Sunday, September 7, 2014

PracticeBalance Again Featured on KevinMD!

My recent post about the challenges of NORA was picked up by the Medpage Today's popular medical blog KevinMD.com. This was a timely release, given the recent events surrounding Joan Rivers' death. To be honest, I hadn't heard about her death being a possible result of an endoscopic procedure until I started reading some of the comments to my post. (Shows you how much TV I watch)!

Of course at this juncture, it is difficult to know the details of how she suffered cardiac and/or respiratory arrest during an elective procedure at an outpatient medical center. She could have been receiving moderate sedation or something deeper, and there may or may not have been an anesthesiologist present (I cannot piece it together from the conflicting reports I have read).

The thing to note is that she was 81. She may have had lots of plastic surgery that made her physical appearance belie her age, but sedation or anesthesia on an 81 year old is never without risk. And sedation or anesthesia of any type on anyone is not without risk. 

Anyway, here is the link to the syndicated post. If you can't stand to read the post again but are curious about the comments, those can be found here.

Monday, September 1, 2014

Two Weeks of Waiting = Torture

(Image courtesy freedigitalphotos.net)

The hardest part of doing IVF is this phenomenon known as the Two Week Wait. After an embryo is implanted, the pregnancy hormone HCG does not rise to detectable levels for approximately 10-14 days; thus, you have to wait two weeks to find out if the procedure was successful and you are actually pregnant. This is an especially torturous time for women, as it's easy to scrutinize every little thing you feel or do:

"I have some cramps... does this mean I'm pregnant?"

"I tripped in the garden yesterday and lurched forward... what if that made the embryo dislodge?"

"My breasts hurt... No wait, now they don't hurt..."

When people ask me how I'm faring in my IVF journey, I always say that the mental aspect of things is MUCH harder than the physical aspect. The mind game of waiting is a big part of that. I can shoot myself in the belly and butt with hormones until I'm blue from bruises, but I have a hard time relinquishing control and living with the unknown.

You see, I am an anesthesiologist. My job substantially involves performing interventions that produce near-immediate results. I give a drug to induce anesthesia, and the patient jokingly says, "I'm going to fight it, doc!" or "Don't you have people count backwards? One hundrrrr..." Boom. They're out cold. I always win. In the middle of a case when the heart rate gets too high or the blood pressure goes too low, I give a drug and within seconds things are back to normal. I'm used to seeing the direct results of my actions.

This is not the case for many other doctors, and it is definitely a reason that some people end up choosing anesthesia or surgery or possibly emergency medicine over other specialties. If you are a general practice doctor seeing a patient in a clinic and you prescribe a new medication or ask them to try some new behavior in regards to their health, you must then send them home with instructions and wait to get the results at the next visit. Changes happen over a much longer timeframe. Even my husband, who is a patent lawyer, submits a new patent application and then must wait months to hear back from the US Patent Office regarding its status.

The other thing is, we have to wait for things in life all the time. When we are going on vacation, we cannot (yet) be immediately transported through thin air to our destination like Star Trek characters. We must wait in lines at airports or spend time driving to the desired location. We set out to change our diets or exercise more, and the results of our personal experiments do not show up overnight; they take months to manifest.

We might get a negative IVF result and then have to wait 2-3 months to try the whole thing again. And this might happen multiple times, accumulating into a period of months or years of waiting. Maybe we do get pregnant, but then we have to wait 9 months for the baby to arrive. A child is born, and we do not immediately plan out his life path; 18 or so years go by while he is growing into his future adult self.

I suppose performing anesthesia, which occupies a significant portion of my life yet is the exception to the rule that outcomes of interventions are rarely immediately known, has skewed my view of time. I'd better adjust my attitude about this waiting thing!

Thursday, August 21, 2014

MRI: Punishment Anesthesia or Growth Opportunity?

(Courtesy wikipedia.org)

I opened my obligatory late-afternoon email to find my work schedule for the next morning: three general anesthetics for MRIs. My heart sank. A week before, I had been assigned to the new neuro MRI suite for a 6-hour interventional radiology procedure, followed by another intervention in the CT scanner. My first thought: who is trying to punish me?

It's well-known in the anesthesia field that these types of cases can be challenging for a variety of reasons. They are lumped into a category of cases that we often refer to as "out-of-OR" of "non-OR" cases. An acronym NORA, standing for Non-Operating Room Anesthesia, has even been coined. These cases usually involve general anesthesia or deep sedation for imaging, cardioversion, other interventions such as ablations, GI procedures, radiation treatments, etc. As opposed to administering our well-established, standard anesthetic in the controlled environment of the OR... with other providers around in adjacent rooms and ancillary staff who know how to help if needed; with all of the important but luckily not-often-used difficult airway equipment at our disposal down the hall; with surgeons around, (usually) patiently waiting for you to perform your part of the case... we are instead sent on safari.

I don't know that I can adequately describe what we anesthesiologists are faced with here: imagine trying to carry out your job - which inherently involves the delicate and potentially dangerous task of inducing general anesthesia and establishing an airway - on a sick, or young and vulnerable, or perhaps developmentally delayed patient. This is the typical patient population that might need an out-of-OR procedure or a general anesthetic for an MRI because they are not able to sit still for the scan. Only now you are doing it in the hallway of an MRI scanner with people you don't know, who don't regularly see what you do and thus don't know how to help you if you need them to. They may be breathing down your neck and in your face wishing you were done already, or on the flipside they may be despondent and ignoring you, drinking their coffee in the corner all the while completely oblivious to what you know as a potential life and death situation. The ventilator equipment is different and usually cumbersome, sitting on the "wrong side" of the room, with lots of extension tubing tangled about so as to eventually reach far into the black hole of the scanner. The monitors are strange and often not easily readable. Oh, and on top of all that, you aren't allowed to have a phone or even a pen (no metal is allowed near the MRI magnet). Once you get the airway established and the anesthetic underway, you place the asleep patient carefully in the scanner and have to... *gulp*... leave the room! (Our normal practice is to be right next to the patient at all times.)

Every time I'm assigned to an out-of-OR day, I feel an initial twinge of dread. But once it gets going and the painful unfamiliarity of the environment fades, a wash of confidence comes over me. I was trained to improvise and adapt to difficult situations, all while providing a safe and effective anesthetic... These skills are being tested, and I'm actually doing it! Things almost always work out fine, even if you yourself have to sweat a little more and people aren't handing you the things you need or following your commands at will. The staff sometimes surprise you with their willingness to help. They might even offer you some homemade treats brought in specifically for their group. The patients, who often have interesting stories, have something to teach you as well. And you go home feeling a sense of accomplishment and gratitude!

The longer I work in this field, the more I try to view these cases as positive challenges and potential opportunities for growth. Experiences that require you to calmly and safely navigate territory in which you are uncomfortable (and do so with style and grace) apply to so many areas of our lives.

* * * * *

The next day at work, I joked with the scheduler, "You must have had it out for me the other day, sending me to do MRIs twice in one week!" "Ahhh...", he chuckled. "I figured you would totally be on top of it. There are some people that I send down there, and they throw their hands up and say, 'I cannot deal with this!'" I took that as a huge compliment!

Friday, August 8, 2014

Book Review: Thrive

I greatly admire Ariana Huffington; I have always loved the content and structure of the Huffington Post. She was a pioneer of the modern blogging movement, and when I first started this blog I read the Huffington Post Complete Guide to Blogging. It was extremely practical, well-written, and helpful for me when I was just starting out and trying to find my voice.

Sometimes, I secretly hope that the people at HuffPo will notice my little blog and ask me to write for them. Of course then I'd have to come up with something really good! Anyway, my admiration for Huffington further broadened when I heard about her new book Thrive. I finally got a chance to read it (long waiting list at the library!), and here are my thoughts...

Thrive is essentially an argument for redefining success in America. Going deeper, it is a plea to focus on stress management and self-care over the typical metrics of success (sound familiar?). Huffington surely possesses the ethos to talk about success, given her prolific authorship (she has written something like 14 books) and her publication empire's often imitated online news model.

The full title of the book is Thrive: The Third Metric to Redefining Success and Creating a Life of Well-Being, Wisdom, and Wonder. That's a mouthful I know, but it gives a good idea of the things Huffington discusses. She first points out that the main two metrics of success in America are money and power. The book opens with a shocking and intimate vignette about how she became aware of the need to write on this subject. It closes with a directive to move "onward, upward, and inward." Love that!

Interweaving personal experiences with classic persuasive evidentiary writing, she argues for a third metric of success. Her "third metric" is a blend of well-being, wisdom, and wonder, and if this was an easily measurable and quantifiable metric, the book would be much shorter. Thus, she forms the body of her book by dividing it into sections to discuss these three w's. She shares deeply personal experiences with vulnerability and courage, an admirable thing in my opinion for someone of her popularity and stature.

My one criticism of this book is that it is heavy on argument and evidence but light on practical ways to apply her points. (That's where your reading of PracticeBalance can come in handy; hopefully I can help fill that void!) Of course, I read the book from the standpoint of being already convinced. She does provide appendices of her favorite apps for structuring social media time, meditation tools, and websites that match volunteers to service projects. I'm very happy that the book is so successful; it's coming from a place of widespread appeal, so her message will trickle through the channels from executives to perfectionist soccer moms.

Have you read this book? What did you think? How do you define success?