Tuesday, July 12, 2005
  What's Good May be Bad??
Link to Yahoo! News story

I came across this story today on the news and all I could think is 'well, duh...' It seems people expect medicine to be perfect and science to be infallible all the time. Maybe they don't remember their high school science classes - everyone used to think the world was flat and that if one could jump high enough, she could reach the stars. Of course, this is giving the general public a very large compliment by assuming they actually made it to high school in the first place.

Science is fallible. We just finished what is probably the most scientifically prolific century the world has ever seen, and still what we know about mother nature is infinitesimal when compared to what we do not know. As we uncover new truths, we may find that what we currently believe is flawed and must be put aside. Medicine is no different, as it is interwoven intimately with scientific discovery. The more we learn about the human 'machine,' the more we find out there is to learn. That is why evidence based medicine has become so popular - for thousands of years, we have been practicing medicine by guessing at what might work and noticing the beneficial side-effects of other treatments (minoxidil for hair growth, for example). Finally, we are putting these treatments to rigorous scientific tests and finding that many of them are not effective at all; some, in fact, may be harmful.
Monday, July 11, 2005
  First Thoughts on Anesthesiology
Well, 4th year has begun - at long last, and I'm toiling away in the OR for 10-12 hours a day in anesthesiology. Needless to say, this is not the schedule I expected for a 4th year rotation. I am learning a lot, however.

Before beginning this rotation, I thought anesthesia was all about the ABC's (throwing back to my old BLS days): Airway, Book, Chair. :) However, I have now learned everything is slightly more complicated than I once assumed.

The hospital at which I am currently working is a rather large county hospital. There are between 40 and 60 surgical cases every day. They break these cases up by type (General, ENT, Ortho, Vascular, etc) and assign them rooms (or sometimes 2 - 3 rooms, depending on the case load). The Operating Suite has 12 ORs, each of which is pretty much slammed all day. Each of the ORs has a CRNA (certified registered nurse anesthetist) working the anesthesia. An anesthesiologist is responsible for supervising 4 rooms (and, ergo, 4 CRNAs). This means that there are 3 anesthesiologists "watching" 12 surgeries at any given time. Impossible, yes. In addition, the anesthesiologist is supposed to be present for every induction (putting the patient "to sleep," so to speak - but not like you put a dog "to sleep") - theoretically, anyway.

What usually happens is the patient is seen in pre-op by the anesthesiologist and the CRNA (and the circulating nurse, and the pre-op nurse, and everyone else in the hospital it seems) and the pre-op checklist is run. This consists of making sure the correct consents are signed, allergies are confirmed, NPO status is checked, the patient's medical issues are re-hashed again to make sure noone missed anything, and finally the options for anesthesia and the risks associated are discussed and an anesthesia plan is formulated. An IV is placed by the pre-op nurse, any pre-operative antibiotics are administered and, when the OR is prepped, the patient is taken back to the OR for their surgery.

What exactly is anesthesiology, you ask? Anesthesiology is the medical specialty of inducing unconsciousness for the purpose of performing surgery. With this goes a few "A's:"

1. Anesthesia - meaning medically induced unconsciousness (or sedation, depending on the procedure)
2. Analgesia - meaning relief from or prevention of the perception of pain
3. Amnesia - meaning prevention of memory
4. Anxiolysis - meaning relief and prevention of anxiety
5. Paralysis - while not an "A," it still falls within the purview of anesthesiology.

Why are these things necessary? Because cutting open your body really freaking hurts, and pain (current, future or past) causes anxiety, which negatively affects your health and mental state. Also, trying to accurately remove an organ while a patient is writhing on the table is hard, which makes surgeons grumpy(er) and we like to make things easy for ourselves (and our surgeons, so they don't bitch at us...) :)

So, now that we know what is anesthesiology (which, by the way, is another one of the fields that use the "ae" in their name if you let them): the medical specialty where you get to put lots of people to sleep before their surgery, we can talk about what actually happens. As I "said" earlier, after all the pre-op hooplah is finished, you are carted off to the OR for surgery. I didn't, however, tell you that as you leave pre-op, you are pre-medicated with an IV benzodiazepine (versed [midazolam] at this hospital). Why? Well, #3 and 4 above. Benzodiazepines are wonderfully known for their anxiolytic properties. They are also used for their sedative and amnestic properties. Noone wants to remember their surgery, so a little IV versed before you get there, and you don't remember ever leaving pre-op until you finally wake up later that night. An IV injection of 1-2mg of versed will provide 2-4 hours of anterograde (meaning forward) amnesia. In other words, we give you this medication, and you don't remember anything that happens for the next 2-4 hours. Pretty sweet, huh? We could have cut all your guts out, paraded around the room, played limbo with them, and replaced them, and you would never know... but we would never do that - or would we???

So, now that you are all relaxed and sleepy, we take you to the OR, move you to the cold surgical table (they keep ORs between 62 and 67 degrees fahrenheit), hook you up to a bunch of monitors (EKG, SpO2, NIBP), place you on an oxygen mask, and finish the induction (remember, we started in pre-op with versed). After you are in the OR, we generally begin with a little lidocaine (a local anesthetic) to numb your veins (some of the other medications sting a little) and to blunt some of the cardiovascular effects of the medications. Next will come Diprivan [propofol] which is a nice little general anesthetic - this knocks you out. This is generally where you fall "asleep." Some anesthetists may have you count backwards from 10-7 (actually 10 to 1, but noone ever seems to make it past 7...). Next will come a muscle relaxant (neuromuscular blocker [NMB], to be exact). The one used depends on both your medical conditions/health and the surgical procedure. If you will need to be paralyzed for an extended period of time, we'll use a NMB with a longer half-life. After you are anesthetized and paralyzed, we use a laryngoscope to visualize your laryngeal inlet and vocal cords, then we pass an endotracheal (ET) tube through them, into your trachea (breathing tube), and connect you to a machine which will make you breathe during surgery. Finally, we secure the ET tube, pass a different tube into your stomach to suck the fluid out of there and we start you breathing an anesthetic gas so you will stay unconscious and paralyzed.

Wow.. that is a lot of stuff for us to be doing to you. This is not even counting the surgical procedure. So, finally the surgical team can begin. We will position you as needed to and you will be prepared for the surgery. The surgeons will come in and do whatever it is they need to do. All the while, we are making sure you are unconscious and pain-free. We make sure you are breathing appropriately and that you are kept warm and safe. Anesthetists and anesthesiologists are really your friends. They protect you from the horrible memories you would have of the surgery and we make sure you are pain-free during the surgery and also afterwards in the recovery room. See what nice people they are?

So, why do I like this rotation? Well, my first day, I had intubated my first patient within 10 minutes of arriving in the Operating suite. Pretty cool. Intubating rocks!! The people are fun to work with (mostly), and I can watch surgery if I want to without all the bother of scrubbing in and actually having to do anything. Besides, I get to sit down - something I never got to do on my surgical rotation :) Also, surgeons are completely clueless about what we are doing on this side of the drapes, so there is usually a slight look of awe when they ask us to do something. Anesthesiology is the only specialty that has power over surgeons - without anesthesia, there is no surgery :] hehehehe!!

Why do I not like this rotation? The beginning of a case is really cool (the induction), as is the end (the emergence), but the middle is really pretty boring. It's fiddling with knobs, IVs and tubes to keep you quiet and happy. Unfortunately, the middle is usually the longest part of the surgery - sometimes in excess of 6 hours. Yuck. Fortunately for me, I always have someone to talk to, since I am always accompanied by a CRNA. Also, the surgeons are just across the drape if I get really desperate for someone to talk to. Another bad thing about this rotation is having to put up with surgeons' bad attitudes - but even that isn't so bad; see above paragraph.

So, have I found a specialty to pull me away from Emergency Medicine? No. However, the tools I'm learning will be useful in my future career - sedations occur frequently in the ED, and there is always someone asking to be intubated (If GCS is less than 8, or this person you have begun to hate, then you must intubate - just kidding). Ventilation skillz are always needed in the ED, and I'm getting lots of practice bagging patients - opening airways and managing masks with one hand while ventilating them with a BVM (or, in this case, the ventilator bag). Breathing is good.

Skills upon which I still need to work:

1. Difficult airways - obese patients, irradiated patients, trauma/emergency patients
2. Nasal intubation
3. Regional/spinal/epidural anesthesia - I haven't done any of these. I want to spend a week or so in L&D practicing epidurals, but I don't know (yet) how to set this up. I think I just need to ask the anesthesiologist in charge. I'll find out tomorrow.
4. Get more comfortable with managing the anesthetic. Need to learn more about the meds/gases used. Also need to be more comfortable with the routine in the OR. That comes with time, and everyone has said I'm doing much better than I should be at this stage. Actually, I had someone try to talk me into anesthesia today. I told them I appreciate the compliment, but no thanks. It's just all that stuff in the middle that I can't handle.

So, like I said before, it's all just a little more complicated than "airway, book, chair," but no too much :)
Ahhhhh.. 4th year. If the rumours are true, this will be a cake walk. Herein is my online account of my 4th year of medical school - follow with me to see if the hype is true or lie.

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