Friday, July 27, 2007

Cooking Up an Anesthetic

I have been on-call quite a bit this month. Today I am post-call and off for the weekend, ah...

For lunch I wanted Linguini Aglio Olio. Unfortunately this is not so straight-forward without the olio. How can there be no olive oil in my kitchen? After scrambling around for a bit I ended up using some olive oil spray, a teaspoon of butter, and a couple of drops of canola oil and to my great surprise, the dish came out edible and pretty tasty. But I guess it's not that easily messed-up as dishes go!


When I was a medical student I watched a senior anesthesia resident during a case, tweaking the rate of IV fluid administration here, adjusting the dial on the vaporizer there. It all seemed so mysterious - why did he pick that particular moment to turn the gas flow up a notch or down a notch? The patient looked just the same. I asked him, "How do you know when to do that?" He answered laconically, "Practice."

As I learned to do the job, and found myself making the very same moves, I asked myself the same question, and my answer was, "Cooking." How many times have I turned the heat up or down on garlic being sautéed in the pan, or added an ingredient to a simmering sauce, or taken a spoon to toss a vegetable around, simply because my instincts told me it was the right move for that moment? And how did these instincts arise? From making the dish a number of different ways about a hundred times.

I find there's a lot in common between delivering anesthesia and cooking without a recipe (though when I mentioned this comparison during residency once, my attending shot it down instantly with a, "No there isn't." Different strokes...). I emphasize without a recipe, because with the exception of resuscitation algorithms, recipes can make for faulty medical practice. It's true that there are drugs and techniques I can say I usually use for any given case, but I try to practice flexibly. The minute we start handing out drugs according to some preconceived "cookbook" - remifentanil and propofol for this, midazolam and fentanyl for that, every time, all day, every day - we've stopped using judgment, creativity, knowledge, and adaptability. We've stopped being physicians, designing anesthetics in an actively engaged way, taking into account the needs of each particular patient or case.

Moreover, very often plan A just doesn't work out. No one starts the day wanting to perform an awake fiberoptic intubation on someone, but if safety concerns arise, and it's the right decision, then plan B it is. It's not what the patient wants, and it's not what I want in terms of comfort for my patient - but it's the right thing to do, and it's not a judgment I would make lightly. Cases like that highlight the folly of a consumer model of health care delivery. "Customer satisfaction" - or its equivalent, patient satisfaction, because patients are not customers - comes second; patient safety comes first. Always.

That said, I try my best every day to be open with my patients, hear their concerns, and carry out a plan that results in maximal safety and comfort for everyone. This is why when a patient once adamantly said she did not want a particular drug, and I was trying to ask questions to clarify my understanding of her experience and her position (i.e. doing my job), so that I could come up with a safe and viable alternative, I was offended and irritated when her husband yelled at me, "Why do you people always start asking all these questions the minute she says that? She doesn't want it, period! We don't need all these questions!" Well, sir, you're wrong, we do need these questions if we're going to be prepared and provide the best care we can for your wife. It's a shame you're too short-sighted and hot-tempered to appreciate that, but that's the truth of it. I didn't reply in those words, of course, but I said to his wife something like, "Your experience with this drug is important for me to know about, because I care about making your comfortable and keeping you safe. Could you tell me a little more about the reaction you had...?"

Speaking of communication, a couple of things keep coming up (most recently, just last night) that I want to highlight because they really help us anesthesia folks provide the safest anesthetic we can (the following is just a sample; I'm sure I could think up more):

-Please follow any instructions you receive about eating and drinking prior to surgery, to the letter (usually some variation of DON'T eat or drink for 8 hours prior). And if you have consumed anything, please say so - this is a SAFETY issue.

-Please remove all contact lenses and piercings. Yes, even those piercings. :)

-If you drink 12 beers a day, please don't say you only drink on holidays. First of all, it's not safe to understimate the amount, because then we might incorrectly estimate the anesthetic dose for you. Secondly, once you are under, we can tell. Trust me. Your body will reveal to us that you in fact drink ten times more than you say you do.

-If you just had cocaine yesterday, or today, please don't tell us you've been off it for months. Again, it's NOT SAFE. And again, once you're unconscious, we'll be able to tell that your body is in fact totally revved on crack. But more importantly, something really BAD could happen to you on the table that we can do something to prevent if we know ahead of time, and we'll be able to choose the RIGHT drugs to help you, as opposed to the drugs that might indirectly contribute to your having a brain hemorrhage.

-Last but not least, please, please, please tell us what you're most concerned about. Your anesthesiologist should WANT to listen and do everything in his or her power to care for you attentively and safely. Please also hear us out if there's something we're concerned about explaining, from our end of things. We are NOT trying to be pains in the neck, but rather to provide thorough and good care. Our job is to protect and watch over you, and most of us do take that very seriously and wish to do our best.


Mitch Keamy said...

What a fine post. Looks like I'm doing something with onions today! You know, people are probably never more stressed than in preo-op, and my sense is that people fall on their "best" coping strategies when they are the most stressed; the angry become angry, the intellectual intellectualize. I personally like insurance sales people and real estate agents. They take five minutes trying to be your friend.
Giving an anesthetic IS like cooking; and I wouldn't want an anesthetic from someone who couldn't see that the metaphor was apt (come to think of it, I wouldn't want to eat at their house, either.) I think, though, that you could carry that metaphor way farther, if you consider PROFESSIONAL cooking. The need to combine the artful with the practical. That's part of the fun of anesthesia. No do-overs; working without a net. I hope you are teaching-you're awfully junior to have figured so much out. It's got to be your classical education...
Have a good weekend

Mitch Keamy said...

Hey, T; I was doing my Saturday chores, and I had an "advanced" thought. Your professor might not have understood your metaphor at the anesthesia end, but more likely, knowing people, he/she didn't understand it at the cooking end, assuming that you, like most people slavishly FOLLOW A RECIPE.In which case, you and he/she are in violent agreement about the need for adaptability.

Semper Gumby!


T. said...

Mitch, I so appreciate your thoughtful and supportive comments. Your last insight may be right-on - perhaps she was indeed misinterpreting what I meant about cooking, since I look at recipes more as guidelines / springboards. Or perhaps not.

I think the aristic science / scientific artistry of anesthesiology is one of its great pleasures for me.

I love teaching too, and feel I've been effective at it in the past, but currently only have a few opportunities to do it. In one of my three community hospitals I've had the opportunity to teach paramedic and EMT students, which has been a pleasure and an honor.