Sunday, June 24, 2007

a day in the life

As a follow-up to my post about how everyone in the hospital thinks everyone else is stupid (and whose small flurry of comments recreated the exact microcosm of stupid-calling that I was talking about, amusingly enough), I decided to tell you about how I spend an average day in the hospital as an anesthesia resident. I will just pick one day last week that I was on call, so you get the full 24 hour experience of it, but overall, it was a pretty typical day.

6:15am - I get to the hospital, go to the locker room, and change into my scrubs, my ugly orthotic shoes for old-lady back pain, and get my equipment bucket from my locker. I tie on my scrub cap and go downstairs to the OR where I'll be working for the day. I know I have two moderately large cases with the oral/maxillofacial surgeons, plus whatever other emergencies they float my way.

6:30am - Setting up my room. I am significantly less spazzy at this now, two years later, than I was back when I was a new CA-1. Basically, I think of administering anesthesia in the OR as running an ICU with just one patient, and as such, I want to make sure before the patient is in the room that everything is ready or at least available for an ICU level of care. I do my machine check, make sure my ventilator is working well with no circuit leaks and that my gas cannisters are full; check my backup O2 cannister in case there's some sort of oxygen pipeline explosion in the hospital and I need to use my reserves; set up all my standard monitoring; and draw up all my drugs and resucitation meds for the case. Knowing that I am going to be doing two midface reconstructions today, I run to the supply room to get a few extra things that I need that were not available in my room--in particular, a special tube that I know we will be using for the nasal intubation that I have planned. I notice that there is no arterial line setup in my room either (possibly purloined from my room last night for an emergency case), so I hurriedly make one up.

7:00am - I go out to the preop area and talk to my patient. We go through his medical history and then talk about the kind of anesthesia I'm planning to administer, along with the risks involved. Not that it's terribly risky, mind you, given a young healthy patient, but risk is never zero, and we talk about some of those issues. I pull aside the surgery team and ask them about their approach and my plan for intubation. The patient is also having some nasal surgery done at the same time as his midface reconstruction, but the surgeons tell me that their approach will be infralabial (through the mucosal surface of the upper lip) so my plan to nasally intubate will be fine. ("Are you sure they don't want to do it transvaginally?" my attending joked.) I fine tune my setup, check with the nursing staff in the room, and when the entire team is ready, I bring the patient in.

7:25am - The patient is on the table and we're ready to induce. My attending comes in and introduces himself, we induce general anesthesia, and we intubate. As I'm securing the tube, the surgical attending compliments my facility with the nasal intubation, saying I did it "perfectly." Perhaps this is some kind of Stockholm Syndrome, but for some reason, the fact that the surgery team is actually valuing my work makes me really happy, even more so than the fact that my own attending told me I did a good job. There's usually this undercurrent of antagonism between surgery and anesthesia and after a few months you start developing a thick skin.

9:00am - The patient has been fully prepped and the surgery has begun. This type of facial surgery can be extremely bloody, so in order to minimize blood loss, we often deliberately run patients at a lower blood pressure than normal. I set up my sodium nitroprusside drip for this purpose and get that going.

9:30am - My attending comes into the room and relieves me for a 15-minute break. I know this is some huge source of sniping between the surgical residents and the anesthesia residents, the fact that we get breaks from the OR whereas they do not. I really don't know what to say to that, except that I'm glad that I get a chance to go to the bathroom and grab a quick snack, and it does help me to stay more focused and vigilant during the case, which is the name of the game. I happen to think that anesthesia as a field is very collegial, and that there's something very civilized about getting residents out for lunch and to the bathroom. We work hard, but we're treated like people, you know? I quickly run to the bathroom and eat a Pop Tart. (Not at the same time, though.)

10:00am - The case is still proceeding, the blood pressure is where I want it, and I start to plan my wakeup. I want my patient to wake up relatively quickly after the surgery is finished, but calm, not thrashing, and ideally reasonably lucid, since his jaw is going to be wired shut and I want him to be able to breathe without getting panicky. I decided before the case that I wanted to have him breathe off the gas and run him on a nitrous-narcotic technique, so I start titrating in some morphine and begin adjusting my gas flows. I also start getting my setup ready for the next case, pretty much similar to what I did before the first case in the morning.

11:00am - The surgeons are putting their final stitches in, and I'm getting ready to "land the plane," as I always think of the process of emergence. There is much flipping of dials and pushing of buttons, and I give my reversal agent and suction out the patient's stomach. I give my full arsenal of antiemetics, since, with a wired jaw, I really don't want this patient to be nauseated and puking in the recovery room. I've titrated in some morphine for post-op pain, and I've gotten the patient back breathing. The drapes are finally down, and I call his name once. He opens his eyes, follows commands instantly. The tube comes out, and we're off to the recovery room. I ask him if he's in pain, and he shakes his head no. "That was gorgeous!" I say to no one in particular.

12:30am - The whole song and dance again, and now I'm in the room with my second patient of the day. Only I think I may be being punished for how well things went with the last case, because I'm having a lot of trouble getting my tube in this time. The patient has midface hypoplasia, and her crowded anatomy is giving us problems. After some struggling, we end up calling for the fiberoptic scope and intubating nasally with that. Thank goodness for my calm, experienced attending, because while we were never in true emergency mode (we had a good mask airway, and if push came to shove, we always could have intubated orally, though that would have precluded being able to do the surgery) I was kind of sweating.

2:00pm - My attending gets me out for a lunch break. I catch him up on how the case is going, and run out to scarf a sandwich.

5:30pm - The case is wrapping up, and I'm planning my extubation again. I worry about the nasal trauma we may have caused with our intubation attempts, but luckily the surgeons decide not to wire the jaws shut on this case, so that's something, at least. It's a smooth wake-up, and after making sure she's stable and comfortable, I wheel the patient to recovery. I fill out a "difficult intubation" form letter for the family (it's basically something for their medical record to appraise future anesthesiologists for furture surgeries about airway problems encountered), but I want to explain to the family exactly what the letter is about. I give the PACU nurse my pager number and ask her to page me when the family comes by.

6:00pm - Since I'm on call overnight, I go relieve another resident from her case. It's an ortho case done under general, pretty straightforward, and I watch the ortho residents (one of whom is my friend Guillem) complete the case and close over the next hour. I extubate without incident and wheel the patient to the PACU, where she complains of a lot of pain, despite getting some hefty doses of narcotic. I check the chart and note that the patient has a history of drug abuse and chronic pain, so I tell the nurse and change her post-op orders around to cover her higher drug requirement. I ask the ortho team if they would like me to write her for a PCA, which can often be a blessing for these pain patients (and for their caretakers), but they don't want one. Oh well, I offered.

7:00pm - In the PACU, I see my Team Captain (TC, the third-year resident on call), who tells me that there's a liver transplant scheduled for that night, send time at 3:00am, cut time at 4:00am. I ask the OR desk which room the transplant is going into, and start gathering the equipment that I need. In the middle of this, I get paged to the PACU, and head over to talk with my last patient's family. The patient looks a little swollen, but gives me the thumbs up when I ask her how she's feeling.

8:00pm - After grabbing a quick bite, I relieve one of my junior residents so that she can eat. We are having burritos tonight, a treat from our overnight attending. I take care of her patient in the meantime, who is having a revision of an A-V fistula.

9:00pm - I get paged that our TC is down in cath lab and needs some help. I run down there and see that they have called us to administer anesthesia for a stat cardioversion for a patient in A-fib. The patient looks like he has a terrible airway, and is so fat that he looks almost completely spherical lying on the table. I run upstairs to get the fiberoptic scope so that we can have it on standby. I manage the airway while my TC pushes the meds, and luckily it all goes without incident. My TC tells me that there's another patient going for emergency cardiac surgery tonight, but that the cardiac call team isn't in house yet. Would I mind helping to get that case going?

9:30pm - I am setting up the room for the cardiac case, which, of course, is completely trashed from the case before. I have the machine set up and I am just loading the drips when the cardiac call resident gets in from home. I stay a while to help and make sure she has everything she needs, and then go back to my other OR to finish setting up for the liver transplant.

11:00pm - I've finished setting up for the liver. Except for the cardiac case, all the other rooms are done, and all the residents on the call team have gotten a chance to eat. I pre-op my liver patient, make sure that the liver attending has been updated, and jog over to my call room to catch a quick nap, setting my pager to wake me up at 2:30am.

2:45am - I'm back in the ORs, giving my room a final look and talking to my transplant patient. She is very jaundiced, but otherwise seems reasonably healthy and in good spirits. We say goodbye to the family and head on back to the OR.

3:45am - The patient is induced and we have her all lined up (meaning one large peripheral IV, two A-lines, a double lumen CVL and a Swan). As the surgeons start, we draw off a baseline set of labs and start checking all our blood products, 10 units of PRBCs and 10 units of FFP. For patient safety, these must all be checked and double checked by two physicians before being given, and then triple-checked right before we actually hang the bag. The patient is a little coagulopathic, so I give her two units of FFP through the rapid-infuser fluid warmer as the surgeons are dissecting. To attempt to minimize bleeding, I also try to run the patient a little on the dry side until we get closer to cross-clamp.

5:30am - The patient is stable, running on some low-dose pressors, but otherwise doing beautifully. My attending comes by to give me a break. I get a drink of water, check my e-mail, and quickly do some other things.

7:15am - I am now officially post-call, and after giving signout, I am relieved by another resident. I go to the locker room, change, and start walking towards the subway, excited because it seems like a pretty nice day out, and I plan to take Cal out to the park. Hooray for the Bell Commission.

The reason I decided to tell you about my day was not because of the comments or general misconception that anesthesiologists basically get paid to sit around and do nothing. OK, so maybe that was partially the motivation, but I really just wanted to underscore one thing. We are all medical professionals, and whatever our role is in the patient's care (anesthesia, surgery, medicine, nursing, what have you), in the end, it's not really about us and our pride. It's about the patient. I really don't mean to sound Pollyanna-ish in saying that, but there's no other way to really state it plainly. It's not about us. We all have the same goal, and that is to take care of our patients well and get them home safely and to feel at the end of the day that we did the best job we could.

I wrote in the past how a neurosurgery resident accused anesthesiologists of "having no ego," and while part of me bristled a little when he said it (though I 100% agree that I had less ego than he), part of me thinks, damn right. I don't want to have ego when I'm working. I mean, not that I want people walking all over me, but the point is that it's not about me. It's about the patient. And since we're all supposedly working with the same goal, why are we fighting all the time? Push out the jive, bring in the love.

(But make no mistake, talk smack about me to my face and I will cut you.)