Long day, longer night

It is about time to say farewell to the summer of 2007. It was hot, rainy, busy, leisurely and, as any other summer, beautiful. What can be better then long days, when it's still daylight outside when you leave your work, especially if your workplace is underground, basement or operating room - no windows, no ideas about the outside world. And sometimes, it is important to inquire about the weather before you leave for home.
I was on long, outofthecountry, vacation trip and came back last Saturday. The neighbourhood looked as if it were part of the Baghdad's outside of the "green zone", recently blown up suburb. Trees were up side down, some leaning against the houses, broken in several pieces. Dirt and water are everywhere. What the hell!? The explanations came from the cab driver and the neighbours - last Thursday there was an unusually strong wind, tornado, monsoon, or whatever that had never been seen or heard of before in Chicago area. Our house was OK - minimal basement flooding, no power, backyard is a mess. Stories started coming in, one worse then another, about what really had happened. The best was my buddy's from work:
"I did eleven cases on Thursday and had no clue what was happening outside. At about 3 or 4pm monitors in the OR were acting up - flickering, turning on and off, but nothing major, nobody was in any danger. I thought it was just some power shortage and didn't take it as anything serious. My wife paged me several times, but i was busy and couldn't call her back right away. When I did call her cell was not working, I thought she had forgot to charge it (again!). Finally, about 9pm, my day was over. I was tired, hungry and ready for a beer. As I came out onto the parking lot and headed towards my car, I did notice an unusually large amount of water running on the street, I jumped across all these puddles and little rivers and approached my car just to find out it was not my car at all. You know, I usually park at the same spot every day. And I did leave my car there that morning. What was more puzzling there was another car there on my spot, the same model as mine, the same color with different plates and interior colors. Imagine my thoughts: "Someone stole my car and parked another car of the same model and color into my spot, but why? What, if anything, am I gonna to say to the police?" I was standing there for about a minute or so, when one of our orthopads came running from the other side of the parking lot: "Ah..! Here it is!" He opened what supposed to be my car with his remote keys. Astonished I asked him :"Do you know where my car is, I left it here this morning?" "Look around, buddy, that monsoon shuffled the cars around, some got smashed really bad". I looked around and noticed that the cars on the parking lot were all over the place. I found mine not that far away, it was OK, just one mirror was gone. At home I found out we had our basement flooded, carpet screwed up and some other damage, but nothing had made that much impression on me as my hospital parking lot adventure - looking at exactly the same car as mine on exactly the same spot I had left mine, but it was not mine! Stuff like that makes people crazy!"

Listen to your doctor..

Human mind is a sacred territory. At certain times it can reveal unexpected secrets, thoughts or desires.
The next patient of the day is a young, in her early thirties, lady scheduled for an outpatient routine gynecological procedure. She refuses general anesthesia. "Just give me a little something, I don't wanna go to sleep!" Of course, it can be done, but it may not be optimal for the surgeon, she may move during the procedure. We do surgeries like this one all the time - everybody goes under, really not a big deal. But she looks terrified - I bet, she hates to fly - it's the same "loss of control" thing. I talk to her, surgeon talks to her - no, no, no general anesthesia, just light sedation! OK, what you gonna do, it has to be done. We bring her to OR, I start dripping the sedative through the IV line. Gradually she doses off. Nurses position her for the procedure - it's called a lithotomy position - legs up in the air in stirrups - women know. I check her vital signs - she appears to be sleeping. I indicate to the circulating nurse, she can start prepping. As the nurse touches "down there" with the sponge soaked with cleaning solution, patient suddenly lets out a powerful moan - "Bad dog, very bad dog". Nurse jumps back terrified. I pump in more sedative. Surgeon chokes on her masks laughing. The nurse tries again to do the prep - "Doggy, doggy, easy..? Bad dog.."
I end up giving her a lot more drugs so she would let us do it without mentioning her dog again. In the recovery room she is awake looking good. I ask her: "What kind of dog do you have?", "How do you know I have a dog?" "Well, I am a doctor, I know things..". "You're creepy". "Who, me! Lady! Let me tell you about you!" - of course, I don't say it.
Under general anesthesia she would not have told us she had a dog.

Don't always pick up your phone

My patient is a healthy 28 years old guy. He is having bilateral (two sided)hernia repair. Easy procedure, slow surgeon - boring, but in our field, boring is totally OK. And then the phone goes off. I pick it up:
-"Hello"
-"Hello" - really old person's voice - "Is it Doctor Mesnick's office? This is Marvin Dombrovski calling, my wife.."
-"Sir, this is an operating room in the hospital, you got the wrong number"
-"So, Doctor Mesnick isn't there?"
-"No, it's an operating room, we are in the middle of surgical procedure here"
-"Surgical procedure? But doctor Mesnick is not a surgeon, he is a..regular doctor, but you know, he is very good, nice doctor, he gave me this blood pressure pills, and it's normal now; good, very good doctor"
-"Sir, just check your number"
-"I would, but my wife's got the number"
-"So, ask your wife"
-"I would, and I've tried, but she is not responding, she is on the couch, I thought she was sleeping, I called her, she didn't answer, that's why i am calling doctor Mesnick - he told us to call him if there is a problem"
-"Wait..your wife is not responding!? Did you try to wake her up? Is she breathing?"
-"What? You want me to pinch her or something?"
-"Yeah, yeah.. try that, and then if she does not wake up call 911"
-"Wait, don't hung up, I cannot dial 911"
"Why?!"
"I can't really see very well"
-"But you called here somehow?!"
-"Well, I've been trying to dial doctor Mesnick's office all morning, but keep on getting wrond number.."
-"How long has your wife been unresponsive?"
-"I don't know..an hour or two"
-"OK, go check on her, give me your number, I'll call you back"
I wait for 2-3 minutes then call back:
-"So? Did she wake up?"
-" I don't think so, I pinched her as you'd told me"
-"OK, stay put, I am calling 911"
It takes some time to explain the situation to 911 dispatcher. In the meantime, my patient is doing fine - stable, the surgeon is just finishing one side and has another to go.
-"Hello, Marvin! I have called 911, they are on the way, can you check on your wife and see if she is breathing? And if she is not..do your know how to do mouth to mouth..?"
-"She is breathing, all right, she is not only breathing - she is screaming at me that i have pinched her, thanks to you, doc!"
-"Wait, Marvin, so, she is OK?, I have to call 911 and cancel.."
-"No, don't call, they are already here, maybe they can pinch her again, so she stops screaming"
"OK, Marvin, take care now, I gotta go"
"Wait, doc, could you find doctor Mesnick's number for me in case something else happens, so,I don't have to call you back?"

I love these people!!

He is 4"10" and 280 Lb. He cannot lay down because he cannot breathe, even sitting up he needs some Oxygen, otherwise he'd die. He takes tons of pills: for high blood pressure, for diabetes, for asthma, for back pain, for arteriosclerosis and for something else he does not remember the name of. He requires 24 hours a day nursing supervision. And now he is here in our presurgical area because he needs a "big whack" as our back surgeon has put it. It means we have to slice open his back from the neck all the way to the butt, so he will look like a giant fish on the chef's table. I will have to keep him alive through all this ordeal while the back surgeon will be putting giant screws into his spine to make it straight. He will be loosing blood, and to keep his blood pressure at acceptable levels i will need to start vasoactive medicine drip, along with tons of fluids through many IV lines and of course blood, lots and lots of blood. We will have to keep him asleep at least until the next morning, when his vital signs are stable, he is off that vasoactive drip, and blood tests are normal or close to being normal. And you know what!? He is going to do great! Why? Surgeon's skills? Sure! My valuable expertize? Sure! But most of all - his attitude!
"Hello, Sir! I will be your anesthesiologist. Nice to meet you. Do you have any medical problems?"
"No"
"What do you mean? What about this Oxygen in your nose"
"Oh..Yeah. It's hard for me to breathe without it, but when it's on - no problems"
"What about your blood pressure?"
" Yeah..I take some pills, so they take care of that, so - no problems"
"Asthma?"
" Yeah.. Inhalers - no problems"
"Diabetes?"
"Pills - no problems"
"And now you are here because you have a huge scoliosis"
"Yeah..But you, guys are gonna fix it, so it won't be a problem"
I saw him next day after the surgery - he looked great, no problems!

What would you do?

My first patient today is a pleasant 47 year old guy scheduled for a cholecystectomy (gallbladder removal) - a pretty routine straight forward procedure. His surgeon has ordered a urine test, he had it done 3 days ago. I don't know what the reason was for that test - patient didn't have any symptoms or complains, but when I read the official result, i think about canceling this case until further investigation, it reads: "This horse might be pregnant!" What would you do?

Expect unexpected..

Here is the one for the next ER episode: I get a call from our ER. There is a trauma coming with potential airway issues, we need anesthesia present. That's how they call us - anesthesia, not doctor anesthesiologist, or anesthesiologist on call, nothing like that, just anesthesia, not even Anesthesia, oh no. Next time I need a nurse I will ask for "nursing": "Hey, can I get some ER nursing help over here?" But forget it, I promise: All the crankiness in the next post. Now back to the coming trauma. When I get to the ER they tell me it's a firefighter. He has fallen from a ladder, while doing his firefighting thing. He does have a broken leg, potentially some other injuries. The ETA is about 10-15 minutes. I decide to just hang around the ER with my buddies ER docs. I have to tell July is the craziest month to get to the hospital and especially ER. Bunch of new overentuziastic residents and medical students are swarming around actively looking for a live or two to save. With no warning they are ready to start pumping your chest and give you mouth to mouth if you ask for a cough medicine. Our future doctors!
I have not even finished my coffee, as this young aggressive crowd started moving in one direction - towards the receiving double door - the injured firefighter has arrived, the July madness has begun. One glimpse at the guy is enough to figure out he was not in any immediate danger - he is fully conscious, breathing on his own, not needing any oxygen. Yes, his leg is broken, for I can see it is being backwards - the heel pointing in the same direction as his nose - not good! (If an anesthesiologist can suspect a broken leg by just looking at it, chances are it is broken). So he will be at the mercy of our wonderful orthopads if he meets two conditions:1. There is nothing else wrong with him; 2. He is able to survive these first minutes in this crazy, typical July ER. Several newly graduated docs are attacking the poor guy at the same time: "Sir, do you hear me!" "Who is the president of the United States?!!" "Do you have any allergies?!" "Does it hurt here?" "Do you or anyone in your family has a history of cancer, heart disease, rabies, ingrown nails, AIDS or at least asthma?" His head is spinning, but that is not stopping the army of young and knowledgeable eager to help. Someone has brought a huge special metal scissors and started cutting his firefighter pants to open up his broken leg to make it readily available to be sutured, cut off, or at least cleaned up. And suddenly it is silence - nothing but silence - it lasts maybe just a few seconds, but that is enough for me and some ER attending doctors to squeeze in through the crowd and what do we see - this big, over 6 foot tall, muscular, manly man, who was just awhile ago injured on the line of duty is wearing a nice bra - bright red with some difficult to appreciate pattern as it is severely wrinkled around his massive chest, the panties are there as well nicely matching the bra in color and style. As I am about to cover my mouth so I don't make it worse for the poor guy, one of the medical student says:"We have called your wife sir, she is on the way". Now imagine the scene - you are in the middle of a busy emergency room on a stretcher, butt naked -if we try not to look at the bra, with million people looking at you, and you are a firefighter! What would you do? Kill yourself with those metal scissors that has unveiled the truth? And the poor guy just says: "I don't care what you guys think just don't tell my wife!" We will not...

Who's weird?

A colleague of mine - an anesthesiologist, solid, well respected doctor, american graduate and very down to earth fellow has put his own wife to sleep for a routine gynecological procedure. Yes, he did! Is that OK? Well.. first of all, it is against our hospital policy to have relatives present in the operating room. But let's put all the legal stuff aside. Is that OK? Seriously! When he was asked why, he said (his direct words): "She is my wife, you know.." Wow! He did let me anesthetize their son 2-3 years ago - that was OK, i guess, but no, not the wife! Is he ashamed some other men are gonna see his wife naked? But her gyne doc is a guy, they even golf together! I don't think that is it. I would be a nervous rack if I had to do anesthesia for any of my family members (God forbid!!!!). So that is my opinion - the guy is just weird. Why would anybody want to do anything like that. Doesn't he trust his colleagues? Or maybe, it is the "naked thing". But we do see people in OR all the time, they are nothing more then just patients! Remember from "Master and Margaret" Bulgakov - "Madam, I have seen not just naked women, but even women without skin" (maybe I shouldn't have put this in here, but I just love the line).
And by he way, his wife did very well, I guess, he did a good job. I told you he is a good doc, but, if you ask me, just weird. No more referrals from me, buddy.

Mass Casualty

Disaster strikes in Minneapolis! One of the main bridges collapsed and people died. Some were brought to the hospitals and some were taken to the ORs for emergency surgeries. I could only imagine the chaos and desperation of the OR personnel - it is a lot to think of: patients'condition, what is wrong, past medical history, allergies, last meal, etc.. I have been there, done that. Complete information is not always available in these situations, most of the time it's not available. But it definitely would be useful! I remember a case from my residency - although I was not involved, it was discussed at our weekly conference: 30 years old law student was rushed to the Operating Room after a deadly car crash - his girlfriend had been pronounced dead at arrival to ER. He had intracranial (inside the head) bleeding and we had to act fast. He was unresponsive, when they brought him over to ER. His family was not immediately available to ask any questions regarding his health history, and I don't think at that point any of the medical personal was thinking of that. While on the operating table he was given a standard antibiotic. People would routinely get this drug in the OR. Soon after that he had developed what looked like an antiphylactic reaction. So besides his already severe acute medical condition, anesthesia team had to deal with that. He died several days later never coming off the ventilator. Of course, I am not saying his death was a direct result of this acute allergic reaction - his brain injury was severe enough to kill him, but it didn't help for sure. His family later confirmed that he'd had a documented allergies to several antibiotics, eggs, and some other things. Certain allergies change the way we plan our anesthesia strategies. That is if we know in advance..It's much easier to figure out one's financial history then gather any medical information. It's not a question of technology, but rather a legal issue and most importantly people in general don't feel immediate urgency in needing anything like that (iphone on the other hand..). It would be nice for everybody to have a credit card like device with all medical information on it, not only in case of emergency, but even when you change your doctor, go to see a specialist, move to another area etc..
Praying along with people in Minneapolis....

Ignorance, stupidity or both.

I think I've mentioned in my other posts how, it seems, irresponsibly people approach their health care needs. When we shop for a car or a house or even do our regular grocery shopping we're armed with knowledge of the market, interests rates, latest car models and their reviews, sale coupons, etc. But when we need anything done to our bodies (i am not talking about body piercing) all we do is just show up! I met a nice 8 year old boy and his lovely, concerned and anxious family. During my presurgical interview Mom mentioned that her sister (boy's aunt) had "some kind of severe reaction to anesthesia" and their pediatrician specifically asked her to mention that fact to me! What kind of reaction?! She didn't know! I pressed: "was it an allergic reaction to a medication, what medication, what kind of symptoms did she have, was she hospitalized, what kind of surgery did she have, etc.." - nothing! No more additional information. She even got somewhat angry with me. "I said there was a bad reaction to anaesthesia! What else do you want?" Both parents were educated professionals. I bet, had I asked the Dad about his opinion on the latest BMW model he would've elaborated for quite awhile. Why is it? I maybe wrong, but it seems that when people are financially detached from any decision making process, and in the case of health care in the USA it is in in the hands of insurance companies, they really loose interest! The schools completely ignore any health care education with exception of "smoking and drugs are bad, exercise is good" type of lessons, but nothing about how to be a savvy health care consumer. Somehow good doctors will take care of you. And it puts an additional burden on health care workers - doctors, nurses, technicians and an additional liability. Of course, I did put that kid to sleep and we did the case with no problems, but I just took my chances (what if his aunt had an episode of malignant hyperthermia - a disease, although very rare, requires special approach to anesthesia management. What else could I do? We called pediatrician office - it was closed, called the aunt - she would not pick up the phone. I didn't want to cancel the case, because they waited for awhile, took a day off from work, but some of my colleagues probably would. Hey, people out there please educate yourself. www.surgerytomorrow.com