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.

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.