Anaesthesia: Intoxication and in His Head...

The Overview

I loved it. Best ICM rotation of life (so far, obviously). Kicks oncology's ass (let it be known -I have no interest whatsoever in oncology... BORING in all its forms). Nor do I care much for peds (kudos to those who have the patience for that... frankly, it just got on my nerves, at least in the family med setting... in fact, I may seriously reconsider my interest in family medicine based on the reality that I would have to deal with sick kids and their parents...).

But enough on what I don't like. Yes, it's true, I had to start everyday at 7:30 a.m. and anesthesiologists have to deal with arrogant surgeons (there is 1 respectful, kind, collegial surgeon for every 3 assholes), and if you're on the cystology/urology service, it is boring as all hell (urology: another shoot-me-in-the-face specialty).

Yet, overall I loved it -thoroughly enjoyable experience. I learned and got to practice intubations, mask-ventilations and putting in IV lines for patients... already, they actually let us DO stuff! I got to do some pre-operative assessments on my own (so much fun... doctor-patient interaction which is nice, but it's about a specific issue so naturally limits how long this lasts, and you provide them with all the information and reassurances that they need to feel a bit more comfortable about their surgeries and the anaesthesia they will undergo... and you get to assess their airways which is always fun =). There were 3 particular 'anaesthesia moments' which made quite an impression on me, which I will now share with you.

Day 1 Intoxication: On the brink of death in Obstetrical Anaesthesia

My very first day in anaesthesia was on the Obs service with one of the sweetest anaesthesiologists at the hospital. We started with a bunch of pre-op assessments for a bunch of women scheduled for C-sections, which was fun. And then we were called to the Obs OR to do the anaesthesia for a woman having a C-section for a breach. She was scared and vulnerable and her big blue eyes were like large watery wells as she looked at us with a desperate trust before we put her to sleep (general anaesthesia aka GA). Baby was delivered successfully. But. She had depressed respiratory drive and slow, irregular heart beat / weak pulse. They started to mask-ventilate. Then it was a code pink and a frantic search for a small enough endotracheal tube to intubate the baby, a flood of docs and supportive staff with crash cart and finally the adminstration of naloxone, which stabilized the baby.

It turned out the mother was being treated for chronic pain with opioids, resulting in opioid toxicity in the infant -naloxone was the antidote. They saved the baby's life but it was scary as hell. To be in there and to be utterly and completely useless as a second-year medical student. The best I did was stay out of the way. They don't count on us to do anything, but the uselessness was just overwhelming. I could not get the crash cart (like I knew where that was kept!), I could not call for help (who to call? what to say? what to ask for? you can't exactly run out into the hall screaming 'help!'), I could not even give the nurse a pair of gloves because I didn't know where they were kept. You know, we know we're not the most instrumental people as students when we go into these ICM rotations. But in that life-and-death situation, it makes you feel like you're trapped in a box and can't get out and can't scream and... helpless, helpless, helpless. And you look over and see the mother completely knocked out under GA -she cannot do anything for her baby, she cannot protect the baby or do anything for it as Nature had intended... and the baby, so small and helpless and breathless and vulnerable itself. We the doctors hold these 2 in our hands and the sense of responsibility is more powerful than anything you've ever felt in your life: they are helpless here, they have put their faith in us and trusted their lives in our hands -it is our duty to ensure they live through it.

Now you know, I am spiritual and I believe in God, and yes, I do believe that ultimately life is in God's hands -we mere mortals do not decide these things. But if anything worse would have happened to that baby or that mother and I was the physician in charge, how would I live with myself? There were so many little things I witnessed that could have affected the way things turned out -and they were all things that are in fact in our control. God helps those who help themselves. Life is ultimately in God's hands, but if you didn't really, really, really do your best, then death is your fault, not God's. I think that's the scary part. That in medicine, yes we do our best, given the circumstances, but there's always something that might have been done differently, that might have been prepared for better, that could have possibly been foreseen and prevented... essentially, there is a lot of human error that results in death. So how do you know when to take responsibility and when to surrender to the reality that you can't control everything? I'm not explaining this properly, but I think what often happens in real life, is that we don't do our best. We say we did our best. But we don't always do our best. We wish we could always be at our best, but we're human, so that's not always the case. So then we have to ask whether or not this is acceptable? That we try to do our best, that we don't always get there and sometimes not doing our best results in death, and sometimes, despite doing our best, death happens anyway. And are both of these situations acceptable? It's something to think about. And I love that I get to face these difficult situations and think about these philosophical and existential questions. And anaesthesia was the first specialty to give me that gift. So thank you.

On Call: The Cool and Complicated Cases

So I also did 1 night on-call during this 2-week rotation -loved it. It was a half-call, only until 10:30 pm, but still, so different from a regular day! All emergency cases -and the only time I got to see them stabilize an airway (intubation) using a fiber-optic instead of the normal laryngoscope way. For a retropharyngeal abscess in a woman with a super-tricky airway and severe enough anxiety combined with hypokalemia and too much local anaesthetic (lidocaine) that made the whole process crazier with sporadic tachycardias with arrhythmias (for the lay-person, in English: heart beating way too fast and abnormally). So again, a crash cart was needed, the anaesthesiologist in charge had to be called, etc. Except this time I was less useless -I was at least able to call the attending physician to come help. An improvement. An experience. Thrilling. And everything went well.

Anaesthesia for Neurosurgery: The live, pulsating Brain in his Head

Second-to-last day in anaesthesia, got to see the neuro side of things. The anaesthesia is the same(ish), but the surgeries -way, way cooler. Hands-down. I almost thought I wanted to become a neurosurgeon (and then I remembered, "Wait a minute, I still want to have a life"). I got to watch them do a focal resection of a tiny piece of scarred brain that had been causing epileptic seizures in the patient. So I asked the anaesthesiologists, "So basically this scar is causing seizures, so they're going to go in, remove the scar tissue and create another scar -how does this help the patient?" And they were like, "Huh. That's a good question. Never thought of it that way -I don't know, you should ask the neurosurgeon."

So during surgery, I'm allowed to go over to the surgeon-side of things, watch them using imaging technology as they are about to cut through the dura after performing the craniotomy, and the neurosurgeon (who is one of the very best neurosurgeons in the whole wide world! literally people fly here from all over to have him do their surgeries) himself, tells me to come close and explains what they've done and what they are about to do and I look inside where they've removed the skull and it is absolutely, freakin' gorgeous. The actual live human brain pulsates right below the thin layer of dura and it is a beauty. Fascinating. Amazing. That pulsating mass inside each one of us is what's responsible for all that humankind has ever accomplished, felt, thought, experienced in all of eternity. Ancient civilizations, poetry, art, Olympic records. It was all first just a mind-form. All just a ghost in that pulsating mass that only this privileged profession gets to see and touch in this state. What an honour indeed.

Afterwards I asked the neuro-guru my question. His response, "That is an excellent question" and proceeded to explain how in a natural scar, the inputs and outputs from and to other neurons remain intact and so abnormal activity can be transmitted to those neurons from the scar tissue, resulting in a seizure. However, the surgical scar severs these connections to other neurons (or at least, they really do their best to ensure this as much as possible) and so this transmission to other neurons is avoided. Later, to my anaesthesiologist attending, the neurosurgeon remarked "She asked such a good question -I wish more residents and doctors would ask questions like these" -made my day. After feeling useless at the beginning of this ICM rotation, it was so rewarding to feel appreciated, seen as intelligent, unique, worthwhile. By then, I also really knew my stuff in terms of all the different drugs, their mechanisms of action, when to give what, why you give what, etc and the residents with whom I was working also told my attending they were impressed that I 'knew my stuff' and was so interested in learning more, in more depth and detail. And it was genuine. Like I really, really loved it.

My final assessment?

But anyway, this doesn't mean I'm going to become an anaesthesiologist. Or that I'm not going to become a family doctor. But it is nice to have all this 'action', surprisingly enjoyed the kinds of doctor-patient interactions, because although they are short-term relationships, they are so intense because there is so much fear and trust and other issues to be managed and feeling like you're doing your job well and putting your patients at ease is rewarding enough without the on-going, long-term follow-up. And the good thing in anaesthesia is that once you leave work, work doesn't follow you home, and for the most part, it doesn't even carry over into the next day. They are paid well too. There is variety (pre-op / chronic pain service, gyn, obs, cystology (yuck), OR, etc, etc...). The kind of person who is an anaesthesiologist (at least the type of people I met) were very cool, energetic, down-to-earth people. But you do have to deal with surgeons and their egos (major downside). All that adrenaline, probably not good for balancing my already imbalanced 'feminine side'. So... lots to think about. But glad it was enjoyable. I learned so much and I loved the experience.

Neurology starts tomorrow -let's see how that goes...