Monday, December 10, 2007
Fun website
Are you a nerd? Do you like geography? Think you know the 50 states pretty well? Well, look no further. This website is for you.
Another OB story
Dr S, the chief of the obstetrical anesthesia division, has been promising to tell us the story about F.C., an interesting patient of his from several years back. He didn't have the time today to tell us the story, but instead related another interesting anecdote.
The day started normally with a couple epidurals for women in labor, overseeing a cesarian section, the usual. He was called to one of the labor rooms with another epidural request. When Dr S walked in, however, he noticed the patient lying stark naked in bed, in labor. A little unusual, perhaps, but nothing too remarkable. After all, patients are very frequently naked in the operating room, though we try to keep at least part of them covered when they're awake.
The vibe here was different. Dr S soon picked up on why when he looked up and saw the patient's husband sitting in the chair beside the bed...also completely naked. They were evidently the "crunchy granola types" and preferred the "natural approach." (Why they were in a top-tier medical institution requesting an epidural rather than squatting at home on the kitchen floor with a bucket of warm water, a pair of gleaming scissors, and some fresh clean towels, I cannot say.) After taking a moment to register the situation, Dr S regained his cool and explained the process, benefits, and risks of an epidural to the patient, who wished to proceed.
As if that weren't weird enough, the story doesn't end quite there. The patient then requested that Dr S remove his clothing before he placed the epidural. This was part of the" natural approach."
This led to a series of musings:
The day started normally with a couple epidurals for women in labor, overseeing a cesarian section, the usual. He was called to one of the labor rooms with another epidural request. When Dr S walked in, however, he noticed the patient lying stark naked in bed, in labor. A little unusual, perhaps, but nothing too remarkable. After all, patients are very frequently naked in the operating room, though we try to keep at least part of them covered when they're awake.
The vibe here was different. Dr S soon picked up on why when he looked up and saw the patient's husband sitting in the chair beside the bed...also completely naked. They were evidently the "crunchy granola types" and preferred the "natural approach." (Why they were in a top-tier medical institution requesting an epidural rather than squatting at home on the kitchen floor with a bucket of warm water, a pair of gleaming scissors, and some fresh clean towels, I cannot say.) After taking a moment to register the situation, Dr S regained his cool and explained the process, benefits, and risks of an epidural to the patient, who wished to proceed.
As if that weren't weird enough, the story doesn't end quite there. The patient then requested that Dr S remove his clothing before he placed the epidural. This was part of the" natural approach."
This led to a series of musings:
- Hospital policy does not explicitly require that one wear clothing while placing an epidural. It does require gloves, a hat, and mask, though. Would the family object to the hat and mask?
- What, if any, extra documentation would be required? "Patient identification confirmed. Risks, benefits, and alternatives discussed. Consent for epidural obtained. After proper hand hygiene and removing my clothes, the patient was placed in the sitting position. Sterile prep and drape..."
- Was the husband sitting on a towel?
- Where would one put one's pager?
In the end, and probably in part because of the multiple quandaries raised by the circumstances, Dr S told them no, he would remain fully clothed for the epidural.
Sunday, December 09, 2007
Epidural hubris
So I just finished doing a combined-spinal/epidural on a woman who has had scoliosis of her back repaired. The usual risks of neuraxial analgesia--inadvertant dural puncture, headache, difficulty placing the catheter--are all greatly increased in patients with a history of back surgery.
This patient was in the hospital last week for induction of labor, but when the obstetrical anesthesia fellow wasn't able to place the epidural, the patient was sent home.
She came in tonight in spontaneous labor, and again requested an epidural. This time I was on duty. And can I say that--*boom*--one one attempt, the spinal was given and the epidural catheter threaded easily!
On this note of success, it's now time to hand off the primary pager to Todd, my co-resident who's been sleeping peacefully for the last few hours, and it's my turn to hit the sack.
This patient was in the hospital last week for induction of labor, but when the obstetrical anesthesia fellow wasn't able to place the epidural, the patient was sent home.
She came in tonight in spontaneous labor, and again requested an epidural. This time I was on duty. And can I say that--*boom*--one one attempt, the spinal was given and the epidural catheter threaded easily!
On this note of success, it's now time to hand off the primary pager to Todd, my co-resident who's been sleeping peacefully for the last few hours, and it's my turn to hit the sack.
Monday, November 19, 2007
Three delightful findings
Every day, no matter how much I'd like to forget it, has its bright spots, like getting to enjoy the snow flurries through the window this morning for about 5 seconds. Here are a few more from today:
- In the September 22 edition of The Economist I ran across a review of Alan Greenspan's new book The Age of Turbulence: Adventures in a New World. Evidently, not everyone would naturally look forward to encountering this 530-page tome: ...nobody ever accused Mr Greenspan of being a lively speaker, let alone a born storyteller, and no reviewer could approach this volume with anything but a heavy heart and a sense of duty.
- From the same review, Who would have guessed that 500 pages in Mr Greenspan's company could slip by so easily?
- And finally, reading in amNewYork I ran across an article about possible subway fare hikes by the MTA. Obviously, most riders are opposed, and there were public hearings provided for them as a forum heard by the MTA board. Some, however, doubted the efficacy of their testimony in convincing the board and yet chose to testify: "I told my co-workers about it [the public hearing], and they said it was like spitting in the wind," said Sahre Davis, a receptionist and community college student from Greenpoint who also testified at a hearing. "I'd rather spit, because I know it will land somewhere."
Day of stress
I'm not a big fan of days like today. Not only was it the first day of a new rotation for me (obstetrical anesthesia), but it was also my first day back from a two-week vacation. This is the first time I've had more than one week off at a time since I graduated from medical school. The longer break was nice, but I knew it would be tough coming back to work.
It was tough to get out of bed to hit "snooze" on my cell phone at 0450. It was tough to go back to sleep, so I just got up after lying there a few minutes. It was tough to stay warm at the outdoor 125th Street station as I waited 30 minutes for the 0539 train which never came. It was tough to change in the locker room since I'd forgotten my combination. (All I could remember was Uncle Paul and Aunt Betty's shed's combination. That'll teach me to offer to rake the yard!)
And then I showed up to the labor and delivery floor where the stars, misaligned as they were, had three--and only three--anesthesia residents showing up for their first day of OB anesthesia. My assignment was the toughest, at least from my perspective. As the resident covering labor and delivery, I received any calls from the OB residents requesting epidurals, evaluated patients for epidurals, placed epidurals, and followed up on epidural patients. (Notice a theme?) I was also the first person called for emergency c-sections, which I would then coordinate with the residents covering the OB OR's. Then there were follow-ups from the day before, and the ordinary confusion of learning new paper work systems, new places to get medications, new kinds of medications, new mazes of corridors and rooms, new nurses' names, new obstretricians' names, and different ways of documentation.
And finally, placing my first few epidurals in OB was not a small source of stress. I'd only placed 4 or 5 epidurals before, and the technique is trickier than doing a spinal since a catheter has to be threaded. In addition, there is the constant danger of pushing just a millimeter too far and puncturing the dura with a large-bore needle (a "wet-tap," colloquially), leading to a severe headache for the patient, frustration for my attending, and embarrassment for me.
While placing an epidural in one particularly obese patient on whom I had trouble locating any landmarks, I thought my needle might be against bone at one point of the procedure. "Just a little more pressure," I thought. With that, the needle leapt through the rather crunchy ligament its tip had been buried in and landed a few millimeters deeper. The tension emanating from my attending who was standing at my side was palpable. I withdrew the stylet...no gush of cerebral spinal fluid! The stars had shifted, Fortuna's wheel was spinning, the Fates smiled upon me. The needle was in the perfect place. I wasted no time in threading the catheter and getting out of there!
I was mentally exhausted by the time I walked in my apartment at 1700. Even though I'd only worked a little over nine hours, the constant multi-tasking and the newness of it all was draining. Given that most people really like their OB anesthesia experience, and given that most of the stress was learning the new system, I think things will get much better quickly. Before long, things will probably take half as long as they did today. We shall see by the end of the month how my perspective has changed on OB anesthesia.
It was tough to get out of bed to hit "snooze" on my cell phone at 0450. It was tough to go back to sleep, so I just got up after lying there a few minutes. It was tough to stay warm at the outdoor 125th Street station as I waited 30 minutes for the 0539 train which never came. It was tough to change in the locker room since I'd forgotten my combination. (All I could remember was Uncle Paul and Aunt Betty's shed's combination. That'll teach me to offer to rake the yard!)
And then I showed up to the labor and delivery floor where the stars, misaligned as they were, had three--and only three--anesthesia residents showing up for their first day of OB anesthesia. My assignment was the toughest, at least from my perspective. As the resident covering labor and delivery, I received any calls from the OB residents requesting epidurals, evaluated patients for epidurals, placed epidurals, and followed up on epidural patients. (Notice a theme?) I was also the first person called for emergency c-sections, which I would then coordinate with the residents covering the OB OR's. Then there were follow-ups from the day before, and the ordinary confusion of learning new paper work systems, new places to get medications, new kinds of medications, new mazes of corridors and rooms, new nurses' names, new obstretricians' names, and different ways of documentation.
And finally, placing my first few epidurals in OB was not a small source of stress. I'd only placed 4 or 5 epidurals before, and the technique is trickier than doing a spinal since a catheter has to be threaded. In addition, there is the constant danger of pushing just a millimeter too far and puncturing the dura with a large-bore needle (a "wet-tap," colloquially), leading to a severe headache for the patient, frustration for my attending, and embarrassment for me.
While placing an epidural in one particularly obese patient on whom I had trouble locating any landmarks, I thought my needle might be against bone at one point of the procedure. "Just a little more pressure," I thought. With that, the needle leapt through the rather crunchy ligament its tip had been buried in and landed a few millimeters deeper. The tension emanating from my attending who was standing at my side was palpable. I withdrew the stylet...no gush of cerebral spinal fluid! The stars had shifted, Fortuna's wheel was spinning, the Fates smiled upon me. The needle was in the perfect place. I wasted no time in threading the catheter and getting out of there!
I was mentally exhausted by the time I walked in my apartment at 1700. Even though I'd only worked a little over nine hours, the constant multi-tasking and the newness of it all was draining. Given that most people really like their OB anesthesia experience, and given that most of the stress was learning the new system, I think things will get much better quickly. Before long, things will probably take half as long as they did today. We shall see by the end of the month how my perspective has changed on OB anesthesia.
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