Wednesday, February 23, 2011
Another NBA All Star event is in the books and again showcased the talents of the best their league had to offer. But while the stars shone, their skills did little to highlight the game of basketball itself, where team often triumphs over individual. The star hierarchy that exists in basketball is also found in most other workplaces. Stephen Hawking is the rock star of physics. Warren Buffet is the rock star of investing and Mick Jagger is…well, he’s just a rock star. In medicine, the surgeon tends to wear that mantle but as is true in sports, even a surgeon needs a team to help a patient survive.
The surgeon depends upon a host of people even before the patient gets to surgery. There are plenty of anonymous people who clean and prepare the operating room itself, get the sheet and laundry together and sterilize the equipment. Specialized nurses predict the instruments like scalpels, retractors and sutures that a specific operation might require and also understand the preferences of each surgeon. Surgeons like to be comfortable before and during their performance in the OR and changes in routine can sometimes put them off their game.
If the surgeon is the captain of the ship, then the anesthesiologist is the executive officer who is charged with keeping the patient comfortable and safe before, during and after the operation. Gone are the days when anesthesia was a one trick pony. Depending upon the procedure, there can be many choices for the type of anesthesia or sedation.
If the focus of the operation is an arm or a leg, then regional anesthetics or nerve blocks may be considered to put only that part of the body to sleep with some sedation to calm the anxiety of the situation. Spinal anesthetic is commonly used for lower abdominal or leg surgery. These types of anesthesia allow the patient to be relatively awake and breathe on their own. Sometimes, though, depending on the type of surgery, the patient needs to be very relaxed or paralyzed and general anesthesia is a must. This requires the anesthesiologist to intubate the patient, putting a tube into their trachea and hooking up a ventilator, in effect taking over the vital functions of the body.
Monitoring the unconscious or sedated patient is a full time job and keeping the patient asleep and alive at the same time is a skill that takes significant experience to learn. Physician anesthesiologists need 4or 5 years of residency training after medical school and they often also split their time caring for patients in the hospital ICU. A nurse anesthetist needs 2 or 3 years of post- graduate training to begin their career. While it is relatively easy to put a patient to sleep, there is skill in waking them up when they are supposed to. It’s bad form for the patient to start moving on the table on the middle of the operation and it’s similarly bad to take too long to wake after the operation is done.
The anesthesiologist also carries veto power and may not allow an operation to go forward if the risk of anesthesia is too high. Often this veto is used in elective surgery when the patient shows up for a planned operation but has developed an illness like a cold or the flu. Sometimes the patient forgot to fast beforehand increasing the risk of vomiting and aspirating food into the lungs is a significant complication of anesthesia. Cancelling a case is a decision not taken lightly. Patients rearrange their life, taking vacation, arranging child care, so that they can get stuff done but safety usually comes first. IN emergent situations, the decision to operate allows depends upon whether the benefit outweighs the risk and the patient, family, surgeon and anesthesiologist all need to be on the same page.
The surgeon is the star of the show and represents the dozens of people on the team required to make a successful operation. Some touch the patient, like the nurses and the anesthesiologist, others, like the housekeeper and the people in central supply who sterile equipment, are invisible. But that is the real world. Even Mick Jagger needs an electrician for the show to go on.