Sunday, August 28, 2011

Thinking of Going Back to Work

Wow. I never thought I would be writing THAT as a title. I am not fully recovered, by any means. Just ask Nej, who has been with me for the last few days. My face turns pale and I can feel the blood draining from my head when I stand up. Then, a round of vomiting follows just like clockwork. But some thing has changed and nothing will be the same again.

The thing that has changed is that I miss being a doctor now. I missed it before, but not like now. Now, I love to discuss cardiac output and stroke volume, pulmonary hypertension and the wedge pressure. I remember ventilation: CMV or AC. You can wean a patient off of a ventilator using either PS or SIMV. But the important thing is to do so gradually, so that extubation will be a success. Otherwise, the endotracheal tube has to go right back in. And we all know that no one hates that more than the surgeons.

The surgeon may stomp into the recover room or ICU bed, since he (inevitable it is a 'he', not a 'she') was just paged with the notification that his patient is about to be reintubated. Rather than seeing this event as a Failure of Anesthesia, I look at the patient and think that wow. 3 minutes. Brain injury. No one on my watch is going to get a lack of oxygen. Not one single person will ever suffer at my hands, or die because of my 'mistake'.

So will I ever be a doctor of anesthesiology again? Hmmm. I chuckle inwardly, because that is such a predictable question yet it rings so sour in my ears. I made a vow to myself and to God when I started Anesthesiology training. It was this: If I ever made an error or somehow contributed to a patient death, that would be The Day. I would walk out of the Operating Room and never look back. I would expect the person and/or the family to sue me, because that is what Malpractice Insurance is for. Even so, 'malpractice' may not always be what actually happened. In medicine, there are unpredictable episodes of seizures, hypoglycemia, chest wall tightness, malignant hypertension, and a myraid of other unpredictable events that could happen at any moment.

The key issue is not just vigilance. I could sit on my anesthesiologist's chair without reading the newspaper or talking on the phone, and I could have all of my attention on my patient. But if I give a drug and forget to write it down....then I made a mistake. So, then I would have to decide, "Gee, is it better to give another dose (thereby giving a 'double' dose), or is it better to not give anything (thereby not adding more potatoes to the pot).

So, no. I am unable to work as an anesthesiologist. I would not consider it fair nor ethical to my patients. My patients deserve some one who remembers, some one who does not forget, some one who is meticulous, and some one who can advocate for the patient. So, I think I felt more like a lawyer than a doctor many of the times, since I was working with surgeons, discussing a particular issue. The most common 'argument' in the ICU was whether to give fluid or furosemide. Fluid or furosemide. Chief Residents have almost punched one another out over this subject. The pulmonary artery catheter and the wedge pressure become important here, considered in to all the history, labs, diagnoses, and current issues a patient has.

I just would not put myself in that position of having to have an impeccable memory. So, to those who have asked and to those who have hesitated to ask: No. I don't think I'll ever work as an anesthesiologist again. Ha. But maybe I could still Chair a Department of Anesthesiology, since no one should die under my watch in that capacity. Maybe I can do Preoperative Assessment Clinic, because I can sit down much of the time, behind a metal desk with Veterans walking by, anticipating surgery. Maybe I can do consultations for Preoperative Evaluation, because I've done it before and I was good at it. The only truly memorable reward I ever got was when one Chief Residents thanked me for making him use his stethoscope. Because patients are people, not just eyeballs.

Just because you are going in to the OR for surgery on a small case (like cataract surgery), does not mean that it will be 'easy' on anyone. Most anesthesiologists have probably seen that one patient who walks into the OR and then without on the OR table. Didn't any one listen to his heart/chest before the OR? It is so irritating to me that lapse after lapse can occur in one patient....and yet the patient will never know. Could this death have been prevented? Perhaps no one will ever know. That is why I tell people not to get surgery unless they absolutely have to....and please ask the surgeon this question: what are my chances of 100% success, if I do the surgery?

Or, is it not much of a choice? Maybe it is emergency or emergent surgery, ASA IVE evaluation. Risks go up and the thoroughness of the anesthesiologist comes in to play. Here is where we separate the men from the boys, so to speak. Or the balls from the no balls. Is your Anesthesiologist going to talk to the Surgeon? Is your Anesthesiologist willing to fight for you, the patient?

What does the Anesthesiologist do while you are asleep? Does she whisper into your ear that 'everything is okay'? Does she take her manicured hand and touch your temples ever so gently, to let your brain feel a sensation other than the cutting. "I wish you were my anesthesiologist." :-). Nicest words ever to be said in this profession.

You see, Anesthesiologist have a 'loner' job in the OR all day with the Surgeon(s). No peers come in to ask what is going on with your case, unless they are here to 1) give you a morning break; 2) give you a lunch break; or 3) give you an afternoon break.

And who leaves their patient in the care of a second person, so that she may eat? Well, one school of thought is that I would never leave my patient at a time when it was pertinent. No one knows my patient better than me, and I don't want to trust this patient's care to any one else. The concept of "continuity of care" applies here. If your Anesthesiologist leaves the room to another Anesthesiologist whom you never met, is that fair? Or should we tell you that we will take a break, but only if we feel comfortable? If I told you I might leave you in some one else's care for a short time, you always look at me so longingly. Your eyes plead with me not to leave you. We have established a physician:patient relationship, and you trust me. Each Anesthesiologist practices medicine/drugs differently. The individual person does make a difference. Ask your Surgeon.

Your Surgeon can request the actual Aneshtesiologist so that the OR Schedule reflects this 'pairing' for this patient. What a compliment to all. If the Surgeon chooses an Anesthesiologist, it is because he has a preference for your particular case. Only the Surgeon knows what the Anesthesiologists are like, and most Surgeons, especially in an Outpatient setting, know which Anesthesiologist they would like to have.

So the next time you are heading for surgery, pause. For those of you who have had multiple surgeries, you already know that your Anesthesiologist is very important and you want to speak to us directly. You know: We listen to your past experiences, we will not give you the same drug that made you throw up before, and we will perhaps add an extra drug to ensure that you do not vomit. We will allay your fears and reassure you that we are listening to you and that we will follow your wishes. You say that you do not want an iv placed in your right arm, because you have had too many surgeries there? It may not make precise medical sense, but hey.....I'll find a vein somewhere else for you. And if you wake up with an iv in your right arm, please know that I did not do it. I tried to argue on your behalf, but they would not listen to me. So some one else did it. I did not mean to betray your trust and I believe that the right arm iv was not necessary. You are a person with wishes and desires and I know that you are placing your life in my hands. In fact, you may not realize how you are doing just that.

The Anesthesiologist is a loner and a lawyer. She advocates for her patient, no matter who the Surgeon is. The Anesthesiologist is a new, independent doctor who is trained in a super-specialty. Only with this person's consent can YOU be taken to the OR. If the Anesthesiologist tells you that she is rescheduling your surgery, that can mean:

1. It is not an emergency. It is elective surgery that can be done at a later date.
2. You may need additional work-up, whether it be a stress test, an ECHO, or Pulmonary Function Tests (PFTs) from your pulmonologist.
3. All your specialty physicians should know that you are going to the OR, especially your primary care doctor. There is nothing worse than having a PCP call me, yelling at me for doing the Anesthesia for the case that I didn't know that he/she didn't know about. Hence the Primary Care Physician's consent is needed for good continuity of care. And it is professional courtesy and common sense.
4. Your surgery just was not meant for this day and this time. While you are asleep on the OR table, somewhere in the USA, some one is dying on the same OR table in another OR. We want you to live, and to be better (not worse) after the procedure.
5. Reanimation: just as important as going to sleep and staying asleep under anesthesia, the Reanimation of the human body is recognized all over Europe as a separate entity. We have to wake you up. How you wake up, when you wake up, what you can do or not do after you wake up...these issues are paramount, especially for Neurosurgery.

So next time you see yourself headed for the OR, just do a little homework, have a  candid talk with your Surgeon, and know that you can request a particular Anesthesiologist. Don't be afraid to ask. :-).

Oh! No one did a type and cross on this patient because the surgeon did not tell us that he was going to make a stern to bow incision and that the case would take 5 hours. Oh! and

1 comment:

  1. That's so exciting, to even be thinking about going back to work! I'm so happy for you! :)


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