-iterated that part of the problem was that she kept explaining things to different people.

Nevertheless, we went back to his room where I stood with the resident who outlined the entire reason for his extended stay and why we were working him up. She used all sorts of technical words and I could see that the poor guy was getting lost. So I waited until the resident left and I asked him if he had any questions. He said he understood most of what the resident said, but the thing that's really concerning for him is why did he get a stroke in the first place, being relatively young for strokes, and what's the odds that he might get another one since imaging showed a history of multiple old lacunar infarcts?

It was one of those rare moments that I felt I could actually help someone as a student - not relegated to simply observing or doing the biding of a resident/intern/attending. I explained the whole diagnostic process to him in detail - starting with the initial MRI findings which were repeated, followed by additional tests including a lumbar puncture to exclude an infectious etiology, and that the fact is we may never know the reason for his stroke. I explained that we were working him up for vasculitis or other hyper-coaguability studies, but I thought that the odds of one of those tests yielding an answer was rather low. We both acknowledged that he's been a heavy smoker (in fact, I just found out right then and there that he had quit for 3 months prior to the stroke - what injustice!) and that smoking cessation probably helped the most in preventing a recurrence more than the anti-platelet therapy they were going to start him on (Plavix).

While I told him that the answer was simply, "We don't know" and we'll likely not know - he seemed to appreciate this much more than the former complete unknown. Sometimes, I guess the fear of the unknown can be great, but understanding helps to alleviate some of the fear even if the final answer still eludes you.

In retrospect, I wonder if smoking cessation was what triggered his stroke? Could his arteries be so accustomed to the nitric oxide present in his blood that the abrupt withdrawal resulted in vasoconstriction and then a stroke? Hmm...an idea for a literature search...

When to speak up

As we were rounding this morning, the patient we saw was clearing getting quite agitated. He was suffering from an exacerbation of myasthenia gravis (MG), and to compound things he has a wife at home with muscular dystrophy. Unfortunately, as physicians, we often focus on the "important" things - items/diagnoses that will kill you. Then, we work on other more symptomatic relief. Yet this patient was not at all concerned about his muscle weakness or difficulty walking - he wanted, above all, to be able to eat! See, his MG had made it difficult for him to even swallow food, and at one point he was even choking on liquids. Despite our best intentions, he felt his concerns about not being able to eat was not being attended to - rather our focus on his over-all well being was clearly getting annoying to him. We figured that the diet could always be changed to accomodate his dysphagia, but for him - food was the main reason to live. In the end, we finally did get there - a compromise was made (no dietary restrictions given - he would choose himself which foods he thought he would be able to eat given his fluctuating severity of dysphagia), but for quite awhile as we stood in his room I felt like saying something - some to smooth the waters and try to act as an interpreter to get him to understand our perspective and vice versa. Instead, I bit my tongue. I didn't want to speak out as the attending was talking with the patient, and I also didn't want to appear to imply that the attending was not making a connection with the patient's true concerns. Sometimes, I get a feeling that they do it on purpose - they do not wish to address those concerns for a specific reason, perhaps because they feel it will steer the conversation towards a route they'd rather not explore or discuss. Othertimes, I think it's just plain mis-communication, often under the umbrella of traditional medicine. It's times like these that I have to consider - just how much of a patient advocate should I become? Do I jeopardize my own educational career to further this patient's interests? What about my own? In general, a happy patient is one who will increase your educational stature/grade/performance, but not if it comes at the cost of irritating an attending. What to do?

Multiple Sclerosis Clinic

Today we saw a number of multiple sclerosis patients in clinic today. For the most part, these were young to middle-aged patients all doing well, coping well with the relapsing/remitting nature of this chronic illness. This - despite the lack of effective treatment or therapy and lots of trials/guesswork. Amazing how strong hope lives in people - is it denial or survival? The responses sure do vary, too - from patients who remain eternally optimistic despite the worst prognosis, e.g. primary progressive MS, to those who overly focus on their deficits to the point of creating new illnesses that lives only in their minds (yet I'll bet are just as real as a true disease process).

Most of these therapies, like insulin-dependent diabetes, require daily or every other day injections. Many bring with them serious side effects. And yet, for many, these therapies, like insulin, are preventative as opposed to frankly therapeutic. They are designed to prevent recurrence of MS (or in diabetes, prevent diabetic comas). For this promise (a promise which may remain unfulfilled - a realization that most of these patients are cognizant of) - they are ready to suffer injection site soreness, flu-like illness, and frequent self injections.

Yet - why should these patients trust us? We spew out data - regurgitate studies, etc., and for the most part the patients go along with the proferred promises - is it with hope on their part, or blind faith/trust? Does it matter?

For that matter - even when told about the serious potentially fatal yet rare risks - why would one choose one drug over another, safer, drug? It's true that one is more convenient - monthly dosing versus every other day, but is that worth the small yet finite risk of certain death from an adverse reaction? The choices these patients make confuse me - I can make no sense out of them, presumably because I can't fathom their motives - be it blind faith in science, medicine, or simple hope or instinct for plain survival?