shiny new scutmonkey: patient allergy stratification

I don't even remember when the last time it was that I made a new comic (I suspect it was right before I submitted the manuscript for my book to the publisher,* so that would put me in the last few weeks of residency, roughly a lifetime ago), and I don't want to make a big thing about this, because the comics...are really pretty stupid. But anyway, here's a new one.

The comics really do take a lot of work, which is probably why I haven't made a new one in just about a decade. There's the sketching and the penciling and the inking and the erasing and the scanning and the cleaning up and the titles and cropping. To think, I used to go through this entire process every single weekend for three years when I was in college and the cartoonist for the Wellesley News. This makes me realize that back then, when I thought I was busy, and had so little free time? I had nothing but time. Kids...don't know stuff.

Anyway, it's many years later now, and I am old, and semi-responsible, so I feel the need as an attending to say: Allergies are real, and can be serious. Listen to your patients. Use common sense, but respect the histories they are giving you.

However, sometimes funny things are funny. Maybe this comic is one of those things. And maybe now you understand why I was on that fine point mechanical pencil bender.

And here, so you don't hurt your eyes (we're all a decade older now, aren't we?), I have it panel by panel.

Happy trails.

* My editor ultimately decided not to include the comics with the book, which...look. At the time, I was a little disappointed, because I'd worked hard on them. But even at the time, I knew it was absolutely the right call. Strong work, Emily Griffin.

one flew over

So we had this bird nest in our garage. Our nanny first noticed it a few weeks ago, high up on a shelf something like eight, nine feet up, propped on a shelf against a corner, atop of a pack of Costco bulk terry cloth towels. We've had a broken window in the garage for...I don't know, probably going on a year now (don't judge), and I suppose it was only natural that at some point, a bird might find its way indoors and make itself at home.

"What kind of bird?" a few people at work asked me when I brought it up, but I couldn't really say, since I never actually saw anyone in the nest. For all I knew, the nest could have been there for months, and I just never noticed it sitting there, high above my head.

However, the nest apparently did have an inhabitant, and around Mother's Day, she let us know.

This also gave me a slightly more specific answer to the "What kind of bird?" question, because at least now I could say, "The kind of bird that lays eggs that look like that." 

The consensus in the anesthesia lounge, both from the build of the nest and the speckling on the eggs, was that these were Carolina wrens. There were five little eggs tucked in there, the size of those Cadbury chocolate eggs with the candy shells sold around Easter (they're what M&Ms should ideally be, in my opinion--better chocolate, thicker shell), and while it certainly made me somewhat monstrous for thinking of this mother bird's clutch of eggs in terms of snack food, I'm sure in the wild, outside of the safety of the high shelf in our garage, the eggs would be a snack for someone.

I had no idea what the gestational age of a baby bird is, particularly when the species is unknown. So I checked on this clutch of eggs a few times, but not daily, as I didn't want to spook the mom (again, I'd never seen her in the nest, for all I knew she'd already abandoned the eggs that the creepy Chinese lady kept peeking at), and anyway, it's not like anything interesting was happening.

Then, one weekend about a week and a half ago while I was in New York, I got a picture text from Joe. 

"I'm not sure if they're dead," his text read, "they're not moving. Maybe the garage was too hot for them?"

Since I was not there, I couldn't really weigh in, and I certainly couldn't tell from the photo. What could we have done, anyway? Put a little mirror under their beaks to see if it fogged up? Put on teeny tiny EKG leads? Put them on ECMO?

"Don't touch them," is all I could think of to reply, "and don't show the kids, it'll make them sad." It was a still photo, but Joe assured me that a video would look no different. And hell, babies that you can't see moving or breathing at all? Sounded pretty dead to me.

When I got home at the end of the weekend, the first thing I did (well, in truth it was maybe the third thing, after putting down my luggage and going to the bathroom) was stand on a chair, put my camera on a selfie stick telescoped out as long as it would go, and take a picture of the nest.

They were not dead. 

I exhaled a long breath I didn't realize I'd been holding in up until that moment.

When I took the MCATs back in--good lord, I think it was the summer of 1997--I remember this one section in the "critical analysis and reasoning" section. This is the part of the test where they give you some deathly dense and deliberately boring excerpt of technical writing and ask you a lot of questions about it afterwards to ascertain that you were able to not only stay awake, but actually retain and synthesize the information. (While this might be a reasonable test for how you would fare in med school, I will venture to say that it has only marginal bearing determining how good of a doctor you might eventually become.) Anyway, most of the sections were, as I said, deliberately inscrutable--an excerpt from a technical manual about how to extract aluminum via electrolysis, for example--but some reading selections were sort of interesting, probably by accident. 

This one I recall was about the breeding habits of certain birds in which "obligate sibicide" was the norm. Meaning: the bird will lay two or more eggs, and as a necessary evolutionary flourish, survival of the fittest, the stronger siblings will kill one or more of the weaker ones. Always. As a rule. I obviously didn't retain too much of what else I had read (though, to be fair, it was more than 20 years ago), but I figured, hey, five eggs is a lot of eggs. Probably by design. It was probably normal to lose a few by attrition. It's likely what we should expect, in fact.

I checked the nest every day (at this point Joe had set up our tallest ladder by the shelving and just left it there because apparently I was becoming the goddamn Birdman of Alcatraz and the ladder was heavy) but I would always approach with this vague, atavistic dread that at some point I'd happen onto one or two or five dead baby birds.

But there were no dead baby birds. Every time I peeked at them (just peeked, never touched), I did a quick head count. I couldn't tell them apart, I didn't name them or anything, I wasn't crazy--but just a quick head count. One, two, three, four, five. Every day, all five were there. 

Sometimes they would be in a different order, sometimes a few of them would be hiding in the back, but always, every day, five of them. They grew.

And grew.

And grew, until their ceiling hung with vines, and the walls become the world all around.

Yesterday, when I went to peek at the birds, it started to look a bit crowded. There was that adolescent gangliness to the brood--they still all seemed content to stay inside, they had a few tufts of baby down showing through, but the nest suddenly seemed like all arms and legs. 

And then this morning, just like that...

...they were gone. 

Joe caught a glimpse of one of the no-longer-babies early this morning, hopping around on a cardboard box by the recycling bin, virtually indistinguishable from the adult birds we'd seen about, but for the few sprigs of downy fuzz it had yet to shed. But by the time I got home from work, none of them were left. The garage was suddenly very quiet.

I'm not totally sure why I'm telling this non-story. After all, it's not really that interesting--lots of people find birds nests near their houses, baby animals come and go all spring and summer, the "empty nest" analogy as applied to human children is trite and hoary, and something I honestly don't really know about yet. (Soon, yes. But not yet.)

I think it was my reaction to the birds. The way I automatically assumed the worst. I think this happens at work a lot--in fact, I think the reason I sometimes assume the worst is because of the work I do. It's like a protective mechanism. You learn the statistics, you recognize patterns, you make predictions, you prepare yourself. Hope for the best, sure; but always, always, always prepare for the worst. Prepare yourself for the bad outcome and you'll never be surprised or disappointed. It's the bad outcomes you allow to blindside you that will truly break your heart.

But you don't always get a bad outcome. Even sometimes, when you should get a bad outcome, when you fully expect it...you don't. You're surprised the other way. People beat incredible odds. Genuine miracles happen. 

When I was a resident doing a rotation in the cardiothoracic ICU, there was a saying we'd murmur to each other back and forth on rounds, under our breath. Well, it was maybe not even so much a saying so much as it was a known phenomenon. "You fly or you die." Patients who had major cardiac surgery seemed to have two paths. Either they would do great--they would fly--or they would limp out of their moment of crisis, hobble through the next few days and weeks, accruing one complication after another, and eventually, succumb. It wasn't absolute, but it held true enough that it was accepted as near uniform fact. You fly or you die.

Life is not nearly as uniform or algorithmic as we would sometimes like it to be, of course. The comfort of a logically predicated outcome and the inurement against heartbreak can sometimes close you off to the possibility of an improbable result. Worse yet, sometimes one becomes so jaded against good things happening that the possibility of a good result seems less likely than it should.

I'm not saying that having five baby birds born in our garage and having all of them survive to leave the nest is an improbable result. From most of my limited conversations with other people who've had firsthand experience in such matters (so...two conversations, then) this in fact seems par for the course. 

But maybe that's not the point either. Maybe the point is just that surprise and delight can sometimes go hand in hand. And that delight can be found in the most improbable places, exactly when you least expect it.

high water mark

Hurricane Irma hasn't arrive in our area yet, but somehow she's already caused some flooding here.

(We were trying to fill our bathtub with clean water in case anything came up, but then we lost track of how full the bathtub was getting and it overflowed. This reminds me of when we're starting a case in the OR, make a hash of the A-line or central line or what have you, and dryly note, "Anesthesia EBL: 10 mL." We caused the very problem we were trying to avoid.)

So, Hurricane Irma's set to arrive here tomorrow. Our friends to the south obviously have it much worse than us, so it feels insulting to even tangentially compare our situation to theirs. But Atlanta is...bad at weather. So. The kids have no school for the next two days. Joe cancelled his clinic tomorrow. We got a few extra flashlights to keep on hand. (We had a bunch already, but somehow they always wander, because the kids think that flashlights are toys, which I guess they kind of are until you actually need them.) We filled up a bunch of thermoses with fresh water. We are charging all our stuff, and all our accessory battery packs, just in case the power goes out. (This is actually the most likely scenario, as the power goes out with some regularity even under normal bad weather conditions.) We opened up the pool cover and checked all the gutters. And, of course, we tried to save a bathtub full of fresh water just in case.

I honestly think it's not going to be a really big deal, in the end, but Governor Deal has declared a state of emergency (which I think it's likely the most prudent decision), so what can you do? I'll be heading in to work tomorrow (ahead of the bad weather, I think--I don't believe it's supposed to get bad until the afternoon) but I'm pretty sure that as extreme weather shelters go, a hospital is probably not a bad place to be.

Everyone stay safe, drive slow, and I'll see you at work tomorrow.

mud weekend

When I decided to go down to 60% at work, I figured the easiest way to do so (for the ease of my group and for my own personal budgetary calculus) was to do 60% of everything. That is to say: 60% of days, 60% of call, 60% of weekends, as well as my share of holiday call, which is distributed on a rotating basis. (For example, this year I worked the fourth of July. Last year I had New Year's and Labor Day; the year before that, Christmas.) I considered briefly a work configuration in which I didn't take night and weekend call, but it was a surprisingly easy decision against that. First of all, there is an element to the kind of work that you do on call--emergencies, surprises, coping with limited staffing--that presents unique challenges, and I think that by continuing to do practice anesthesia under that subset of circumstances will keep me, you know, sharp. And the second, more pedestrian reason is that the additional pay cut for not taking call would be more than our family can afford at this point.

So! Huzzah for call! The good thing is that, because of some strange quirk in the schedule, my weekend call for the last third of the year was fairly front-loaded, meaning that once we get past mid-October I won't have very much (or really any) weekend call until after Christmas. The bad part of this is that I'm currently in the middle of a stretch in which I am on call every other weekend for a month and a half. Sigh. C'est la guerre. 

I don't really mind--I'd rather be on call now than later on in the year anyway, especially once we hit that Halloween-Thanksgiving-Christmas stretch and seemingly every weekend is programmed to the hilt with Fall Festivals, canned food drives and Winter Wonderlands wherein you pay $3 to shoot Santa out of a cannon. (That's accurate for a school Winter Wonderland festival, right? I don't know, I've never gotten to attend because I've always been working. Other possibility: pelt cans of Coca Cola at a guy wearing a polar bear outfit.) 

And still, even at its most dense, this call configuration is better than during my Peds residency, when I was on call some portion of three out of four weekends per month. Remember those days? When having a "golden weekend," rare and exalted as a unicorn, simply meant that it was a weekend that we weren't at work? Current medical trainees: it gets better. Soon (not that soon, but sooner than it seems to you at this point) you will look back on these days with rueful affection and wonder how the hell you used to live like that. And then you will dive into your swimming pool filled with gold dubloons and the grateful tears of your patients and swim around like Scrooge McDuck.

OK, that last part is not true at all (and at some point I would like to talk more about this: the notions that society has about how doctors live and how many of us--especially those of us who started in practice within the last 10 year--actually live) but I'll save that for another day when I have more time and am not rushing to get ready for work pre-call. However, I will leave this here, as an illustrative example and a thanks. Thumbs up to all the people who identified those geriatric shoes in my last entry as Clarks Wallabees--they cost more than $100 when purchased new, so, you know, out of my budget. But then I looked on eBay (highly recommended an online searchable thrift store--you can really find some very nice items on there if you're fairly specific about what you're looking for and don't mind the pre-owned factor occasionally) and scored this lightly worn pair in my size for less than $26.

I am now one step closer to my life goal of becoming Carl Fredrickson.

Thank you again. Carry on.

sartorius

Blogging has changed a lot in the almost 13 years (!) since I started writing online, and I often think--particularly during this most recent long hiatus, when I was too busy to perform anything but the most basic of life tasks (see: job, performance of; family, keeping alive of)--why do I still do it? What is it, aside from perhaps the compulsive need for me to document the minutiae of my life, that makes me continue to write online?

It's not a business decision, certainly. It probably speaks to the direction that online media is moving these days that this blog is such an aberration--a more than decade-old blog that is almost completely non-monetized. I have my "real" job to thank for that--although it's been the job that has been the biggest obstacle to me writing often and regularly, it also allows me to keep all my writing projects, even the bigger ones, completely recreational. I think about that sometimes, how something ceases to be fun when you have to do it, and I am thankful that I have been able to have some very modest success at a hobby that really, I expected nothing more from than enjoyment.

But there's a little more to it too. There's an element to writing, like any activity, that you have to work at. If you don't write regularly, your brain freezes up. You lose fluidity. Stringing together sentences and ideas become laborious, painful; the end-product wonky, full of holes.

Why do I still continue to write here? Because in its own low-investment, low-impact way, each time I post something online, it's like a little exercise. Let me tell you a story, and see if I can make the words work. Let me try to build this wall of words and see if it will hold water. Believe me, I understand that keeping a blog is not nearly as high-minded as some of the "real" writing people do both online and off. But dashed off and conversational or not, it still works, you know? It's 13 years of writing exercises, archived in chronological order.

My first book didn't exactly blaze its way to the top of The New York Times bestseller list (another reason I'm thankful to have gone to medical school and to have the luxury of writing on the side--the stress of having my professional success subject to the caprice of the literary marketplace makes any day in the OR look like a walk in the park), but I do think I have another book in me. I think I would like, someday, to write a book about the practice of anesthesia. It's probably one of the most misunderstood fields of modern medicine, and also one of the most fun.

In my mind (a place where everything always works out perfectly) this book would be a combination of medical history--the Ether Dome, "Gentlemen this is no humbug," sort of thing, I love that stuff--interspersed with first-hand stories of learning and practicing anesthesia. Shine some light on what the hell it is exactly that we're doing back there, at the head of the bed behind the blue drapes. Help people know more about anesthesia than the labor epidural and the notion that propofol "killed Michael Jackson." I'd like to tell some good stories, and I think I have more to tell.

Anyway, someday I'll do it. Until then, I guess I'll just stay warmed up, and keep writing here.

*          *          *

(And now for something completely different...in which I erase all the lofty musing from above and just talk mindlessly about clothes.)

Now that I actually spend some time out of the hospital and out of scrubs, I have noticed that I can't find any clothes to wear. Wait, let me clarify. I have clothes. But I have too many clothes. Because it seems that my attitude towards wardrobe curation leans towards the "survivalist hoarder" end of the spectrum, and I literally (LITERALLY) have clothes from high school still hanging back there because what if I need to attend a "Reality Bites" themed party and I don't have anything to wear? (This is all the more pathalogic when you consider how many times I've moved since high school.) So what actually have is a messy closet packed full of clothes, none of which I actually wear, and which are actually interfering with my ability to find the small percentage of clothes that I do wear. FIRST WORLD PROBLEMS Y'ALL.

Anyway, I'm going through a major closet purge right now (I was going to say "diuresis" but I'm not really sure if that's a real thing that people say or if that's just a thing that medical people say--either way it brings up unpleasant images of hollow viscera evacuating), the goal of which is to have a closet where I could walk in, pick any two pieces of clothing, and have them match. I know this is extreme--not everything is meant to match with everything, after all--but look, I'm a busy lady, I don't have time to plan my little outfits like Cher in "Clueless." I just want to be able to grab stuff, put it on me, and know that they go together.

These are the things I actually wear:

• Red, white, navy, and grey. Yellow occasionally as an accent.
• Cotton knit tops. Preferably boatneck, 3/4 length sleeves. Stripes are a plus.
• The occasional button down, as long as they are soft and don't need to be ironed too rigorously.
• Sweaters, cardigans preferred.
• Skirts, A-line, knee length or shorter, certainly not longer. (This is not a slutty thing, it's more of a short people thing. Long skirts make me look like Momma in "Throw Momma From the Train.")
• Jeans, straight leg, dark wash primarily, occasionally white against my better judgement. (And this is not a "my ass looks huge" thing, it's an "I have kids" thing, and any light colored pants end up with stains and footprints all over them.

So, basically: nautical private school student.

In Atlanta it's warm enough that this getup can get me through most of the Fall into the Spring, with the exception of a few frigid weeks after Christmas where you actually have to bundle up--I have an warm but also exquisitely ugly yellow parka from L.L. Bean that will get me through that stretch. My goal right now being that I want to streamline my closet enough that I will have to put in next to zero through into what I'm putting on my body in the morning. Which is probably only one step up from being Charlie Brown opening up his closet to a row of identical yellow shirts with a single black zig-zag stripe across each one, but hey, I'm sure it made his morning routine very efficient.

Oh, and by the way: those brown shoes above. Please tell me about them, because I want to find them and marry them and make little shoe babies with them. (Brownie, Flopsie and Lacey, natch.) What are they called, does anyone know? And where can I find them? The picture above was from an Etsy vintage shoe sale (only $35!) under the heading "Dexter desert boots" but they were not in my size, which for the record is a 6 or a 6.5 American. You guys, THE SHOES. I realize that in some sense they are hideous and orthotic but SO AM I. Please and thank you.

Furthermore, anyone looking for evidence that I am projecting my own fashion sense (or lack thereof) onto Nina need look no further, because: mea culpa. Likely in a year or two she'll be clamoring for only the tackiest taffeta/polyester/princess shit, so I'll inflict my questionable aesthetic while I can.

OK, back to work.

spotlight on specialties: anesthesiology

Sorry, I'm a little bit in remiss in that I didn't post this link up earlier, but here's a link to the AAMC article on the field of anesthesiology, for which I was interviewed along with a number of much more distinguished and accomplished colleagues. If you're interested in the field of anesthesiology, either as a potential career or if you just want to know what exactly it is we do all day, check it out.

An excerpt:

“Anesthesia is hands-on, fast-paced, and has tremendous capability to make a positive impact on our patients’ lives as anything else we do in the hospital,” says Dr. Au. “In my opinion, it's one of the most interesting, most exciting fields in medicine, and I firmly believe I have the best job in the world.”

I've said it before and I'll say it again here because it's appropriate: it's a difficult juggle to balance work and family, but it's all the more difficult because I do indeed love my job.  If I didn't love what I did at the hospital as much as I love what I do at home, my choices would perhaps be easier, though maybe not as satisfying.  So really, in the end we should be grateful for the difficult choices, and the chances we have to make them.

(And on an unrelated note: the above photo panel is from pictures I took with my phone during residency--isn't it amazing to see how far cell phone photography has come?  Wow! The future! hovercrafts that fold up into briefcases! And etcetera!)

death or something like it

Good discussion on that last post!  It's clearly a topic that many are hungry to talk about, and I think what's becoming increasingly evident to me is that the choices we make with our lives in medicine really aren't any different than the choices people make in any other high-powered field where a lot of people are counting on you.  In some ways, it makes the choices more difficult, but in other ways, the clarity of purpose and the natural inclination to triage makes getting through our days, if not necessarily easy, than at least one where our top priorities are unambiguous.

OK, ready for the next thing to talk about?  And--hey, look.  Usually I don't go hunting around for topics to stick in my craw.  I swear, usually I just wander around with a smile on my face and a song on my lips with little birds braiding my hair, a regular blithe spirit.  Or Blythe Danner.  But then, oh look, one of my partners at work e-mailed me this article from The Wall Street Journal Online.

What You Lose When You Sign That Donor Card
Giving away your organs sounds noble, but have doctors blurred the line between life and death?

An excerpt:

The last time I renewed my driver's license, the clerk at the DMV asked if she should check me off as an organ donor. I said no. She looked at me and asked again. I said, "No. Just check the box that says, 'I am a heartless, selfish bastard.'"

Becoming an organ donor seems like a win-win situation. Some 3.3 people on the transplant waiting list will have their lives extended by your gift (3.3 is the average yield of solid organs per donor). You're a hero, and at no real cost, apparently.

But what are you giving up when you check the donor box on your license? Your organs, of course—but much more. You're also giving up your right to informed consent. Doctors don't have to tell you or your relatives what they will do to your body during an organ harvest operation because you'll be dead, with no legal rights...

...The exam for brain death is simple. A doctor splashes ice water in your ears (to look for shivering in the eyes), pokes your eyes with a cotton swab and checks for any gag reflex, among other rudimentary tests. It takes less time than a standard eye exam. Finally, in what's called the apnea test, the ventilator is disconnected to see if you can breathe unassisted. If not, you are brain dead. (Some or all of the above tests are repeated hours later for confirmation.)

...But [beating heart cadavers--the term used in the article for brain dead patients]...don't receive anesthetics during an organ harvest operation [though they] react to the scalpel like inadequately anesthetized live patients, exhibiting high blood pressure and sometimes soaring heart rates. Doctors say these are simply reflexes.

...Organ transplantation—from procurement of organs to transplant to the first year of postoperative care—is a $20 billion per year business. Average recipients are charged $750,000 for a transplant, and at an average 3.3 organs, that is more than $2 million per body. Neither donors nor their families can be paid for organs.

It is possible that not being a donor on your license can give you more bargaining power. If you leave instructions with your next of kin, they can perhaps negotiate a better deal. Instead of just the usual icewater-in-the-ears, why not ask for a blood-flow study to make sure your cortex is truly out of commission?

And how about some anesthetic?

(Read full article here...such as it is.)

OK, let me leave off the table now the details of the neuro exam and EEG monitoring and the criteria for brain death.  I can talk about those too of course, but I am not as qualified to do so as some, and, unlike the author, I know better than to ignore my somewhat less than expert grasp of the nuances of the subject material and trumpet my knowledge, whatever its flaws, as the clarion bell of unimpeachable fact.  These issues may be better for a neurologist or neurophysiologist to discuss--one may well be reading this entry now and want to weigh in in the comments section--and, I venture, the author of the article may well have benefitted from talking to such an expert in researching the article himself.  (They're called "cold calorics" or "vestibular caloric stimulation" sir, ask any second-year medical student.  We're not looking for "shivering" in the eyes, even though, yes, ice is cold.  By the way--you see a similar response with warm water.)

What I want to talk about is this accusation that we don't use anesthesia during organ harvests.

WE ALWAYS USE ANESTHESIA DURING ORGAN HARVESTS.

Organ harvests, who for those like the author of the article (OK, I'll stop) are unfamiliar with the terrain of organ transplantation in a hospital setting, are always booked in the operating room, and always booked with anesthesia staffing.  We as the anesthesia team help transport and support the patient, usually from the ICU, vented and on drips, down to the operating room.  We put them on our anesthesia machine, monitor them just as we do any other patient.  We anesthetize them, give them medication, oxygenate them, treat their hyper/hypotension and tachycardia, just like any other patient.  The definition of "pain" lands into some sticky semantic territory--so far as I understand it, "pain" implies a perception and processing that requires some higher brain function, which brain-dead patients by definition lack.  But I don't argue that even brain-dead patients have sympathetic (in the central and peripheral nervous system sense) reaction to nociceptive stimuli, such as surgical incision--and we treat those responses the same as we do in any other patient, often with pain medication.

The hard part is when the surgery is over and we have to walk away.

Because it's not what we do.  We take care of patients, and those who donate their still-working organs after brain death--that is to say, after they themselves have lost all reasonable expectation for meaningful use of those organs--are still our patients.  In some ways, it's harder as an anesthesia practitioner to separate out these patients from the others we take care of--almost all our patients look like they're sleeping, almost all patients under our care require ventilatory support and/or circulatory support, almost all our patients lie completely still and largely unresponsive.  We tend to them with attention, respect, and care, until the very end.  And in the case of an organ harvest, it's the anesthesia providers who are turning off the life support.

And that's hard to do.  It's hard because we respect the patients, respect life and its passage, respect the choices they have made to help others.  To imply otherwise is ignorant and insulting at best--and it is quite flatly an insult, to imply that doctors simply regard patients as a collection of interchangable profitable parts--and irresponsible at worst.

Because the implications and the ramifications of this article and articles like this are irresponsible.  It's irresponsible to write as a voice of expertise (the author has, I believe, written a book on this topic which, SHOCKINGLY, is coming out next week) in a major news outlet on a topic of which you clearly have an imperfect understanding.  It is even more irresponsible to use that platform in a way that has some very real, lasting public health implications for life-saving treatments and therapies for other patients for whom the breadth and depth of the organ donor pool is, quite literally, their last and only chance.

And look, I'm not an idiot--I understand that The Wall Street Journal has, in the past, published incendiary shock-value pieces that have been quite successful in book promotion (Amy Chua's "Tiger Mom" article comes to mind, and I don't deny that, when that particular firestorm hit a month before my own book came out, I wished I had either the subject material or iron-clad balls to generate that particular caliber of self-perpetuating publicity).  But this is about more than selling a bunch of books, or generating a lot of attention, or getting a lot of replay on Facebook.  Because of this article, someone might decide not to donate their organs, and because of that, someone else is going to die.  A real person.  I've met and taken care of many of them.  You may have too.

Again, it comes down to choice--obviously the choice of whether or not to donate ones organs after death is a personal one and should be at least considered seriously.  I know people don't live their lives explicitly to benefit strangers, nor do they usually intend to die toward that same end.  But fact is that this is the moment we're at in the evolution of medicine.  When organs in some patients fail, we sometimes have the ability to transplant in organs from other patients who can no longer use them.  Maybe someday we'll grow organs in jars--no doubt that kind of research is in its infancy or early childhood--but for now, to save and improve lives, this is what we're working with.

I don't wish this kind of decision on anyone, and may we all live happy and healthy to the ripe old age of 100, but the fact of it is, some of us don't.  Death, in the circumstances where organ donation may be an option, is often unavoidable, after the exhaustion of all  other options.  But the choices, the informed choices you make before death with what happens to your body afterwards--well, that's up to you right now.

But know that, whatever decision you make, we as your doctors will take care of you.  Always.  All the way to the end.

help me help you

Off the top of my head: five tips for people who might need to undergo anesthesia.


1.) Know what medications you're taking, and know what you're taking them for.

I guess this must seem easier for us, because by and large if you're reading this you are on the younger end of the spectrum, statistically more likely to be healthier and on fewer medications, and demographically at least somewhat medically inclined, but--you'd be surprised how many people have no idea what medications they're taking or for what condition they were prescribed.

Patients--please know what medications you're taking! It really makes a difference, and can affect how your body might respond to anesthesia or the various insults of surgery. And it's often not quite enough information to tell me that you take "a blood pressure medication," because there are many different types and they all work through different means. Is it a beta-blocker? An ACE inhibitor? A diuretic? An alpha-2 agonist? And guess what--even if you don't know half of what I just said, it doesn't matter. Just know the names of meds you're on, tell me, and I'll figure it out, because it's my job. If it's hard for you to remember, write your med list down or have a family member help you. Carry the list with you in your wallet if necessary.


2.) Know your own medical history.

Equally important, see above. Do you have a scar over your sternum? Do you have a device implanted under your left pectoral muscle? Sure as hell I'm going to ask you about it. I'm not being nosy, I need to know these things to make sure I can take care of you in the safest way possible. If you can't remember, or have a hard time because you have a long medical history, write it all down (list of diagnoses, surgeries, doctors with contact info) and carry it with you, maybe along with your med list. Better yet, keep it as a file on your computer, so you can update and print it out as necessary.

I know it's annoying to have to answer the same questions again and again, but it's a matter of safety as well. So bring your information. And don't just trust that, "it's in the chart," because sometimes it's not. Anyway, a good medical practitioner doesn't just trust someone else's History and Physical, they do their own.


3.) Do yourself a favor and think long and hard about your allergy list.

As an anesthesiologist (or even as a doctor in general), when I ask you about drug allergies, what I'm really asking you is, "will the benefit of me giving your a certain medication as indicated be outweighed by an adverse reaction of giving you that medication, and do I have good alternatives?" Putting lots and lots and lots of drugs on your allergy list to which you're not actually allergic does nothing but tie my hands to treat you in the safest and most efficacious way possible. Feel free to tell me if you tolerate some meds worse or better than others--if Flagyl makes you queasy or that historically you respond better to morphine than Dilaudid. I do want to know these things, so yes, tell me. But when you tell someone that you're allergic to every antibiotic on the planet because sometimes antibiotics give you the runs, it can really hamper our ability to treat you in a safe, effective, evidence-based way, because the word "allergy" means something very specific in medicine, and we take that word very seriously.

(Also: no one is allergic to epinephrine. Your adrenal glands make epinephrine. If you were allergic to epinephrine we wouldn't be standing here having this conversation right now. Sorry, pet peeve. I don't blame patients for saying it, by the way--I blame the boneheads who, knowing better, write it down anyway and thus immortalize it in the medical record.)


4.) Don't eat or drink after midnight the day of surgery, but it's OK to take most medications.

The surgical team may ask you to hold certain medications prior to surgery, and most of these medications make sense to stop. Since you're not going to be eating for a good couple of hours the day of surgery, it makes sense, for example not to take medications that will further lower your blood sugar (meaning oral medications for diabetes, or your full dose of injected insulin--brittle diabetics, consult your endocrinologist for specific instructions). Also, as surgeons try to keep bleeding to a minimum when they're cutting on you, so with some exceptions in specific cases (like if you've recently had a stent placed in your heart for example, of if you risk for clotting outweighs your risk for bleeding), it's usually advisable to stop taking any blood thinners or certain anti-inflammatory medications for a period of time prior to the surgery date.

But for the most part, other medications are fine to take the morning of surgery, if that's when you usually take them. In fact, I prefer it if you take most of those morning medications, particularly including any medications for your heart, your blood pressure, any breathing issues you might have, or medications for chronic pain. When you think about it, it makes sense: you want to be medically optimized for surgery, not with your blood pressure through the roof, wheezing, and with your pain out of control even before incision.

 Have questions about taking or stopping a specific medication before you get to the OR? Ask to speak to an anesthesiologist prior to your surgery date. Don't just call the surgeon's office and ask--often the person fielding the call (not always a medical professional) will not have the first clue, and will instead say, just because he or she thinks it's the safest answer, "don't take any medications the day of surgery." I had a myasthenic patient come in for an afternoon surgery having skipped several doses of Mestinon because the secretary she talked to told her not to take her meds. Like I said, if you have medical questions about day of surgery medications, ask to talk to an anesthesiologist beforehand. Again: it's our job.


5.) If you have any specific fears or concerns about the anesthesia itself, let us know beforehand.

Help us help you! Are you claustrophobic and hate the idea of having a mask over your face? Do you have a needle phobia? Did you have a family member with a very bad reaction to anesthesia, or have you yourself have a traumatic anesthetic experience in the past? Do you have questions about "The Michael Jackson Drug" and want to know exactly how the same fate will not befall you? Let us know! We can help you! There are things we can do to make things easier! Better! Smoother! Less scary! We have all sorts of tricks in our bag, is all I'm saying. We just need to know when and for whom to pull them out.


Medical professionals in this or other fields: another other tips?


* * *


For people of a certain age, Whitney Houston runs throughout the soundtrack of our childhood and adolescence. So if you want to pretend that you've never been alone in the bathroom hoping that the tile acoustics would help you better belt out the chorus of "One Moment in Time," I'd think I'd have to call you a damn liar.





Thank you, Whitney. You were transcendent.

"my dear Doctor Whipple..."

I was doing some internet research today when I happened upon some copies of the original letters written by Virginia Apgar (yes, that Apgar) to Allen Whipple (yes, that Whipple) concerning the formalization of medical training for perioperative care, into what would eventually become the Department of Anesthesiology at Columbia Presbyterian Hospital.

Now I don't know if it's just because I'm a dork (certainly) or because the players were such medical legends that getting a chance to read their correspondence (along with handwritten notes jotted in the body and along the margins!) feels like watching history unfold in real time.  Or perhaps it's just seeing that familiar address on that old letterhead--the correspondence below detailing the formation of a department where, seventy years later, I myself would train--that got me all goose-bumpley.   But certainly, there's a reason that these were called The Days of the Giants, and Virginia Apgar no doubt stood tall among them.

For more on Dr. Apgar, they have quite a trove of biographical information, pictures, and letters in the "Profiles in Science" section in the National Library of Medicine.  Definitely worth checking out if you're a medical history wonk.  Or just look at this picture of C. Everett Koop and wonder why people don't grow beards like this anymore.

colonoscopy face

I tweeted today that someday, I want to make a video of all the faces that doctors make while they're doing colonoscopies.  Our GI colleagues are as talented as they are brilliant, but as we all do, they sometimes make some funny faces while they're working.  And since I'm almost always standing directly across from them, I get to see the full spectrum.  Here are a few favorites.

We love our GI colleagues, and I hope that I look as cute when I'm making my "concentration" face as they do.  (However, as I know I likely do not, it's a lucky thing that I'm wearing a surgical mask 75% of the time.)

on dreams

The night before I return to work after having been on vacation, I always have an anxiety dream about anesthesia.  It's something that I hoped I would outgrow, and I guess I have to some degree, since for the entire first six months of my anesthesia residency, I had anxiety dreams about anesthesia every single night.  Most of these dreams had to do with the standard things that residents are anxious about--I had dreams about machine malfunctions, patients sitting up on the table in the middle of surgery, leaking canisters of volatile anesthetics that rendered me unconscious before I could reach the machine to turn it off.  But some of the dreams I had early on were completely nonsensical, like the one where I was at an airport and I was called upon emergently to resuscitate a sea lion.  Why was I in an airport?  Why a sea lion?  If this implies anything unsound about my state of mind, please also remember that I also had a young infant at the time, and the very fact that I was even able to sleep deeply enough to dream was a triumph in and of itself.

So anyway, the dream I had Sunday night was that I had to put a thoracic epidural in my own grandmother.  To what purpose it was unclear, but I do remember having to sit her up on the OR table and prep her back with Betadine while explaining to her in Cantonese what I was doing.  Aside from the construct, it was actually a very realistic dream, and when I woke up, I had to orient myself for a few minutes to decide whether or not my work day had ended or whether it was just beginning.

What anxiety dreams do you have about medicine?  Have they changed over time?  I would like to think that they will, or that I might at least at some point in my life be able to go on vacation without having to count on one full night of tossing and turning and dreaming with a pulse-ox tone backbeat.  But it's been more than 15 years since I last took a math class, and I still regularly have dreams about showing up for the big calculus final having not attended a single lecture (it's always something where I forgot that I registered for the class, and didn't realize it until the Add/Drop period had ended), so I don't have real high hopes that my medicine anxiety dreams will ever fully go away.

and yet, it's only Monday

(Groan.)

a marriage of convenience

A text message exchange from earlier this week:

JOE
Momo, don't laugh at me, but I have a patient and I want

blood ready for the surgery, but might not need it. Should I

"type and screen" or "type and crossmatch"?

MICHELLE

Depends how fast you would need it. If you want it

sitting outside the OR to give at a minute's notice,

type and cross. If you will unlikely need it immediately

and have 30 minutes lead time once you think

you might want to transfuse, type and screen.

MICHELLE

Crossmatch involves an additional step, typing the

unit of donor blood against the patient's blood.

JOE
Type and cross dress? Ever done that?

MICHELLE

Yes, that's where the blood bank put the unit

in a dress and heels.

For my own vanity I will leave out the countless occasions that I texted Joe in the middle of the day asking him ridiculously simplistic questions about the human eye as it pertains to my scope of practice (that is to say: mostly corneal abrasions, and when it is OK to use nitrous after a scleral buckle). We are like a built in free consult service for each other. Marriage!

the ballad of the unsung hero

Many people probably saw this already, it was printed in The New York Times on April 9th, but just in case you missed it, I thought I should give it a little bump:

Doctors Remove Ammunition From Soldier’s Head

The reason I'm posting this is not because it's one of those "Ripley's Believe It Or Not" medical stories (even though it is), but it's because if anything redeems the much maligned field of anesthesiology from the jaws of modern day television, in which we are all portrayed as lazy, unfeeling, drunken, drug-diverting billionaires who don't give a shit about our patients and leave whenever the going gets rough, it should be a story like this.

An excerpt for those who don't want to click:

...[A]s the patient, an Afghan soldier in his 20s, was prepared for surgery, the chief radiologist, Lt. Col. Anthony Terreri, took a closer look at the CAT scan. Stunned, he realized the object was an explosive round, primed to go off.

“It looks like we have a problem here,” he announced.

To say the least.

Maj. John Bini, a trauma surgeon and a veteran of homemade-bomb injuries from two previous deployments in Iraq, immediately evacuated the operating room. Only the anesthesiologist, Maj. Jeffrey Rengel, who put on body armor, was left to watch the patient.

The surrounding hallways were secured, and a bomb disposal team was urgently summoned. All electrical monitoring devices in the operating room were turned off for fear of detonating the round. To keep track of the patient’s vital signs, doctors turned to manual blood pressure cuffs and a battery-operated heart monitor, and they began counting drips per minute to estimate the amount of the intravenous anesthesia they were giving the patient. “It was taking anesthesia back about 30 years,” Dr. Rengel said.

Within a half-hour, the bomb disposal team arrived and confirmed, based on the CAT scan, that the patient indeed had unexploded ordnance in his head.

“They said, the way these things are set up, this type of round has an impact detonator on the front of the charge,” Dr. Bini said. “They just said, ‘Don’t drop it.’ ”

With that for reassurance Dr. Bini put on body armor as well, and he began the process of surgically removing the round from the patient’s head, joined in the operating room only by Dr. Rengel and a member of the bomb team...

...Dr. Bini said he was unaware an unexploded bomb embedded in a patient’s chest had been the plot of a TV show — a two-part episode of “Grey’s Anatomy” in 2006... “None of that stuff you see on TV approximates reality,” Dr. Bini said.

Nice work, Dr. Rengel, we're all proud of you.

And also, you must shit ice cubes.

blank check

In my anesthesia group, the second call doc is known as the "Rover," which sort of means that they are the out of OR everyman. Aside from administering anesthesia in the endoscopy suite (11 cases yesterday, thank you very much) we are also the doc that gets called for all new pain consults and central line placement requests, as well as anything else that people may need. The pain consults are mostly what you'd expect--post-surgical pain management, acute on chronic pain, oral conversions of IV narcotics, what have you. But now, twice, I've gotten called from services that want me to write narcotic prescriptions for patients being discharged from the hospital. Let me be clear: they are not asking for advice on what oral pain meds to discharge the patients on, or recommendations about conversions or tapering or dosing. They just want me to show up and write a prescription for the patient to take home with them.

NURSE: Dr. XYZ said to call you guys to come write the morphine prescription. She's supposed to be discharged right after.

MICHELLE: Wait, but I've never even met this patient before. I've never even heard of her. And I'm never going to see her again. I don't think it's really appropriate for me to be writing a morphine prescription for this person. Who's the primary doctor in charge of her care?

NURSE: Dr. XYZ.

MICHELLE: So why doesn't Dr. XYZ write the prescription?

NURSE: He says he can't.

MICHELLE: He "can't"? He's...not a doctor? He doesn't have a DEA number?

NURSE: He just told me to call you and for you to do it.

MICHELLE: Look, I want to help you, but I'm not going to do that. I can't just come and write narcotics for a patient that I've never taken care of, know nothing about, and am never going to see again. That's just completely inappropriate. Someone who is responsible for that patient needs to take it on themselves to write that prescription. Either the primary doctor on service or her primary doctor outside of the hospital. Someone who is going to follow up with her. Someone who is going to see her again, ever.

NURSE: But Dr. XYZ wanted you to do it.

MICHELLE: I'm not trying to pass the buck here, or give you a hard time, I know you're just following orders. But...look, if he wants advice on what narcotic to send her out on, or wants me to help him calculate the appropriate dose, that's fine. But I'm not going to come and just write a prescription for someone I never met. Frankly, I'm an anesthesiologist in the OR. I don't even carry a prescription pad.

NURSE: (Pause) So...you're not going to do it?

Any doctor with a DEA number can write a prescription for narcotics for patients that need it. Whether or not they want to take responsibility for writing those prescriptions is a whole other thing. Which begs the question...if they as the primary physician don't feel comfortable taking the responsibility, why would I?

Here's one for the comments section: What's the most inappropriate thing you ever got called for in the hospital?

on the fifteen-second diagnosis

Often times in the OR, I am thankful that the patient is asleep. Not so much for their comfort and safety, though obviously that's the primary goal, but more so they don't have to hear the conversation in the OR.

Do doctors talk about their patients? Yes, of course we do. Do we talk about them differently to each other, behind closed doors (or at least closed eyelids) than we do to the patients and families themselves? Yes, we do. And I'm going to be honest, usually this is not a good thing. Sometimes it's more just about an honest exchange of information--a surgeon telling the anesthesiologist that despite the surgery they're performing, that the patient's cancer is most likely terminal, in a frank way they've been unable or unwilling to talk with the patients themselves. Sometimes we complain about patients for things that make our jobs harder, even if it's not really their fault. Morbidly obese patients are difficult to operate on, patients who have smoked three packs a day for the past 45 years are difficult to oxygenate, patients who have been on chronic steroids are difficult to start IVs on. And then sometimes, there are things said in the OR, unrepeatable things, that would make Hippocrates turn over in his grave. (Or sarcophagus, whatever.)

I am not saying that the way that doctors talk about patients when patients aren't around is OK. I'm just letting you know that it happens. Certainly, things are better now than, say, in the 1960's and 70's, when doctors would ogle their naked lady patients and everyone was clad in unfortunate nubbly earth-toned fabrics. People overall are much more PC, and people are certainly much more mindful of patient privacy and respect and just basic comfort than in the more paternalistic age of medicine, where the doctor's word was the word of God. But like any profession in a highly emotionally charged atmosphere where you work closely, day in and day out with people going through potentially life-changing events (see also: those in law enforcement, the armed forces, social work), the attitude of those in the medical profession might to the outside observer often seem callous or vulgar. And probably, sometimes it is.

My last post, I made a comment about how having more than three cats or more than five drug allergies was a soft sign for mental illness--though perhaps more accurately, I meant "neurosis." Though I had a twinge of conscience even as I was typing that last, I want to apologize for not listening to it and if my five allergy statement discounted the fact that behind every chart, there is an actual living, breathing human patient behind.

I think this is a problem we fall into a lot in medicine. When you first start medical school, you're so shiny and new, your skin so pearly pink and translucent, you take everything personally. The first time you witness a bad medical outcome, you cry. The first time a patient tells you something that is not completely true, it knocks you to the ground. The first time you make a mistake--the first of many, many, many times--you beat yourself up about it endlessly. You feel everything. Patients haunt you. Every experience leaves a stain.

And then, for better or for worse, you start to get a little jaded. Your skin thickens up. Things don't affect you quite as deeply. Big things start to become banal. At the end of my residency, called in for stat intubation for a patient in the ICU, I put in the breathing tube while chatting casually with a classmate about how her new baby was doing at home. The life-changing becomes the everyday. The catastrophic becomes the mundane. I'm not sure if it's a good thing or a bad thing, but it certainly helps you get through the day. If I had to feel everything as intensely and deeply the way I did when I was a third or fourth year med student, there's no way I'd still be able to work today. In fact, most likely I'd be rocking back in forth in a fetal position in some sort of sensory deprivation tank. You need to toughen up in order to help your patients, but the toughening up can also have a distancing effect, sometimes to the disservice of those you're working to help.

It has been said before that the practice of medicine is all about pattern recognition. The more patients you see and the longer you've been in practice, the better you are at recognizing the patterns, and the faster you can react. Fever, nausea, elevated white count, right lower quadrant abdominal pain? Appendicitis. Tachycardia, hyperthermia, hypercapnia, muscle rigidity? Malignant hyperthermia. My guess is that the more fast-paced and stressful the work environment (the ER and the OR come to mind as probably the prime environments), the more likely practitioners are to make snap judgements. We are taught to group and classify patients, often in knee jerk ways, and while this can usually be helpful from a diagnosis and treatment point of view, this tendency towards generalization can sometimes bite us in the ass. Not all patients are a "type." Not all patients with the same list of diagnoses are the same. It might be easier if they were, but they are not, and we shouldn't act like we know more than we do just because we as medical practitioners have privileged access to people in ways that few other people do.

This was probably an overlong tangent to spin off of the fact that many have noted--myself included--that a long list of med allergies either indicates a long chronic illness or, alternatively, a patient who is a little bit kooky. That's part of that pattern recognition again--after a certain point, you just start to see patterns in everything. But I do need to be reminded, as do all of us, that there's a story behind every patient, and there's a patient behind every ID band.

(I still think that having more than three cats means you're crazy, though.)

(That's a lot of cats.)

60 posts in 60 days, day 5: milk of amnesia




I guess I have Michael Jackson to thank, but suddenly, everyone and their 85 year-old grandmother knows what propofol is. Now if only cisatracurium would get this kind of press.

head above water

Sorry for the sudden drop-off in updates this week, but I have been negotiating the transition from stay-at-home back to work, and have thus been a little...harried. I think that I mentioned this in a previous Twitter, but when you work outside the home, your evening parenting experience picks up this unfortunate utilitarian flavor. Basically, I'm running in the door, taking the quickest shower possible (to cleanse my skin of the multi drug-resistant microbes), and it's this breathless race of MAKE DINNER FEED DOG FEED BABY GIVE THE KIDS BATHS SNACK FEED BABY BEDTIME FOR EVERYONE GO GO GO that fails to elicit the heartfelt talks and snuggling that might manifest in a more relaxed pace of parenting spread out over several more hours. And there's the unfortunate feeling that I don't get enough time to spend with my kids, which is probably true--on Thursday after I got home, I fed Mack, and he proceeded to sleep for basically the rest of the evening into bedtime. I know it's bad mojo to wake a sleeping baby, but by 8pm, I was coughing loudly and poking him in the belly with one finger just so I could at least play with him a little bit before I had to go to bed myself. (During the work week, I go to bed on average between 8:30 and 9:00pm. Much like your grandmother.)

Adjustment back to work was another issue. I have never been away from clinical anesthesia for six whole weeks before (I didn't do any research electives during residency or anything like that, and when I took my maternity leave with Cal, those six weeks didn't count because I had just started my anesthesia residency three weeks prior to that so I didn't know enough to forget), and I have to say, I was a little afraid of being rusty. And while the truth of the matter is that while my hands didn't get rusty--muscle memory is a powerful thing, see also: riding a bike--but my brain feels rusty, having not been thinking about anything close to medicine (aside from a smattering of self-centered OB and Peds) for a month and a half. So that was a little disconcerting. I'm sure it'll just take a little time, and a little reading, to get my wits about me again, but it makes you realize just how cerebral the practice of anesthesia is. Which is why I'm sure no one understands what we do, because all they see is us standing there, watching the patient and frowning.

Also this week (because you know how much I just love to make my big moves all at once--IT'S ALL OR NOTHING, BABY), I submitted my second round of manuscript revisions to my editor. Honestly, I've read this manuscript so many times by this point that I don't even trust that if there are any glaring errors or discontinuities, I will catch them--but I do think that it's pretty OK and fairly close to the final product that I had envisioned. I don't know, we'll see. Of course I will still have to read through it fifteen million more times, but I am looking forward to moving on from the words-on-a-screen stage to the hey-this-might-actually-be-a-real-book-that-people-will-read stage. That will be fun.

So that's that. Oh, and I keep trying to take a picture of Mack smiling (it seems like he's actually doing it on purpose now, just starting this past week), but I never have my camera close by when he's doing it, and whenever I run and get my camera I can't get him to smile anymore. Perhaps I need a more hilarious camera.