We meet at 7:00 am in the “Anesthesia Ready Room”, a small office with only three computers shared by the 50-person anesthesia private practice. I was excited to be assigned to follow Dr. D, who is widely respected by surgeons. He’s a pale 38-year-old sporting wide circular glasses. We go into OR 17 to set up for the case, a left total knee arthroplasty. He shows me how to pull medications by inserting a needle attached to a syringe into the rubber sealed glass vial. We go over how to pull doses of common anesthesia medications, e.g., succinylcholine, rocuronium, propofol, etomidate. “As a general rule, the right dose is usually half of the vial. That was true during my training, but people have gotten a tad larger now so maybe round up.” He adds, “The exceptions are these.” He points to a nondescript compartment in the anesthesia cart where epinephrine, phenylephrine, and ephedrine are stored. “I’d say the most common medication that I see get overdosed with serious consequences is phenylephrine (“Neo”). It’s meant to be made into a drip (“gtt”, latin for guttae or drops) by inserting the dose into a 100 mL bag for pressor support over time. A typical rate is 100 mcg/min. We use it by giving 200 mcg as a one-time dose for pressor support between induction and the operation beginning.”
“One of the hardest things to do as an anesthesiologist is to do nothing. The patient’s blood pressure drops when we induce the patient. A lot of people want to reflexively fix that with a pressor like ephedrine or phenylephrine,”. Dr. D continues. “Watch how much the blood pressure increases once we start intubating and cutting on the patient.” We put the pulled medications (in syringes with attached needles) into a locked drawer on the ventilator workstation. He then asks if I have intubated before and with which laryngoscope blade. I respond that I’ve intubated twice, and have used only a “Mac” (MacIntosh laryngoscope features a curved blade versus the straight Miller laryngoscope). “I don’t understand people who use Miller. It’s forcing the pharynx to be a straight configuration when it’s clearly not.” He grabs a “7 French” endotracheal tube (ETT) and Mac 3. I ask, “Should I get a stylet?” (Stylets are a stiff malleable metal wire that is inserted into the ETT to help guide it through the cords.) He laughs, “Stylets are not necessary. It’s $11 that goes down the drain.”
We head to pre-op to consent a 58-year-old for general anesthesia and potential blood products. She is about to undergo a total knee arthroplasty (replacement) with general anesthesia. He asks the patient standard anesthesia questions: any dentures? Previous anesthesia, and if so, any problems? The patient answers that she has terrible post-operative nausea. He asks her to open her mouth wide, and touch her top lip with her bottom teeth (assess range of motion of jaw). She signs the forms, and then the anesthesiologist performs an adductor canal nerve block under ultrasound guidance. A pre-op nurse is dedicated to assist with these nerve blocks. Looking for a good lifestyle job in healthcare? The nerve block nurse’s only job is to wheel an ultrasound cart over and hand the anesthesiologist a pre-op needle, which means she’s busy only about 30 percent of the time and then goes home at 2 pm. We head back to the OR.
After a few minutes waiting in the OR, the nurse wheels the patient in. I clumsily attach the pulse oximeter, three electrode lead stickers, and blood pressure cuff. I mistakenly attach the “left leg” lead, supposed to go under the left breast, on a layer of gown. “Honey, this isn’t my breast!” I grab another sticker and place it below her breast and attach the electrode. He supervises me closely as I preoxygenate the patient with a mask delivering 100 percent oxygen. He then pushes the propofol into the IV and we wait a few seconds. He instructs, “gently touch her eyebrows to assess if she’s asleep.” The first time her eyelid twitches but after five more seconds she is fully induced.
“Let’s see how you mask ventilate. This is probably the most important skill in anesthesia. If you can mask a patient you can relax.” I adjust the pressure in the circuit with a knob as I squeeze a 2 L bag with my right hand and use a “C” grip on her mask and jaw to elevate the jaw. “Really squeeze at the angle of her mandible. Get in that crease.” I am squeezing the mask with my thumb and index finger in a “C” shape to rotate it against the jaw that is being pulled up and out to move the tongue forward and open the airway. The first breaths I hear a leak as I squeeze the bag with my other hand, but adjust my grip. I look for chest rise, fog in the mask on exhalation, and finally check the end tidal CO2 mass spectrometer waveform on the anesthesia workstation.
As I mask the patient monitoring the end-tidal CO2, tidal volumes, and peak pressures (keep under 20 mmHg to prevent air from going into the stomach), the attending asks me, “We know we can mask the patient, so we can relax. Why do we pre-oxygenate?” I answer with a snarky response, not understanding the full significance of the question. “Umm, to get more oxygen in them.” He responds with a smile, “Yes, but why does it work?” He explains that at the functional residual capacity (FRC, the amount of air in the lungs when exhaled such as when paralyzed) there is 2 L of air, and therefore 400 mL of oxygen (20 percent at 1 atm). Your body uses about 35 mL oxygen per kg per min, which varies depending on the health of the individual and food intake.” For a typical 70 kg person, that is 35 mL oxygen per second so I would only have about 10 seconds before the patient starts to desaturate if we intubate without preoxygenation. He summarizes, “Pre-oxygenation is really denitrogenation of the air.” Instead of only having 400 mL oxygen, by masking the patient with 100 percent FiO2, the patient now has 2 L of oxygen, allowing for about a minute before the patient begins to desaturate. In reality once you preoxygenate, you have several minutes before you need to worry.” After another few breaths, he states, “You’re ready. Give it a try… Wait. Take your badge off, you don’t want to cause a corneal abrasion. Those hurt more than a kidney stone!” He pushes the Rocuronium, a paralytic agent that will prevent the patient from moving any somatic (voluntary) muscle.
After I transfer my badge, notebook, and pens from the front scrubs pocket into my pants, I grab the Mac blade, scissor the upper and lower teeth with my thumb and index finger to open the jaw, and place the blade in horizontally, avoiding the teeth. My goal is to first locate the right tonsillar pillars, then sweep the tongue with the blade over to the left, and insert the blade deeper until I identify the epiglottis. I struggle to find the epiglottis in this patient, and hand it over to the attending who quickly inserts the tube. “Good technique, that was a hard airway. Better luck next time.” He adds, “Careful when removing the blade. A chipped tooth comes right out of my paycheck. $10,000, no question.”
I auscultate both lungs (listen with a stethoscope) to confirm good airflow, look for fog in the tube, and confirm end-tidal CO2 for a few breaths. He laughs as he’s already given a few bag breaths and turned on the ventilator setting to pressure control (ventilator mode that delivers volume up to a set amount of airway pressure). “It’s good to do that as a habit, but I saw the tube go through the vocal cords, I see good fog in the tube, and consistent end-tidal CO2. Confidence in medicine is key, especially in surgery. Confidence comes from experience. Now, relax. You’re welcome to grab some breakfast or coffee. We’ll just be sitting here until the case ends.” (In search of a stooI, I wander the OR hallways until an OR nurse guides me to the stash. I lug the stool through the maze of gadgets in the OR suite while trying not to touch anything sterile.)
Dr. D has a dedicated chair. We sit together and look at our phones (no need to wear gloves unless touching the patient) for two hours while occasionally talking about subjects he thinks will be helpful, e.g., his ABCDEFGHI mnemonic for taking over a patient. Airway (confirm placement of airway), Breathing (look at end-tidal CO2, peak pressures, pulse oxygen saturation, arterial blood gas, if applicable), Circulation (blood pressure and heart rate, EKG), Drips (ensure medications are in, including pain, nausea, etc.), Effluent and Fluids (ensure good urine output and adjust IV fluids accordingly), Heat (don’t forget the Bair Hugger), and Injury (make sure the neck is in a neutral position, the eyes are not in contact with anything, the arms are not under pressure and pronated; he explains to me that the ulnar nerve is the most common injury during anesthesia. A lot of time the surgeon is not present when positioning the patient, he explains this is a bad habit because the surgeon is just as liable for any positioning injury as the anesthesiologist). The surgeon tells us that they are starting to close as he unscrubs and steps out of the room to allow his PA to suture the skin and dress the patient.
[Editor: “Doctor Says a Device He Invented Poses Risks” (New York Times, December 24, 2010), “Two decades ago, Dr. Augustine, an anesthesiologist in Minnesota, helped pioneer the idea of keeping a patient warm during surgery. Doing so, studies have shown, produces benefits like less bleeding and a faster recovery. Dr. Augustine’s invention, the Bair Hugger, changed surgical practices and made him a fortune. The device, which works like a forced-air heater, carries warmed air through a hose to a special blanket that is draped over a patient. These days, Dr. Augustine asserts that his invention is a danger to surgical patients receiving implant devices like artificial heart valves and joints. The forced air, he says, can spread bacteria associated with hospital-acquired infections. Coincidentally, Dr. Augustine, who no longer has a financial stake in the Bair Hugger, also says he has a safer alternative, a warming device that works more like an electric blanket and does not use forced air.” A twin-size electric blanket is $25 on Amazon in 2020. Why did 3M pay $810 million for a company making this hot air system? Why wouldn’t hospitals just buy blankets from Amazon and throw them out after each surgery? Ordinary blankets are used in the OR, washed, and reused.]
We turn off the anesthesia gas and reverse the rocuronium with sugammadex. The anesthesiologist explains as we wait for the patient to wake up that rocuronium has become the standard paralytic because of this new reversal agent. “It was a brilliant move by the pharmaceutical company. If you don’t use the reversal agent, the patient could feel short of breath and weak for several days.” He adds, “You also don’t want to get that call from a lawyer when the post-op patient has respiratory distress. ‘Why didn’t you reverse her?'” When the patient starts to move her arms, and cough, I deflate the ETT balloon cuff, and pull the tube out. The anesthesiologist pushes the bed into “steer” mode and carts her off to the post-op recovery room, jumping on the frame and riding the bed around every turn as he waves to the OR staff. I struggle to keep up with him. He backs the patient into the post-op room, and “gives report” to the nurse. We head to pre-op (right next door) to get ready for the next case.
The last case starts at 11:30 am. After I help with the intubation, Dr. D tells me I can leave. I am out of the hospital by noon! This might explain why the anesthesia elective is restricted by lottery. The goal is simple: intubate as much as you can. The anesthesiologists don’t care if you show up, leave after the first intubation, or stay for the day. Most people stay for 2-3 cases, and are out by noon like myself. With our new puppy stowed away in a crate, I am eager to get home.
I go to the outpatient surgery center on Wednesday and Thursday. The cases are shorter, meaning less waiting and small talk. Between cases in the surgeon lounge, a newly hired general surgeon talks about the difference between the outpatient surgery center versus institutional hospital ORs. “The turnover time at the hospital is abysmal.” My attending is only 34 and in her first year with us, but she is able to explain to the surgeon, “That’s because our institution is stupid and run by administrators who do not understand incentives. Here, the OR staff get to leave after their cases are finished. Over at the hospital, if the case finishes early, they just get reassigned to another room until their shift is over.” (i.e., the hospital pays for a set period of time while the outpatient center pays for a set number of surgeries, so people try to finish early and get home)
My intubation technique is slowly improving. I am working on two areas: (1) elevating outwards, not upwards, and (2) not inserting the blade too deep, thereby missing the epiglottis for the esophagus. A female anesthesiologist with two young kids at home gives me the best advice: “Don’t pull up to the ceiling. Aim for the edge between the ceiling and wall.” This gets me the next two successfully. Her med school liberal political beliefs seem to be eroding. When we are both on our phones waiting for a knee replacement to finish, she mocks a New York Times article that complains about the Trump administration’s attempt to impose work requirements on food stamp recipients. “Check out this photo. Two fit 35–year-olds with no kids and there is a big TV and Playstation in the background.”
Statistics for the week… Study: 0 hours. Sleep: 8 hours/night; Fun: 2 nights. Example fun: classmates have a day-party outside with beer ball and beer pong. Jane and I attend, but decline post-game invitations to downtown bars. On GroupMe, Straight-Shooter Sally scolded classmates who gathered indoors downtown: “Some of us have parents and grandparents who could be hurt by your [Covid] decisions.”
The rest of the book: http://fifthchance.com/MedicalSchool2020