putting you to sleep

Monday, July 21, 2014

Pitcher CC Sabathia could not sleep at night, worried that he might need significant knee surgery that might end his career. After seeing the team orthopedic surgeon and discussing options, microfracture surgery which might cause him to miss two seasons, was not needed. Masahiro Tanaka, another Yankees pitcher with elbow troubles, sought opinions from three different orthopedic doctors before deciding not to have Tommy John surgery to repair an ulnar collateral ligament injury. Every day, thousands of people seek second opinions to be reassured that a planned surgery is appropriate. Every day, people forget that the surgeon is only one part of the operating team.

Most people will not know the name of the anesthesiologist assigned to put them to sleep and perhaps more importantly, to wake them up. On the assigned day of an operation, the patient and family show up to the hospital or surgical center and begin the pre-op process, where nurses assess and prepare the patient for their procedure. Eventually, an anesthesiologist or nurse anesthetist shows up at the bedside, introduces themselves and begins their evaluation. Odds are, they are randomly assigned that day to the surgeon but hopefully, they have reviewed the medical record the day before. For patients who are hospitalized, that visit may take place the evening before. But few people consider who that anesthesiologist might be.

Anesthesia is not what it used to be. Depending upon the surgery, the patient may have options to choose different types of anesthesia, whether it be local, regional or general. Most people have had a local anesthetic where medication is injected into a small area of the body. From laceration repair to a dental filling, the purpose is to block pain fibers but touch, pressure, vibration and movement sensat8ons are all intact. For that reason, most people feel stuff under local; the goal is to have little or no pain.

Regional anesthesia blocks whole sections of the body. The anesthesiologist can inject medications into the spinal canal area like an epidural used during labor or C -section, or inject medication into a vein to anesthetize a single limb. It’s easy to talk about, but there is technical skill needed to get the anesthetic into the right place, in the right amount and to monitor the patient to make certain complications don’t occur and the anesthetic wears off at the proper time.

General anesthetic is the one often seen in television dramas where the patient is sedated and sometimes paralyzed so that an operation can occur. Not all operations require a patient to be paralyzed but should that be the case, the skill of the anesthesiologist is even more important. The paralyzed patient needs somebody to breathe for them and to monitor and support their vital signs. This is where the critical part of this critical care specialty comes to bear and why the pre-op visit is so important.

Not every patient is young and healthy and the patient with heart disease, lung disease, diabetes or on dialysis, all pose a challenge to the anesthesiologist. Pick a disease or illness and it can cause an anesthetic complication. Every patient has a unique set of circumstances that will affect the choice of anesthetic and the type and amount of medications used. Not everybody qualifies for anesthesia; patients can be too sick or too complicated so that the risk of dying during the operation or postop course is greater than the benefit that surgery might offer.

History and physical are the important tools for that pre-op evaluation. Past medical history is obvious, but not so with family history where a relative who had a bad anesthetic outcome might be the clue that it could be hereditary. Medication history is more than prescriptions meds but also needs to include over the counter medications and herbal remedies that might interact with the anesthetic. Physical exam might uncover an issue that would increase the risk. Showing up the day of an operation with a cold or other infection might be enough to have the procedure postponed. For the anesthesiologist, it’s all about controlling risk and minimizing disaster. Heart attack, stroke, pneumonia, vocal cord damage from being intubated, temporary and not so temporary confusion are some of the anesthetic risks independent of what the surgeon is doing.

The anesthesiologist is one of the invisible doctors in medicine, where their work is invaluable to their colleagues and their patients but most people don’t know their names or qualifications…nor do they seem to care. Radiologists who look at x-rays rarely touch patients but their opinions drive diagnosis and treatment decisions. Pathologists look at tissue samples and cells to make a variety of diagnoses including cancer/not cancer. Their world is set apart from touching patients, yet their skill is invaluable.

So back to Mr. Sabathia and Mr. Tanaka. Surgeons sought by elite athletes often have their own team, from anesthesia, to scrub nurses to physical therapists. Regular patients often search the country for the surgeon but leave picking the rest of the team to chance. Credentialing and peer review committees hold doctors, including anesthesiologists, accountable to maintain their knowledge and skills. It’s a stressful time when the doctor shows up at the bedside before surgery. Still, it might be nice to remember their name…they may hold your life in their hands.

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universal precautions

Monday, July 14, 2014

It was on the screen for just a few seconds and was a reminder that for all the swan dives, flops, histrionics and theatrical death seasons, soccer players are a tough lot. The Brazilian and Dutch players went up for the ball, banged heads and Dirk Kuyt fell to the ground, blood dripping from the scalp laceration. The medical team walked him to the sideline, washed and stapled the cut, no need for anesthetic, and Mr. Kuyt returned to the field cleansed of blood and good to go.

Look closely because something is not quite right:

world cup laceration

Photo attribution: Bleacher Report UK Twitter feed

 

There is a trust relationship that exists between physician and patient and the expectation is that the doctor will do no harm and the patient will not withhold important information. Somehow, in the heat of the moment, the physician was able to get gauze and water to briefly wash the wound, open a staple gun to close it but forgot the gloves. Washing hands and wearing gloves should be routine, even if care does not happen in a doctor’s office or hospital. Just where are the gloves on those healing hands?

Philosophically, the purpose of wound care has little to do with closing the skin to provide a nice scar but instead to diagnose any injuries that might underlie a laceration and to prevent infection. All wound will heal…eventually. In caring for wounds on the field of play, it is not unreasonable to take on a temporary fix and do a more thorough job after the game is done, but the expectation should be that certain basic tenets of medicine be followed. For a scalp laceration, it is reasonable to anesthetize the area and thoroughly wash out the wound to minimize the risk of infection. It is also reasonable to explore or look inside the wound to make certain that there is no underlying skull fracture. Part of the process may include sticking a finger into the cut and feeling for any bone edges.

 

Universal precautions are the medical shorthand for having health care workers use barrier clothing (gowns, gloves, face shields) to avoid contact with a patient’s bodily fluids, including blood, and prevent transmission of infections like hepatitis and HIV. These precautions are situation specific. Doctors and nurses would not gown up with a face shield and gloves to look after a small laceration, but likely would to care for a major trauma victim. The worry that a health care worker could be infected by a patient heightened in the early years of HIV-AIDS, when the disease could barely be treated and controlled. Just as important as gloves and gowning, was the idea that diseases should not be transferred from one patient to another. Hand washing became another mainstay of infection control, since the vector of transmission in hospitals was often the medical staff, carrying an infection from one room to another.

The other side of the trust equation is patient honesty. The Greg Louganis incident happened more than a generation ago in the 1988 Seoul Olympics. The American diver hit his head on the springboard lacerating his scalp, requiring sutures. Mr. Louganis knew that he was HIV positive but did not tell his doctors, including the one who sutured his wound…without wearing gloves. He wrote in his autobiography: “I wanted to warn Dr. Puffer but I was paralyzed. Everything was all so mixed up at that point: the HIV, the shock and embarrassment of hitting my head and an awful feeling that it was all over.” He returned to diving competition and won gold.

At the end of the day, most people do the right thing. Doctors and nurses wash their hands, wear gloves and treat every patient as if they are disease ridden. Everybody is treated in the same manner and judgments do not need to be made about an individual patient. Many hospitals and clinics now have their providers use cleansing gel or wash their hands in front of the patient, not only for hygiene but also to build trust. However, the lesson to learn is that the patient or their advocate also need to be vigilant and ask for things that they know to be appropriate. Even the most fastidious doctor can forget want is normally habit and should not take offence if the patient asks them to wash or wear gloves. At the end of the day, those who don’t ask, don’t get.

 

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