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On call this past weekend, I was paged to the post-partum floor to evaluate a young woman who had vaginally delivered a healthy baby boy 16 hours ago. Her chief complaint? Intractable back pain.

[Background: She had delivered 2 babies aided by an epidural block in the past, and complained of back pain during this pregnancy, which she totally attributed to her previous epidurals. She admitted to no previous social or drug abuse history in the past. When she arrive to our hospital in labor, and it was determined that she could have an epidural, the CRNA covering OB tried multiple times, unsuccessfully, to insert one. Both the nurse anesthetist and the anesthesiologist were unable to locate the epidural space. She had what is known as a “difficult back” in our business. She went on to deliver naturally.]

But now, despite 4 Ibuprofens, 2 Tylenols with Codeine, and 2 Percocets, she was still complaining of back pain. I was summoned to see her.

Her pain was completely localized to where her needle punctures were (lower lumbar back), and the area was painful to touch. No redness, no swelling, no bleeding, and no pus was observed. She had no numbness, tingling, or weakness in either lower extremity. She denied headache, stiff neck, or blurred vision. She ambulated in the room without difficulty, and had encountered no problems voiding or moving her bowels.

She claimed to have back pain throughout her pregnancy, but not like this. When she told me that she wanted something liquid like Morphine for the pain, I blinked. When she said that that’s the only thing that helps her when she has bad pain, I blinked twice. Then she told me that Morphine is what they gave her once when she came to the hospital with bronchitis. Blink. Blink, blink.

Direct quote: “I just want to feel knocked out. None of those other drugs are helping me.”

If her pain persists or worsens, she will undoubtedly undergo some radiologic studies and a neurological evaluation. But how does the presentation of her symptoms and her story strike you?

I always believe my patients until given reason to believe otherwise. I do not doubt AT ALL that this woman’s back was sore. But she received enough pain medication to relieve the pain of several patients, IMHO.

I left her room feeling saddened. She did not receive her “liquid pain medication” as requested, only more pain pills to carry her throught the night, and some feeble reassurance on my part that we would take good care of her and get to the bottom of her pain.

What? No Propofol?

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Not the best news for the New Year, but something that we all need to be aware of and get a little outraged over, just the same.

I have already written before about how Propofol is your friend and mine. Now, some insurance companies have determined that its use is medically unnecessary for colonoscopies. This is a bad and ill-informed decision on a number of counts.

Propofol is a drug with a quick onset and quick metabolism. What this means for YOU is that it will start working practically immediately, and last for the duration of your procedure, without any long-lasting after-effects. It causes no nausea or vomiting. It wears off quite fast. In small, titrated doses, it causes no respiratory depression.

Of course, colonoscopies can be done without Propofol; in fact, before the inception of this drug, colonoscopies were performed with various combinations of narcotics (think fentanyl, demerol) and benzodiazepines (think valium, versed), or without any sedation at all. They still are performed this way in many doctor offices and centers. My advice to all of you is to never opt for no sedation at all. As for the narcotic/benzo option, well, yes they work, but not without hitches.

Colons are long, tricky organs, with many twists and turns. Not so easy to navigate a 5 foot snake-like instrument through. A still, flaccid patient makes this a much easier endeavor for the colonoscopist and patient alike, and can often determine a successful or unsuccessful procedure. A comfortable patient has a relaxed abdomen. Narcs and benzos must also be given in incremental doses, like Propofol. Unlike Propofol, they do not wear off quickly, and narcs can cause nausea and vomiting (frequently) and respiratory depression. When narcs and benzos are combined, they pack a one-two punch, working synergistically together and often unpredictably. They also do not as reliably provide patient comfort like Propofol does.

Please give me Propofol for my colonoscopy.

Propofol needs to be administered by someone both very knowledgeable about how it works and very skilled in handling situations that may arise due to Propofol administration. Situations like airway and/or hemodynamic compromise. When an anesthesia provider gives you your drugs for your colonoscopy, YOUR heart, blood pressure, oxygen saturation, and breathing are constantly monitored for the duration of the procedure. Your anesthetist has no other responsibilities than watching over you to ensure a safe and effective anesthetic for the colonoscopy.

The insurance companies do not want to pay the anesthesia fee for these procedures. They would rather have YOU receive your sedation for this procedure by either the colonoscopist or one of his/her designated nurses (RNs) working with him. The same people who will be quite busy looking for any irregularities in your colon, biopsying lesions, removing polyps, filling out paperwork, applying abdominal pressure to assist in navigation of the large colon and otherwise involved in the procedure. All this, and administer incremental sedation while watching for and treating any side effects as a result of the drugs being given.

I’ve been involved in giving sedation for colonoscopies going the narcs/benzos route, and the Propofol route. The latter route has 100% reliable endpoints - namely, a sleeping, relaxed, comfortable patient. The former route is unpredictable and frequently provides inadequate, sub-par sedation.

Colon cancer is the our nation’s third largest cancer killer, after lung and protrate cancers. Getting people to have their colonoscopies for screening, let alone for symptoms, is Job One in both the prevention and treatment of this disease. Patients wake up after their colonoscopies with Propofol in disbelief that the procedure was even performed Do you have any idea what kind of great PR this is for the person who may feel a wee bit scared of having a colonoscopy done?

Please give me Propofol for my colonoscopy. And don’t take away my anesthesia provider, either.

The science and the art

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There is nothing more instantly gratifying for an anesthesia provider than relieving someone’s pain. This can be both the lure and the catch that reels in so many nurses and physicians that go into this specialty.

When patients are asleep for surgery, we deliver some of their analgesia proactively, in anticipation of the expected pain; and some of the medications are administered reactively according to patients’ unspoken autonomic responses.

In our textbooks there exist tables that offer predictors of how much pain to expect from the various operative procedures. But most seasoned anesthetists will tell you that analgesia administration becomes intuitive, although not written in stone.

This is one example of why giving anesthesia is both a science and an art.

The shape I’m in

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Yesterday, like most days, my patients came in all different shapes, sizes, and situations.

Patient #1 was petite and frail, in her early 60’s, and only 5′ tall. She had the body habitus that we who work in the OR always love to see. Light as a feather, and easily lifted and re-positioned. Which we needed to do several times during her operation for lung cancer. It was quite easy for the surgeon to get access to her anatomy, and it was practically effortless for the anesthesia team to find the blood vessels we needed for anesthesia care, and for putting in her special breathing tube.

In stark contrast to patient #1 was . . . patient #2. He weighed over 400 pounds, and with a height of under 5′9″, his BMI was estimated to be around 60. He was so big (and wide) that he would not fit on our standard OR table. All of his excessive tissue caused him many, many problems, one of which brought him to our OR yesterday. He had one of the worst cases of obstructive sleep apnea I have ever seen. He had to be intubated on arrival to the hospital, and he came to our OR to receive a tracheostomy, in order to save his life. But his redundant skin and tissue everywhere, especially below his chin, made it nearly impossible for his surgeons to find their proper way. This was really a scary patient to take care of - his airway could have easily been lost.

After surviving the near-storm of patient #2, my 3rd patient presented with a mouth full of loose teeth. While this may seem like a dentist’s dream (kidding), it’s an anesthetist’s nightmare. And the proposed surgery was not even to remove these teeth - surgery was on the patient’s belly. This patient, too, needed to be intubated, so now things get really tricky. Inserting a breathing tube into someone’s mouth is an art that is honed in anesthesia school and through career experience. There is always an inherent risk of doing dental damage during oral intubation because instruments have to be inserted into someone’s mouth. When we anesthesia providers are presented with loose teeth, the risk of dislodging something now increases precipitously. There are several ways to get around this, fortunately, and yesterday, the styletted lightwand came to our rescue. The tube went in seamlessly, all teeth (loose and otherwise) intact, and we were then free to deal with the rest of the patient’s problems!

Giving anesthesia involves a lot of problem solving, and also careful planning to prevent problems.

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The Operating Room is a whole other universe, and all the usual rules that apply in the outside world tend to fall away in here. That is not to say that the OR is a bad place; quite the opposite, it is a very orderly and territorial environment. It lost its circadian rhythms just moments after its inception, and everyday life depends on the cooperation and interfacing of many different people and departments to help the OR schedule reach its completion for the day. Only to begin all over again tomorrow. So, what follows is a guide to how life is conducted and the rules of etiquette that people live by behind the big double doors with the sign that reads: RESTRICTED TO OR PERSONNEL ONLY

For staff:

  1. Sleeping patients have the right of way. Stretcher traffic in hallways dictates that the anesthetized patient should always go first.
  2. IVs are inserted in the non-dominant arm, when possible.
  3. Patients are never moved or repositioned without the anesthesia provider giving the count: Ready - 1, 2, 3!
  4. Every member of the OR care team is also a member of the contamination police. If you observe a break in sterility, it is your responsibility to announce this to every one in the room. ASAP
  5. When the sponge or needle count is off, it becomes EVERYONE’s responsibility to fervently look for the missing object.
  6. The surgeon is the captain of the ship. He/she brought the patient to us, and will manage the patient postoperatively, too, and after discharge. If the surgeon wants the room cold, it will be cold. If he/she wants music during surgery, toons will be procured.
  7. “Be nice to the people you meet on the way up, cuz you’re going to meet the same people on the way down.” We are all important and vital, and no operation can happen without everyone working together. This includes, but is not limited to, the surgeon, anesthesia, the nurses, OR techs, orderlies, management, lab, and maintenance. It takes a village . . .
  8. As the anesthesia lightens and the patient awakens at the end of the case, all music and extraneous conversations and NOISE come to an end, to enhance a smooth and quiet wakeup and transition for the patient.
  9. In the OR, you get rewarded for working efficiently and in a timely manner by getting the add-on cases.
  10. If you are cold, long sleeve shirts from home are unacceptable to wear under your scrub top in the OR, but warm-up jackets from home are fine.
  11. Women must make sure that every strand of their hair is covered under an OR bonnet, but men can wear OR caps where the scalp hair around their ears and back of their head is exposed.

For patients:

  1. Showering, cleaning out your navel, and brushing your teeth are GOOD THINGS to do before any OR procedure.
  2. Leaving all jewelry (including tongue rings), polished nails, and makeup at home is always the right policy.
  3. Passing gas after a colonoscopy is ALWAYS DESIRABLE and doesn’t really count as real flatus.
  4. Pulling out your own IV is frowned upon; pulling out someone else’s IV will not help you win friends in the OR environment.
  5. Knowing what medications you take makes everyone’s life easier, and making a list of them is a prudent idea.
  6. If you are having same day surgery and you don’t have a ride home, don’t bother coming.
  7. Nothing to eat or drink after midnight includes lozenges, juice, candy, gum, and coffee with or without cream.
  8. Asking questions about your impending procedure is healthy for you and helpful for us to know your knowledge deficits. If you don’t want to know, that’s okay too.
  9. If you know where your best vein is, we will probably find it. The vein they usually find for taking blood may not be the best vein for threading a longer IV, please remember that.
  10. You may think you’re immune to the stuff, but we’ve never met a human being yet who we have not been able to “knock out.” Some take more, some take less, but everyone goes to sleep with our drugs if we want them to.
  11. Try to be a good historian. We are very interested in your allergies, if you have any: to drugs, to food, to dye. If you dawdle in recreational substances (alcohol, street drugs, scripts), we will not report you, but we need to know. The medications we give you will interact with what’s already in your bloodstream. For your personal safety, be honest with us. It’s all confidential. That’s the law.

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The power of our drugs never ceases to amaze me. Take muscle relaxants, for instance. By delivering as little as a teaspoon of a drug like rocuronium or vecuronium, we anesthesia providers can literally paralyze YOU for your surgery. This comes in pretty handy when your surgeon does not want you to move during your operation!

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The Indians of South America have known about muscle relaxants for a long time, using curare dartsto “poison” their prey. Actually, how it works is by paralyzing all of the muscles of the hunted animal, including those of respiration, thus leading to their death through asphyxiation.

So, why does your surgeon want YOU paralyzed?  Well, not for all surgeries, but for certain types, it’s critical that all of your muscles are completely flaccid. Why? 1) it makes it so much easier for the surgeons to find what they are looking for; and 2) it avoids (and virtually eliminates) any sudden or unwanted movements by YOU during the surgery. Doctors do not like to operate on a moving target!

[ Of course, general anesthesia that requires muscle relaxation involves a whole lot more than just paralysis. YOU are administered intravenous (IV) or inhalation agents to make sure that you are asleep, and pain medications, often narcotics, are also given to insure your comfort and analgesia. ]

So, how do we achieve this state of TEMPORARY immobilization? We give you this medication through your veins; this is one of the reasons why you have an IV. As the duration of these drugs does not last forever, we will dribble in more of it as the surgery requires. Different muscle relaxants have different durations of action, and we can choose among them according to the needs of the surgeon and the length of your surgery.

Miraculously (although it’s not a miracle at all but something very scientific and calculated), YOU regain your ability to move by the end of the case. In the hands of the skilled, competent, and experienced anesthesia practitioner, these two events will be timed perfectly. Certain drugs we give can get rid of any lingering effects of the muscle paralysis, too. There are no magic wands, but I must tell you that giving these drugs (actually administering all types of anesthesia) can be both wondrous and humbling. The tremendous responsibility, respect, and conscientious care that must be ever-present in the anesthesia provider is not something that we take lightly.

Your surgeon will fix your problem, and your anesthetist will keep you alive. And sometimes not moving.

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Not that long ago, my husband had a colonoscopy done at the institution where I work. It was a no-brainer decision for him to have it done there - I know and work with the members of both the gastroenterology and anesthesiology departments, so my husband and I had a certain comfort level with who his care providers would be. All went smoothly, as expected and hoped for, and when he was finished, I went to his bedside.

“Hi babe! How ya feelin’?”

“I feel high. And good!”

“How’d everything go?”

Under his breath and out of the side of his mouth, he muttered, “I’ll tell you later.”

Blink.

Blink, Blink.

Well, that certainly grabbed my attention! When your husband tells you something like that, the words echo in the auditory canals for more than several minutes, and when they finally land in your frontal lobe, they don’t leave. It was all I could think about!

He recovered quickly from his anesthetic (straight Propofol), was spoken to by his doctor and given his discharge instructions by the nurses. As we were walking to the parking lot, my curiosity was clearly burning a hole into my skull, and I had to know what he wanted to tell me that needed to be deferred to LATER.

“So,” I asked him, half of me not wanting to hear something bad, “what did you want to tell me later?”

“Duh, nothing,” he said matter-of-factly, as if . . . what in the world was I talking about?

“You told me you wanted to tell me something later,” I reminded him, now anxious to hear this juicy tidbit of information.

“I did?”

This is the power of Propofol, and why it is sometimes affectionately called “milk of amnesia” in my business. We still laugh about this, and to this day, he has no idea what he wanted to tell me later. Maybe it’s better that way?

Happy Thanksgiving to all!

The turkey’s revenge . . .

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Food for thought. Happy holidays!

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Can anyone listen to that haunting refrain from Eleanor Rigby and not feel its sad message?

“Where do they all come from?”

Many of them come from our local nursing homes, and land in our ERs and ORs. Elderly people with little to no family, or concerned family, to advocate for them. People with chronic decubitus ulcers the size of baseball mitts, arthritic contractured joints that make simple movements prohibitive, recurrent urinary tract infections, inanition.

These are the lost people of our society, and they cannot speak for themselves: the crowning culmination of a life. lived. long. They come to our ORs to have feeding tubes inserted into their abdominal wall; to have their bedsores scraped and excavated; to have their broken bones repaired; to have months and sometimes years of neglect “fixed” so that they may return to exist. In a life without hope or happiness, only today, over and over again.

“Where do they all belong?”

This old, edentulous woman, this shriveled shadow of a man in the bed. Surely he once laughed, and dated; she married and bore children. She cooked; he worried about his family. She did the ironing and darned the family’s socks. He had opinions; he balanced the checkbook. She felt the hot sun on her head; the icy winter blast of wind braised his cheek. She lost her husband too soon; his children all moved away.

There is nothing we can do to save them from us.

This beautiful day

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A stunning fall morning. Cool, crisp, and comfortable; the skies so, so clear. The weatherman predicts the high around 70 degrees. The air is so still - it’s hardly moving at all. It’s one of those days that makes you feel glad to be alive. You pat the dog, and kiss your spouse goodbye - what shall I make for dinner tonight, babe?

Hi Ho! It’s off to work you go. You greet your co-workers and share a cup of damn-good joe. You talk about the kids, last night’s TV, and the cases for the day. Then it’s time to hunker in for the next 8 hours; you know the drill. Every one assumes their work positions and the surgeries start rolling.

And then, it happens.

Of course, it can happen any time, any day. And it often does. You are always prepared for it, and yet it is always disturbing, unsettling, and unnerving.

Level One Trauma coming to the Emergency Room. Gunshot would to the head. You run to the ER - the patient is bleeding and unstable. This one’s coming right to the Operating Room, and fast.

Philadelphia just had 2 cops shot in as many days. The second one has just rolled into your OR.

What insanity is this, to be shot in the head while you’re doing your job?

What world is this of guns and bullets, justice and hatred?

What city is this that has the highest murder rate in the country?

Whose father is this who will not be coming home to his wife and kids?

What dinner will he not eat tonight?

What beautiful day will he not enjoy, with all its cloudless splendor and deceptive stillness?

This beautiful day.

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