Running Man

Anaesthetists are like the Bomb Squad. We are bloody good at defusing difficult and dangerous situations and we are generally calm and collected when things are going wrong. We differ from the Bomb Squad in one important respect. If you see a member of the bomb unit running, they are running away from trouble. If an anaesthetist is running, they are running towards the problem....

The other day, I was making a rare :) trip to the tearoom when I was literally bowled over by a colleague running in the direction from which I had come. No time for questions, I turned and followed him at high speed to the Urology theatre. He had received the dreaded phone call, the one that goes something along the lines of “Resus in theatre...”

Turns out the Urologists (bless their little frustrated plumbing souls) were removing a renal cell carcinoma from an unfortunate gentleman. The tumour had, as they are prone to do, invaded the inferior vena cava. In a startling flash of insight, they had asked the vascular surgeons to help out. So Dr Vascular surgeon clamps the IVC, proceeds to open it, and then all hell breaks loose because the clamp slips off. Suddenly, 3 litres of blood appear in the suction bottle, our previously stable patient now has no blood pressure and things are going horribly wrong.

Our intrepid urologist peers over the blood-brain barrier and says, “we have a little bit of bleeding here..” No kidding Sherlock....Fortunately they soon get control and we spend 15minutes filling the patient up with blood and blood products.

So now, I offer some thoughts on the running anaesthetist...

1. If you see an anaesthetist running, GET OUT OF THE BLOODY WAY! - this is my pet peeve - Sometimes we have to run to labour ward theatre, which is a LONG way from our department and I am always amazed as to how 2 people wafting down the corridor can manage to block an entire passage. It could be your relative I am running to...
2. The older I get, the less use I am when I arrive at the scene of the disaster. I tend to be in so much oxygen debt that I have to spend 30 seconds gasping before I can offer any constructive help to the resident. One of my mentors insists that you may as well walk and not be out of breath. I think he is just old.
3. Why do bad things never happen in the theatre you are right next to? Always with the marathon runs....
4. A little information prevents a lot of chest pain. Often, there is no need to run.           Unfortunately, I often have to run to figure that out. Sigh.
5. Did I mention...... GET OUT OF MY WAY?

              

Itchy Fingers

I work in a teaching hospital 80% of the time. Despite the fact that I love to teach and convey my knowledge to our residents, there is one aspect of teaching that really grates me.

Anaesthetists are not really perceived as being great procedural doctors. Most of our day consists of putting up IV lines and injecting stuff through them. Yes, we regularly insert endotracheal tubes but that to me is not a procedure - it is more like breathing or, to put an aeronautical spin on it - more like raising the undercarriage on an aircraft after takeoff. It is part of the process.

However, occasionally, we do get to do procedures. I am talking about things like epidural catheters, central lines, nerve blocks and procedures specifically aimed at control of chronic pain. This is where I have my great difficulty.

You see, I have very itchy fingers. I find it really difficult to watch a trainee do a procedure. It always seems to take forever if I don’t have the needle in my own hand. What they are doing never looks right - and as a result, I tend to want to jump in and get my hands on. NOW. Often, this is the only way to actually help. In many procedures, the way the needle feels as it passes through tissues is crucial to safely placing the catheter. And until someone figures out a way so gauge feel by simply looking at someone manipulating a needle, I will continue to pace, get agitated, and then shove on a pair of gloves and take over.

Does this make me a bad teacher? Probably. But that is simply the only way I know how to do it. Perhaps a daily supratherapeutic dose of Patience will help......

Superman?

On a lighter note.... As anaesthetists in private practice, we are often not unlike a travelling roadshow. In fact, in the distant past, the anaesthesia provider would travel armed with a big black bag containing his vapours and some method of delivery (generally a schimmelbusch mask.)



We have come a long way from the old days of dropping volatile vapours onto unsuspecting patients, to sophisticated anaesthesia delivery systems. However, the travelling anaesthetist is as much of a reality today as in the past.

Last week, on my private practice day, I counted how often I changed clothes. I went to 2 hospitals (one of them twice) during the day. Including getting out of my pyjamas into my street clothes, and then back into my pyjamas at the end of the day, I changed clothes 9 times.

Pyjamas - street clothes - theatre clothes at hospital 1 - to street clothes for trip across road to hospital 2 - theatre clothes at hospital 2 - street clothes for trip back across road to hospital 1 again - theatre clothes at hospital 1 (again) - street clothes for trip home - going out clothes - pyjamas again. Phew....This makes Clarke Kent look like an amateur.....

Evacuate!

One of the problems with being the anaesthetist is that often, I don’t know the whole story. Sometimes it is better this way, other times not.

Recently, I was asked to dope a young lady for an evacuation of the uterus. This usually involves curetting/scraping the uterus in order to clean out anything left after a miscarriage. So I go and see this 21 year old woman who is sitting with her fiance. We chat, I ascertain that yes, she is in fact the healthy specimen I was told about, and we whisk her off to theatre. I assume my sympathetic role, poor girl, she’s had a miscarriage etc..

As I am putting the monitors on, the scrub sister starts talking to the patient and asking about how many weeks she was, and the patient answers that she is 4 weeks pregnant. Now a little light starts flashing in the back of my head. She hasn’t had a miscarriage at all. (miscarriages tend to present later..) On further enquiry by the nurses, it appears that her wedding is in 2 weeks, and she isn’t ready to have kids yet. So now, I am doping for an abortion, and not an evacuation.

Is there a difference? From a technique point of view, no. From a personal point of view, yes. Would I have agreed to dope her if I knew it was an abortion? I don’t know. But I was uncomfortable that this decision was taken away from me. Personally, I disagree with the concept of abortion, and I am given rights in our constitution to reasonably refuse to be involved in that which I do not agree with. Please don’t get me wrong. I am not judging the patient. She too has the right to do what she wishes, and we are obliged to facilitate that. So my rights gave way to hers and we cracked on with the case....

Where we are at

I recently spent a few days in Bloemfontein. This would not have been my first choice of holiday destination, but it was the venue for the annual South African Society of Anaesthesiologists (SASA) congress. I enjoy attending meetings and congresses because it gives me a chance to catch up with the people who taught me anaesthesia and who have subsequently left state, or worse, the country.

Having spent 5 days with these people, I have some observations.

Firstly, we are so far behind the curve (in state practice) that it is not even funny. I attended a mini course on transesophageal echocardiography (TEE), presented almost entirely by ex Free State Universtity consultants who are working at a cardiac surgery centre in the UK. More on the TEE later..

We suffer under a huge burden of rheumatic heart disease, with resultant dysfunction in mitral and aortic valves. My surgical colleagues have a single response to this disease - replace the valve. Apparently, the standard of care is to repair the valve. Because our surgeons don’t repair, we have not been trained to assess valves adequately with the echo. So, hopefully I can now give some input and suggest valve repair. They also dope patients for trans-apical aortic valve replacements - a procedure which is exceptionally high risk, given that these patients are too sick for routine aortic valve surgery.



Secondly, we have lost so many brilliant minds in the field. Looking at a large group of anaesthesiologists, the most prominent thing for me is the age gap. There are lots of young guys like me (<35) and there are lots of people in their late fifties and up. In between, there is nothing. Where are all these anaesthetists? They have gone - Canada, United Kingdom and Australia. One hospital in Canberra currently has 5 consultant anaesthesiologists who are South Africans, all from Jhb. This is a big problem for us and reflects the problems in this country. There was much debate about whether they were “pulled” overseas, or “pushed” - General consensus was the latter.....

Thirdly, and perhaps most alarmingly, there is a very high incidence of moonbags. The less said about this, the better.

Little things

Kids, rugrats, sprogs. All different names for the same entity. And for most of us, cause for the smallest of flutters. You see, kids aren't simply small adults. They have unique physiology and they have given me more grey hairs as an anaesthesiologist than any other patient group.

Having said this, however, I consider myself to be reasonably confident in dealing with anaesthesia for small people. This is born of a large amount of experience - we have a very busy paediatric surgical department and, in addition, perform a (relatively) large number of surgeries for congenital cardiac conditions. So, when I was called upon as a registrar, late one night, to dope a 3 year old boy for a repair of a nail-bed injury, I didn't worry too much. As they say, pride comes before a fall....

As anaesthetists, we dislike poking children with sharp sticks while they are awake, so when we anaesthetise children we generally induce anaesthesia with gas. We explain to the parent that we are going to get the kid to breathe in our gas, and they will drift off to sleep. We also tell them that this is not a painful process and that the child will probably have no recollection of the induction. This explanation falls into the category of "if I say it often enough, someone will probably believe it."

To be honest, every once in a while I can pop a kid off to sleep without it really noticing, but these are few and far between. The fact is, the gas smells funny, and children don't like having things thrust in their faces, especially in an unfamiliar environment like an operating theatre. As a result I usually try to sneak the kid off slowly and surreptitiously (ninja style) but if they start crying or fighting we go full blast, hold them tightly and get it over with as soon as possible.

Unfortunately, this is the situation I find myself in on this particular night. Despite all my cajoling and ninja techniques, this poor child is fighting and kicking. So we switch to the infamous "gorilla style" induction. Hold him tight (anyone who as had to confine a strong 3 yr old will know that this can take 3 people) and go full blast with the Sevoflurane (anaesthetic gas). Sevoflurane typically works in 2-3 minutes especially if the child is taking deep breaths, which they typically are when they are crying. So you can imagine my surprise when after a good 3 minutes of fighting the kid is still wide awake.

"Don't worry," I tell the mom, "he'll sleep soon.." We carry on for another 2 minutes or so - no change. Now I am starting to think about why he isn't going to sleep. I turn around and see, to my horror, that the breathing circuit is not connected to the anaesthetic machine anymore. Our patient must have kicked it off very early in the process. I have spent 4 minutes trying to put the child to sleep with room air. Any parent will tell you that this approach is generally suboptimal.

So I have a dilemma. Do I tell the mom the truth i.e. that I am an idiot, or do I surreptitiously plug it in and carry on? I'm embarrassed to admit, all these years later, that I simply plugged it in. Once the child was actually getting the gas, he went to sleep in about 60 seconds flat. I wonder if the mother noticed. If she did, she never said anything....

Trainees

Yesterday, one of my junior registrars (residents for those of you in the US) came up to me to thank me for an ad-hoc tutorial I had given her. What surprised me most was that she then said that she finds me quite scary. This came as somewhat of a shock to me since I like to think of myself as the "good cop." I have never yelled at a registrar, nor been (in my opinion) unreasonable to any of them. Yes, I expect them to do a good job, but I believe my teaching style is more collaborative than combative.

This got me to thinking about our trainees. On average, we get new ones twice every year. Some years there are many newbies, some years there are few. What doesn't change is that they are generally young. Man, I wish I was that age when I started. Some of the guys joining this year were in primary school when I left med school. Youth isn't necessarily an advantage in this game, though. Our best registrars are those who have done many things before joining anaesthesia. You can't have perspective on ward management of patients unless you have been a medical officer/junior on a surgical or medical ward. Working in casualties makes you hard, and sharp as a doctor - good qualities in an area where the brown stuff often enters the fan rapidly and without warning. My 2 years doing orthopaedics and my rural experiences have helped me to have a more holistic view of patient problems, and the lack of this in registrars who join straight from community service is very noticeable. We as consultants have to then fill this gap.

I have reached a point in my career where it has become necessary to decide whether to stay in the state sector or not. If we had no registrars, the decision would be easy - Go. But, despite the fact that occasionally they drive me mad, they always phone me after hours with pre-meds when there are 2 consultants on cover for the list and some of them are downright unteachable, I love teaching them. Call it intellectual puffery if you will, but nothing beats showing a junior a technique that works for me and having them say, "Hey, that worked well, I'm going to do that from now on..." There is no greater satisfaction at work than seeing one of the people I helped to train pass their specialist exams and become mature, confident and capable consultant anaesthesiologists.

As doctors who have been trained by our betters, we owe it to those who follow to train them to be as good as, if not better than ourselves. I know that when I am old, and not simply an 'old fart', I want someone who has been trained by someone I trained to dope me.