Medical School 2020, Year 4, Week 32 (Anesthesia, week 2)

The calm before the storm (March 9-13, 2020). All the talk in the hospital is about coronavirus. Small talk has become easier with physicians able to recycle the same opinions for multiple hall conversations. 

The first patient is getting a surgery for pes planus or “flat foot”. After I place the laryngeal mask airway (LMA; less invasive alternative to intubation, less protective airway that sits above the epiglottis), the anesthesiologist tells me I can do whatever I want today.  “You can stay and hang out with me, or you can try to get some other airways.” I stay for the first 30 minutes and watch as they cut the fibularis longus tendon and then hammer out the joints of the talus with the tarsal bones and then fuse it. It seems medieval, but that’s orthopaedics/podiatry. With another hour still to go, I head to the anesthesia ready room to snag some more intubations.

The admin anesthesiologist for the week is reviewing the OR assignments and a 26-year-old medic in training is sitting on the couch on his phone. “I just need 15 intubations for the month and then I’m done,” he said. “They told me to show up here, but I’ve just been sitting here for 30 minutes.” (By contrast, we medical students are assigned an anesthesiologist via an evening text from the anesthesia coordinator.) We wait for 1.5 hours as anesthesiologists periodically stop by. I ask if they have any intubations, but they are all LMAs.

The senior partner, who is more than 65 years old, is wiping down the keyboards, mice, and handles with disinfectant to cleanse fomites containing the coronavirus (fomite comes from the Latin fomes meaning “tinder,” a term for something that can start an infection first used in 1546 by Girolamo Fracastoro). A 37-year-old anesthesiologist with a thick Eastern European accent tries to warn him. She asks, “What are you doing? We’re all going to get COVID-19 from the Tunnel of Death and elevators.” (The “Tunnel of Death” or “OR tunnel” is the doorway and initial hallway through which patients and staff get to the ORs.)

More anesthesiologists funnel in to join the conversation. There is clear frustration among the anesthesia private practice group that staffs the entire hospital with the hospital’s administration regarding preparation for coronavirus. Several talk about the three anesthesiologists who died during the 2003 Toronto SARS outbreak. The senior partner: “Admins are in charge of the preparation, which invariably means we are screwed, though I am even more concerned about our hospital’s preparation after the meeting yesterday. There is no PPE. We have 8 respirators with only enough parts for 10 uses! I’m not coming in if they don’t get their act together. The administration is already working from home.” A younger new graduate responds, “I’ve lost $30,000 in the market. I’ll take your shifts!” He adds, “I’m still confused whether this is airborne versus requiring respiratory droplet precautions. Unless this is like TB, a surgical mask should suffice.”

The Eastern European: “I am not coming in if we don’t have the right equipment. I’d kill my father in five minutes.” The senior partner continues: “I wasn’t worried about this until I talked to my Italian doctor friend. If over 65 years old, no vent[ilator] for you.” The Eastern European: “It’s the same as dialysis. You don’t get dialysis in Europe if you’re over 65 years of age. And you know what, I can’t judge them when we put 91-year-old grandmas from the nursing home on dialysis.” The young graduate: “This whole discussion was the problem with ACA and the death squad panel. ” The senior partner: “But how much is age predictive of functional status? We see lots of 40-year-olds that look 80. There is just no good way to ration care.” The Eastern European anesthesiologist retorts, “I’m okay being in the death panel!” The young graduate walking to his next case: “Look look, the answer is a chronic disease severity score.”

The senior partner summarizes:  “The administration is useless. If they really wanted to help, get APRV (Airway pressure release ventilation, a mode of ventilation that gives a longer inspiratory time to help fluid filled lungs maintain oxygenation) on the new ventilator machines. It’s just a software update.” Anesthesiologists leave the room for the next case (no intubations…) as one spreads the rumor of a technologist stealing 2 cases of masks last month and selling them for $100 a box (of 20) on Amazon. “The hospital fired him and is pressing charges.”

The consensus opinion is that the hospital will be overwhelmed by COVID-19 demand. We have more than 1,000 beds, but just over 75 ICU beds, and a limited number of ventilators (though possibly a big stockpile of older models in a warehouse). The young guy who was enthusiastic about picking up extra work was the outlier: “It’s mostly going to kill old people.” The senior partner responded, “A lot of us are in that category.”

[One week later, we got our first confirmed case, transferred from a small community hospital in a remote area.]

At 9:00 am, I walk to the endoscopy suite, having heard this is the best place to get high frequency intubations with quick turnover between “scopes” (Esophagogastroduodenoscopy or “EGDs” and colonoscopies) that require ETTs due to position changes. The anesthesiologist in the endoscopy suite runs 4 rooms with the help of 3 CRNAs (certified registered nurse anesthetist). “Fine with me,” he replies when asked if I could join. “What’s your goal?” He quickly grins and says, “Go to room 2 and ask Todd. They do ERCPs [endoscopic retrograde cholangiopancreaticograms or an EGD with cannulation of the bile ducts] in there so a lot of intubations.” Todd, a CRNA, waves me in. I watch the interventional gastroenterologist biopsying a common bile duct stricture caused by a mass. The cases last about 45 minutes and the next patient is wheeled in quickly. I’m able to attempt five intubations before noon. Four go well, but, having failed to visualize the cords well, I mistakenly insert an endotracheal tube into the esophagus of a 40-year-old male with a recurrence of rectal cancer. Todd picked it up quickly before we delivered more than 3 bag breaths, and corrected it without issue. I placed an NG tube to decompress any air in the stomach. I am disappointed in myself, but an important lesson is given by the practical CRNA. “If something doesn’t go smooth, speak up. Never lie.” He continues, “I am amazed how when something doesnt go right, newer crna’s are defensive and withhold information from the anesthesiologist. I think it comes from insecurity. And they weren’t spanked for lying as a kid.”

Our last patient was a 65-year-old with an MI three weeks ago undergoing EGD for cirrhosis. “I don’t know if this patient should be getting an elective procedure right now so soon after a heart attack, but what do I know? I’m just a CRNA. My boss and the interventional gastroenterologist both signed off on it.” I check back in with the podiatry room, then leave at 12:30 pm. 

My intubations improve throughout the week with a clear technique developed and learn how to estimate the correct size of an oral airway by measuring the distance from the patient’s mouth to the tragus of the ear. My last day I got to use the GlideScope, a video laryngoscope. I was able to see the vastly improved relaxation using propofol as the induction agent compared to etomidate (used in shock and heart failure patients). Propofol drops the blood pressure a lot more than etomidate. The attending summarizes: “The most dangerous part of anesthesia is between induction and the operation beginning. Remember sometimes we want the blood pressure to drop during the extremely stimulating intubation.”

The last day of the rotation is at the outpatient surgery center. The pre-op nurse checks in the first patient, a 71-year-old male with COPD undergoing knee arthroscopy, asking if he brought his personal CPAP machine for the post-op recovery nap. The patient’s wife points to a duffel bag on the table. “I’ve never seen a Marlboro CPAP bag!” says the nurse. The patient’s wife responds, “We were such loyal customers that they sent us a bag. And it fits his CPAP machine perfectly!”

The anesthesiologist lets me lead the show. I hook the patient up to the monitor, preoxygenate for several minutes, push the meds that I drew up from the vials, and successfully intubate the patient. The anesthesiologist explains the importance of managing postoperative nausea. Post op nausea increases aspiration risk, impacts patient satisfaction, but most importantly money. He explains, “The post-op area is a high resource area, almost as high as ICU.” Every nurse can have at most two patients. He continues, “A patient with post-op nausea will hold the bed for longer. It’s not uncommon that after the patient is done in the OR, you are twiddling your thumbs in the OR on PACU hold.”

How to assess the risk for post-op nausea? If the patient has the four most important risk factors, there is an 80 percent chance of post-op nausea: (1) history of prior post-op nausea or motion sickness, (2) female, (3) lengthy surgery, and (4) inhalation anesthetic.

How to treat it? There are four treatments for post-op nausea, the most successful being Zofran, glucocorticosteroid, and an extremely low dose of droperidol. (Smoking cigarettes is helpful and supported by research, but no U.S. hospital has thus far set up a designated post-op smoking area.) Droperidol is an antipsychotic (a “typical” antipsychotic, and therefore a strong dopamine antagonist). This is less commonly used even though it has great results because of the antipsychotic term. Everyone is scared of the black box warning for QT interval prolongation (repolarization segment on the electrocardiogram that, if prolonged, can lead to serious arrhythmias). “Funny how the drug got the black box from FDA even though Zofran has the exact same QT prolongation risk. Somehow Zofran as a new drug slipped through it…”

The anesthesia rotation was highly instructive and it seems like a great lifestyle, especially for those who like to shop online from their phones for several hours per day. However, I would never be able to handle the waiting.

Statistics for the week… Study: 0 hours. Sleep: 8 hours/night; Fun: 2 nights. Example fun: Samantha purchased a smoker for Luke’s birthday. We smoked ribs and “beer” chicken (whole chicken stuffed with a cracked beer to keep it moist) for five hours while drinking beer and the new fad White Claws.  Lanky Luke, having completed anesthesia last month, jokes, “Let’s just say Samantha was not happy seeing our credit card bill after that rotation. I bought so much stuff on my phone during those two weeks.” Their bank account having survived, Sarcastic Samantha is excited to get a new job when Luke matches in a new town. She recounts a typical week at her job as a hospitalist PA rounding on psychiatry inpatients for medical consultations. The 50-year-old female told her, “Doc I need a disimpaction!” Why? “‘I haven’t pooped!” “Let’s start with some laxatives and a suppository first.” The next day, she asked how the suppository went. The patient  responds,”I don’t know.” “What do you mean you don’t know?” “I think I heard two things drop in the toilet.” “Good, good, that means you pooped. Let me know if you need more help.”

She tells us another story from the psych unit: “The next day, my 32-year-old just started screaming on the floor. You could hear her through the double closed door in each room. She wouldn’t shut up. We rolled her onto a sheet, and plopped her on her bed. Wouldn’t stop for an hour.” Since we were outdoors, Samantha gave a demonstration of the screaming volume. “A nurse overheard her whisper to another patient that she was going to pretend to fall and sue the hospital. She doesn’t realize we have everything under video surveillance so we literally see her slowly lower herself down onto the floor and start screaming again.”

The rest of the book: