Futility, in its third year

Let's be honest. People don't, for the most part come to theatre for fun. We are doing a job here, and generally that means that patients are sick, and they are coming for surgery to cure their problem. With the possible exceptions of elective cosmetic surgery and a small number of what may be termed "unnecessary" procedures, the vast majority of patients leave theatre cured, or at least well on the way to being cured.

I'll be the first to admit that we as anaesthesiologists, for the most part, don't do much healing. Yes, we take sick patients, and steer them safely through the rough seas of major surgery and yes, we perform a very important role in the team. But we don't cure. Occasionally, our surgical colleagues are unable to cure either. I had occasion to reflect on this today.

A mitral valve replacement was scheduled in a grossly overweight 25yr old woman. We forgave her for being obese because her effort tolerance was so poor due to her very tight mitral stenosis. On a side note, I was trained by a consultant who would have described the tightness of the mitral valve as being "like the bottom of a duck, on a frozen lake in Moscow in winter."

"And," he would continue, "how do you know a duck's butt is tight? Because you NEVER see a duck sinking"

Anyhow, I digress. Suffice it to say that this was a tight mitral valve. The patient reported feeling dizzy and lightheaded every time she got up form a chair, and as for walking, lets say she couldn't do much. Despite the difficulty in placing invasive lines, my colleagues soon had her off to sleep and surgery proceeded. The course was uneventful and she was delivered to ICU in fairly good nick. Then, the wheels started to fall off.

The blood pressure fell precipitously, the ICU guys struggled to ventilate her (combination of obesity and fluid overload in the lungs) and despite increasing doses of Adrenaline, she was not doing well. At this point I was alerted to the fact that she may need to go back to theatre, a responsibility which would fall to me as the on-call consultant. So I went back to ICU to review her, to see why it was that she wasn't doing well.

As I walked into the ICU, I could see that things were taking a turn for the worse. She was surrounded by many surgeons, ICU docs and, most worrying, an ever increasing number of monitors and machines. We have a dogma that prognosis in ICU is inversely proportional to the number of machines around the bed. The heart-plumbers had opened her chest and the ICU registrar was standing with a big syringe full of neat Adrenaline, pumping it in by hand, 8ml at a time. To put this in perspective, if you had a severe allergic reaction, the recommended life saving dose of Adrenaline is 1mg i.e 1ml per dose. This lady was getting 8 times this. Despite these heroics, I could see that the BP was less than 60/30 most of the time.

I think the village policeman could have sensed the eventual outcome here. Unfortunately, we tend to get too close to our patients, not on a one-to-one emotional level, but we invest huge amounts of thought, planning and energy into their care. Often, this means that we lose objectivity. Anyone could see the patient was going to die, but we continued. Now she is lying in the ICU, on partial heart bypass to support her own heart, and still deteriorating. She will die, despite our best efforts. That much is certain. The question though, is when do we stop? The dramatic scenes on TV medical shows never play out like that in real life. There is more likely to be a slow dawning of the reality that someone will die even although we gave it our all.

Futility is the term used to describe what happened today. The problem comes when we try to say, at what point did treating this lady become futile? In hindsight, it is obvious. But we don't live in hindsight, so we find ourselves doing more and more heroic things in order to prolong life in the face of certain death. Why did this patient die? I'm not sure if we will ever know why her heart just gave up after coming through the surgery and immediate postop period so well. She had the right operation, perhaps the timing wasn't ideal. But it won't stop us from trying again, another day, on another patient, because we must continue.

By the book

Community service has been a feature of medical practice in this country since 1997. Following internship, newly qualified practitioners are required to do a year of community service. For the most part, at least when we did this, comm service was performed in the rural areas. Thus it came to be that we were sent off to the far reaches of the Northern Province to service the community.

The funny thing about out year in the bush is that it seems to grow better with each passing year. It was dreadful while we were there, but in retrospect it seems like a good idea and I have been heard telling junior colleagues that a year in the rural hospitals will do them good. While saying this makes me sound like an old man, I happen to know that I am right.

There is nothing better for one's skill and confidence as a doctor than to be placed in an environment where resources are limited, and you can't hide behind the laboratory of radiology departments. Clinical acumen, and a couple of good books are the tools by which lives are saved. Take one memorable incident, for example.

We were on call for the afternoon theatre list - a list which is usually populated by the obligatory closed manipulation of a childhood fracture and uterine evacuations following backstreet contraceptions, sorry abortions. Typically there would be two doctors assigned to this list, one to cut and the other to dope. So off we went to theatre, my wife (who was doing her internship) and myself (as the "senior" doing comm service). Imagine our consternation when gazing down the list we see Mr X, who is booked for a drainage of a Quinsy. Now a Quinsy is an abscess of the area around the tonsils. As such, it is very close to the airway and one or two large pipes carrying blood to and from the brain, namely the internal carotid artery. As such, it represents a rather tricky procedure for a junior doctor.

We felt somewhat out of our depth, so we phoned the senior doctor who seemed somewhat disinterested, his advice being, "just drain it carefully, everything will be ok." So armed with this confidence from afar,  we were left with no choice. Fortunately, we remembered that we had a CME journal where this particular procedure was described and we hastened home to fetch it. Having located the article we then proceeded to put the poor chap on the table.

One can only imagine how this fellow felt when he saw that his doctors, who he had been conditioned to believe and trust in implicitly, were using a dog-eared magazine to plan his surgery. My wife elected to be the provider of a compliant patient and set about giving some light sedation. Her job as anaesthetist also included holding the journal open on the right page so I, the dashing wielder of the knife, could place the cold hard steel in the right place. We elected to sit the patient up, and approach this from the front. This required the securing of a surgical blade to a tongue depressor with sleek tape (ubiquitous pink tape that holds hospitals together all round the country). Duly prepared, I set about draining the abscess. Of course, being lightly sedated, the patient was not completely co-operative, and quite a few times he almost lost his tongue. But in the end the abscess was drained, the airway maintained and the patient delivered to recovery in a better state than he was when he came in.

I am convinced that there is a guardian angel that covers doctors in resource constrained environments. When I look back on that procedure and think how we would approach such a case in our hospital, I can't believe we got away with it. At our august institution the patient would receive a full general anaesthetic and there would be much wringing of hands about how the airway would be maintained and protected from the pus which was to be released from the abscess. Yet, similar procedures are carried out on a daily basis in the periphery with very few poor outcomes. We have often said that you only get the complications you know about. This certainly seemed to be the case in the rural areas.

Update - the little voice

So today, I went to see the patient I referred to in my previous blog post. She, miraculously, believes I saved her life. Apparently my surgeon has been pouring honey into her ear about me all week. Oh well, I'll take what I can get. It is nice to be appreciated occasionally.....

Anyhow, I suggest to her that she be investigated for a coagulation problem. Once we are both on the same page, ie. that coagulation refers to blood clotting, she pipes up, "Oh, but this has happened to me before. When I had teeth out as a teenager, I bled so much they had to give me blood..."

At this point, I started looking around for the ton of bricks I was about to get hit with.. Reason being, you see, I asked her last week if she had any blood clotting problems. She denied this. I guess I didn't phrase the question in the right terms. If you only have a short time with a patient, you simply cannot get all the information and double check every answer. So I'm left with two conclusions. Firstly, what is important to me in a consultation may not be important to the patient. Secondly, I need to get better at communicating how important things are, so I get better information.... Communication skills are not well taught at medical schools.. This is something I will take into my teaching. I simply have to figure out how.

That little voice

The funny thing about anaesthesia is that there are so many ways to do the same thing. I like to think that this indicates that we, as a speciality, are an enlightened bunch, unburdened by the restrictive "do it my way because we've been doing it like that for 40 years" mentality which is prevalent amongst our surgical colleagues. Of course, it may also mean that we don't have the faintest clue what we are doing. (Un-bloody-likely!)

However, when that nagging little voice in the back of my head tells me to do something a certain way, I know better than to ignore it, and I submit to it, like a junior medical officer submits to the whim of the consultant. I had the misfortune to be reminded of this over the weekend. The 13th case on my Friday private list (yes, 13th case for those of you in full-time state practice - it IS possible to do more than 3 cases per day) was booked as a partial gastrectomy for a chronic, non-healing ulcer.

Since the patient had been out of the ward on a smoke break when I was doing my pre-op visits (go figure) I had to see her quickly on the red-line (the reception area of theatre). Now this already puts me on the back foot. I don't know what problems await me when I see the patient. Fortunately she is a 60yr old female, fairly well preserved despite a smoking history which is verging on biblical.

My plan for her would have been to give her an epidural, and put her to sleep. But, after looking at her, the little voice started up. For some reason, I was worried about the epidural. For those who don't know, an epidural is a small catheter placed in the area around the spinal cord where local anaesthetic can be administered for pain relief. Although it usually works brilliantly for pain control, there are some risks involved, and the one that scares us as anaesthetists the most, is haematoma formation in the area where the catheter is placed. This is a disaster, with the worst case scenario being permanent paralysis. I still can't explain why I didn't do an epidural for this lady, my only defense being that I had a bad feeling about it.

So I put her off to sleep, bang in the central line and Dr Ego starts his operation. Almost immediately I sense an increase in surgical anxiety. I pop my head up over the drapes and I see blood. Everywhere. She is oozing and bleeding actively from all over the place. This continues throughout the surgery, total blood loss is about 1200ml. Which is a lot, especially for this particular surgeon. However, he seems happy, we close her up and install her in ICU.

However, the niggling voice continues overnight and I try to sound surprised when Dr Ego phones me at 07h30 to say that the patient has bled 2litres overnight and he wants to go back and have a look for a source of bleeding. So I race off to the hospital, where the patient has already been put onto the table. She does not look good at all.... Now I have a surgeon pacing, nay, champing at the bit to get going, but my gut tels me to increase the level of monitoring first. If I hurry her off to sleep, she is going to die, she is so far behind on fluids and blood. So I tell him to go have a coffee, and put up an additional big IV, an arterial pressure monitoring line and then gradually put her to sleep.

Despite all this added care, she still drops her pressure and makes a fairly credible attempt at dying. Fortunately I have my real time arterial pressure monitor, and I pick it up immediately (as opposed to the noninvasive BP which only reads every 3minutes and is unreliable when the pressure is low). A few big hits of adrenaline, 3 units of blood and a whole load of sweating later, she is looking better. If I didn't listen to my gut and allowed myself to be pressurised by the surgeon, the outcome would have been worse. We never did find a source of bleeding, and put it down to some kind of coagulopathy. (Probably related to the 8units of blood she was given..)

I can't say how often that gut instinct has saved my bacon. It is something that seems to come with experience although I have come across experienced guys that don't have it. But it reinforces to me the importance of good training at an institution where the majority of the patients are really sick.  Then, everything else seems easy....

Disinhibition

As anaesthesiologists, we are present at a very vulnerable period in the surgical experience of our patients. This vulnerablility is primarily of our own making - we put patients into pyjamas to remove the power suits that define people in their daily lives, we make them lie in bed and we shine bright lights in their faces.

Then, we poke them with sharp sticks (IVs), shove oxygen masks on their faces, make them lie on ice-cold tables and render them unable to live unaided. In addition, sometimes we are our own worst enemies. A junior colleague of mine recalls the story of needing an anaesthetic. The male anaesthetic nurse didn't introduce himself to her prior to shoving his hand down her theatre dress to place ECG electrodes. As she said "Most guys would have to at least buy me a nice dinner before doing that!" She recalls feeling exceptionally vulnerable, despite being in a similar environment to the one she works in on a daily basis.

The CEO of the large multinational is lowered to the same level as the blue-collar worker, and that does strange things to people. Add a potent cocktail of mind-altering substances (think Michael Jackson), and the situation becomes even more interesting. The majority of anaesthetic agents cause some degree of disinhibition. Normally, the frontal cortex exercises some modicum of control and regulation of our desires and impulses (obviously in some people this is less well developed..). This control is released by anaesthetic drugs, and this effect is most pronounced at the beginning and end of the anaesthetic. Now let me say at the outset, that the vast majority of patients behave completely normally as they go to sleep and wake up. However, there are the exceptions....

1. The Swahili Speaker. - This guy (it is always a guy) is white, 20-35yrs old and most likely to be a heavy social drinker. They also typically are the chaps who say "Hey doc, you must be careful, because I am resistant to anaesthetic" They provide some mirth as they are being induced, because as they drift off to LaLa land (and yes, that IS a proper medical term) they start to speak gibberish, usually accompanied by emphatic finger pointing as though making a point (think Ou Krokodil).. I find the best approach is to casually say, "Yes, but we only do that on Tuesdays" and watch the confused  expresssion as the anaesthesia takes over.

2. The Nymphomaniac. Now propofol (our induction drug of choice) is a funny drug. Especially in young females coming for short/sedation procedures. I don't know why, but quite a few of these ladies wake up professing to have had "the most wonderful dream Dr." This statement is usually delivered in a very seductive way as the hapless woman emerges from her anaesthetic. Fortunately for them, they rarely remember this. I don't know, maybe I really AM that good...but I doubt it. On a more serious note, this phenomenon is a real medicolegal risk and is why a male doctor should never be left unchaperoned with a sedated patient.

3. The Brawler. These guys really scare me. There is no way to pick them up, unless they have done it before and warn me. Take, for example, a case I had a few months ago. Young, healthy guy, coming for colonoscopy (requiring light sedation). At the end of the procedure, as we are moving him off the theatre table, he sits up, looks me straight in the eye, and with no warning, delivers a fairly rapid right hook. Fortunately I was able to float like a bee and move my head back and he simply glanced off my nose. Any closer, and that would have been the end of the list. Afterwards, I went to see him. He was so embarrassed that he didn't know where to look. He had no recall whatsoever. I suggested that he warn any future dope-artists, because these guys tend to be repeat offenders. What kills me is that they are usually the nicest patients....

4. The Runner. This character is mainly seen on Saturday evenings. They are the chaps who were shot by the police "for no reason at all doc. I was on my way home from choir practice, and the police shot me out of the blue" Yeah, right. The fact that you had a 85" plasma on your head at the time had nothing to do with it. So we patch them up, and often, when they emerge, they wake up running. In their minds, they are running from the police still. The fact that they are often big strong guys makes this quite entertaining. Often quite a few nurses and porters are required so he doesn't run himself off the theatre table. (of course, if you have really BIG nurses, you don't need so many.)

5. The Sailor. Also hugely entertaining. Typically, this is an elderly, very straight-laced gentleman, you know the type, proper, ordentlike man. I recall one day working in a theatre right next door to the orthopaedic theatre. My colleague wheeled in this lovely old guy, full of beans and chatting pleasantly to her. When she wheeled him out an hour later, he was cursing so much that he was surrounded by a blue haze so profane that even the surgeons were embarrassed. 15 minutes later, and he was back to normal again. No recall (probably a good thing).

As I said before, these are the minority. And yes, we understand and don't victimise patients when they behave strangely around their anaesthetic. It is understandable. We made them do it. But don't blame us for having a little giggle, because sometimes it really IS funny....