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?

              

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.....

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....

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....

Comfort Zones - or "A day in the life of an anaesthetist who hasn't gone away for the holidays"

A recent blog by one of the sublimely funny guys I follow on Twitter (http://bit.ly/6nAzeX) highlighted the joys of living in the big smoke during the Christmas holidays. It feels like the vast majority of people (who have the wherewithal) simply disappear to the coast, and the streets echo with the sounds of house alarms going off, howling dogs and the incessant ring of my cell-phone.

Now don't get me wrong, being in the service provision industry (I provide immobile, amnestic patients to surgeons), I am well aware that no work = no pay. However, I didn't stay in town to work my a*s off. I'd like to go to my salaried gig, do as little as possible while still looking productive, and then go home to play in the pool with the kids, drink good red wine, and wait for the new year.

Unfortunately, my 'phone, and my colleagues have other ideas. Take today as an example. There are rumours floating around of a really sick cardiac patient in the local private clinic, and a cardiac surgeon desperately looking for an anaesthesiologist to dope the poor sod for his valve replacement. I get a small spike in adrenaline, because this patient, from what I've heard, is practically sitting down to tea with St. Peter. But never fear, my senior colleague is going to do the case. Relief washes over me, until I discover that said senior colleague has a bad case of Bombay bum, and is man-down. Now the job falls to me as the next most senior cardiac anaesthetist.

So what, you say, you are a cardiac anaesthesiologist, how hard could it be? And therein lies the rub. The biggest problem facing me now is not the pre-terminal patient. We get enough of those in our fine ivory tower on the hill. No, my problem is that I am going to be way out of my usual haunts. New hospital, new surgeon (although widely respected), and unfamiliar team = something approaching palpitations.

We take for granted simply knowing where things are. In our hospital, every OR is uniformly equipped and stocked. i.e when I open the third drawer on my trolley, I know exactly what I'll find there. Now I am stuck in an unfamiliar environment, and have to ask the long suffering anaesthetic sister where everything is. It doesn't help that I, being blessed with a Y chromosome can't even see the things directly in front of me. All of this conspires to create a zone of acute discomfort for me, which I'm trying desperately to hide behind a veneer of confidence. It doesn't help that I have never done a private cardiac case before.

Fortunately, the case goes well, the training takes over, and at the end of the day, a cardiac dope is a cardiac dope whether the walls are white or green. I hope no-one noticed my hands shaking....