Hospital Life: From Anesthesiology to Zebras
by Lorien E. Menhennett
I belong in the hospital.
Not because I’m deathly ill (thank goodness), but because I want to work there someday.
I’m on spring break this week, and had the opportunity to shadow two physicians: an ICU director (a pulmonologist, Dr. Saunders*) and an anesthesiologist (Dr. Matthews*). Not only am I fascinated and intrigued with what they do, but (call me crazy here) I really like the hospital environment. Of course, the ICU and the OR are very different places, but I enjoyed things about them both. In this blog post, I will describe some of what I observed and learned in both the ICU and the OR, and why I find these places so interesting and compelling. I will also attempt to impart some of the passion and compassion I witnessed both of these days.
I began my day at a local community hospital ICU by going on rounds. For those of you who have never gone on rounds, it’s quite an overwhelming experience. Total information overload. Dr. Saunders, the hospitalist, pharmacist, cadre of interns, and I circled the ICU, stopping in front of each room, going over each patient’s current status. Which, for patients in the ICU, is pretty detailed: recent labs, overnight events, medications, lines, and so on. The interns were in charge of relaying all of this information and then answering questions about what it all meant. What did it mean that Mr. Smith’s potassium level was low? What did it mean that Mrs. Jones’s renal function had worsened? And more importantly, what would you do about it?
Acronyms flew like geese on a fall day, but I quickly caught on to what at least a few of them meant. “SBT” — spontaneous breathing trial — is a particularly important one in the ICU for patients who are on a ventilator. SBTs are a good predictor of whether a patient will be able to breathe on their own, off the vent. And getting the patient off a ventilator as soon as possible is key, because the longer someone is on a ventilator, the more likely they will stay on one.
I was incredibly impressed with the hospitalist, who really took the reins of rounds. He had an amazing memory for both the big picture of a patient’s prognosis (are they ready to come off the ventilator any time soon) and for the minute details (what their most recent ABG — arterial blood gas — showed). He also integrated teaching so seamlessly into the process, coaching and correcting, but not criticizing, the interns.
Toward the end of rounds, we looked at all of the patients’ chest X-rays. First of all, it’s not like it is on TV. (OK, OK, nothing is like it is on TV, I know. But bear with me.) On TV, when you see an X-ray of someone’s broken bone, it’s so obvious. There will be a huge gap there. Or if someone has a tumor, there will be a bright, white, grapefruit-size mass sitting in the midst of a black background. Again, obvious. But with these real-life chest X-rays, it was a mystery to me how the physicians could tell anything from them. They would point to a splotchy, whitish area and say it was pneumonia. And I’d think, “OK, I get it.” Then on the next one, I’d think I saw a similar splotchy area, and then the hospitalist would say, “This X-ray looks great!” The way they had trained their eyes to see such detail was just incredible.
This is what I really gleaned from those two hours of rounds: There are two levels of understanding when it comes to a patient’s condition and prognosis. And they need to be integrated. You need an understanding of both the minute details, and the big picture, as well as how those details contribute to the big picture. This requires a great deal of synthesis of clinical information and basic science. (Yes, all that basic science you learn does have a place!) The interns struggled with this, understandably; they are fledgling physicians. But for the hospitalist, I could tell this had become second nature to him. That was just amazing to watch.
One thing about working in the ICU is that while some patients get better, some of them don’t. But with current advances in medicine, they can linger for weeks, months, even years. So at some point, it’s up to the family whether to let the patient go or prolong their life artificially. I sat in on one of those family discussions. It was Dr. Saunders, an intern, a nurse, the patient’s daughter, and me, all piled into a tiny office. Dr. Saunders began the meeting by asking the patient’s daughter what her understanding was of her mother’s condition. As he explained to me later, that gave him a sense of where she was both emotionally and cognitively with the situation. Then he presented some additional facts about the patient’s condition and prognosis. Before he even had a chance to give a recommendation, though, the daughter said, “I think I know what needs to be done. I don’t want her to suffer anymore.” Dr. Saunders agreed, and encouraged her to talk with the rest of her family about the decision. It was a sobering reminder about the nature of life, and of death.
Dr. Saunders told me afterward that this meeting was one of the easier ones — people aren’t often receptive to the idea of letting go of a loved one. Even if, from a physician’s standpoint, it is the best thing for the patient.
Later, I got to see something of a “zebra.” (That’s doctor-speak for a rare condition.) Dr. Saunders and I headed to the ER to do a pulmonary consult on a woman who came in with severe chest pain and shortness of breath. The diagnosis? Catamenial pneumothorax of the left lung. A pneumothorax is a collapsed lung. A catamenial pneumothorax is a collapsed lung associated with a woman’s menstrual period, and with endometrial “implants” on the lung or pleura. No one seems to know exactly how or why this happens. But it had happened multiple times to this woman. The physicians decided to treat her with a chest tube and later VATS (video-assisted thoracic surgery) procedure. Which sounds really scary but is actually minimally invasive and allows the surgeon to repair the problem.
We also saw more patients, had another family meeting with the relatives of a man who had had a stroke (this one over the phone), and somehow managed to squeeze in lunch at the infamous hospital cafeteria (the food was actually pretty good!). Never a dull moment. And every moment something different. That’s one thing I really liked — the variety of the day, what we saw and what we (well, technically he) did.
The OR is a place where what seems like magic happens. The surgeon cuts a person open. The surgeon removes things, implants things, repairs things. The surgeon sews the person shut. But all of that is made possible because the person is unconscious, kept unaware of the trauma their body is undergoing. Making that happen is the anesthesiologist’s job.
Dr. Matthews, the physician I was shadowing, got pulled last-minute into some administrative duties (he is the department chair of anesthesiology at the hospital where he works). So I spent part of the day with two certified nurse anesthetists, who perform anesthesia under the supervision of a physician. Between Dr. Matthews and the nurse anesthetists, I now have a better picture of how complex anesthesia is, and how fascinating.
At first glance, anesthesia might look easy. You stick a tube down a person’s throat, pump them full of drug cocktails, and let a machine regulate their breathing. But there’s a reason they make you go to medical school to be in charge of this stuff. It involves the subjects of biology, chemistry, physiology, and pharmacology (to name just a few). It involves understanding all aspects of a patient’s history and how that history interacts with the situation at hand. It involves rapid decision-making, sometimes in crisis situations. It also involves patience, compassion, overall good bedside manner, and a sense of teamwork. (Oh, and it helps if you don’t faint at the sight of blood.)
I observed two surgeries that day: a tummy tuck and an arthroscopic shoulder surgery. And I watched two nurse anesthetists at work. One thing I noticed — which they corroborated — was that they each had their own “style” of working, and of relating to the surgeon, surgical tech, and other nurses. They both explained to me that there are different ways of accomplishing similar things (such as pain relief, for example), and that different practitioners prefer different methods. One of them told me, for example, that he prefers to avoid using certain intravenous muscle relaxants because they require you to use another drug called a “reversal” to reverse the muscle relaxant effect at the end. He said that in his experience, patients who received those drugs seemed to experience more nausea after awakening.
Something else that really stuck out to me was that at one point during the shoulder surgery, the patient’s blood pressure became a little low. Not dangerously so, but lower than the nurse anesthetist wanted to see it. He had two different drugs he could use to remedy the situation — one would raise both blood pressure and heart rate, and the other would raise blood pressure while decreasing heart rate. The problem was, we didn’t really want to mess with her heart rate at all, so what to do? He chose the second drug, based in part on the woman’s age and medical history, and how the drug would affect her based on that history. Lo and behold, a few minutes later, her pressure was back up, and her heart rate had only decreased a couple of beats per minute. It was incredible.
As with working in the ICU, life in the OR is anything but boring. Every patient is different, and requires something a little different from the anesthesiologist. Keeps you on your toes. And I like that.
*Names have been changed.