Sunday, October 29, 2006

A Little More Gas


The anesthesiologist is the surgeon's best friend. The only times when that's not true are the times when that's not true.

In thinking about the relationship (because Enrico asked me to), I've come to some conclusions, most of which are less than earth-shaking. As with most collegial relationships, the best are those in which there is mutual understanding and respect; and that, for the most part, comes from working together consistently. I had the luxury, for the better part of my career, of working with excellent anesthesiologists, and working with the same ones on a regular basis. So. What makes for an excellent anesthesiologist? Pretty simple: don't drive me crazy.

OAFAT (pronounced "Wah-fat"). It stands for "Obligatory Anesthesia Fucking Around Time." Surgeons -- me at least -- are just the teensiest bit impatient. If I've got a case to do, I want it to get going. Patient's in the pre-op holding area: I want to go in there, talk to him, explain everything, touch a little flesh, and then get him into the OR. Hell, I'll be there to push the gurney, move the patient from it onto the OR table. Now, I'll be the third or fourth to admit that surgeons vary widely in all things. I've already posted about the ones that are chronically late. Some seem constitutionally unable to arrange convergence of patient, lab data, history and physical (I always hand-carried lab and H and P myself, to the OR, the night before scheduled surgery.) Others take inexplicably long to do an operation that can be done in half the time; or they regularly spring surprises on the OR crew, changing the plan with no warning, announcing a need for critical instruments at the last minute (when I was doing a particularly big operation, I'd talk to OR personnel the night before to be sure everyone was on the same page.) There are surgeons that have limited understanding of how to prepare a patient for surgery. So far be it from me to suggest that anesthesia folk are unique in their deviation from standard. But diverge they do; they sure do. If I had long list of operations lined up, there were some gas-passers whose names I loved to see on the schedule. With others, I knew it'd be an annoying and frustrating day.

Let's put it this way: I know from observation over a large number of years that it's possible for an anesthesia person to examine and counsel a patient very thoroughly and sensitively, get them into the room and off to sleep safely, have them wake up smoothly and comfortable exactly when the operation is over, and do it consistently and predictably, all the while adding only a few minutes to each end of an operation. And repeat the process throughout the day. So why in HELL am I out here in the hall, pacing up and down, looking into the pre-op area, seeing that person STILL in there gabbing away with the patient? Or standing at the patient's side, observing her looking around the room nervously wondering why she isn't asleep yet, while watching the anesthetist tearing off tape, popping open vials, looking for tubes, sending the nurse out to get this or that, adjusting dials for FIFTEEN GODDAM MINUTES, when I know another person would have had all that stuff laid out in advance?? I'm just asking. Worse, why did the patient's blood pressure crash when anesthesia was induced? Or how come the whole crew had to stand around at the end of the case while the patient refused to breathe enough to be extubated or moved to the recovery room? And mainly, why do those scenarios always happen with some docs, and never with others? Or nurses, for that matter. Why, in short, can't they be more like me? (Cue Rex Harrison...)

OK, so it's about more than driving me crazy. And I know it's not a one-way street. Surgeons drive anesthesiologists crazy also. But when it works, it's a beautiful thing: and even when we know each other well, it takes a certain back and forth throughout the operation: me saying what I'm about to do, making it known if something is happening out of the routine, announcing when I'm nearly done.

A good anesthesiologist has an orderly mind, and a smart one. He or she needs to be expert in cardiopulmonary physiology, and the drugs that effect it. I think anesthesiologists are better scientists than surgeons. She or he needs to be able to think fast and to run logically through lists of possibilities and probabilities -- in that way, they are like surgeons. It's helpful if he or she can connect with patients positively and easily, since they rarely meet before the immediate pre-op commencement ceremonies. Like piloting a plane, giving an anesthetic is critical at takeoff and landing, and -- one would hope -- can be boring in between. So a good anesthesiologist must know how to turn pages without disturbing the surgeon. Be facile at text messaging. Have an iPod with good music and know how to hook it to the stereo in the OR. Laugh at the surgeon's jokes, and tell a few of his/her own.

Giving an anesthetic is no easier now than it was decades ago, in part because we're able to do more complex things on sicker people. But it's safer. One of my mentors liked to say you're never safer than when you're under anesthesia: there's real-time monitoring of your most critical functions, and safeguards to detect changes in important parameters before they get anywhere near the levels required for notice a few years ago.

For anyone out there looking to make a career choice in medicine who thinks they like hanging out in ORs but who wants actually to have a life, consider anesthesia: the work is dramatic and intellectually rigorous, they get to hang out with surgeons, and when they work at night, they get the next day off. What could be better? If at times we drive each other crazy, well, who doesn't, really?

But when the shit is hitting the fan, when we're in there together -- me trying to stop bleeding, he squeezing blood in with both hands, when we pull off an amazing save of a desperately ill person because we've both done our jobs extremely well and when it couldn't have happened if either of us hadn't, when it's over and we're moving the patient to recovery and I say "thanks man, that was a great job," I really really really mean it.


[Update: 2/1/08. Sometimes I re-read an old post and think it was pretty good. Other times, I wonder what I was thinking. The tone of the first half of this one falls into the latter category, although the last couple of paragraphs aren't too bad. Judging by the comments, some anesthesia folk rightly took offense (and likely quit reading before the latter parts), and got what I hope is an erroneous impression of who I am. But one not unjustified by what I wrote. I can only say, and hope it's believed, that I actually had an excellent relationship with all but a couple of the many gas-passers with whom I worked. And hope that anyone else who reads this and takes umbrage will poke around at some of the other stuff here, before judging on this post alone.]

25 comments:

DisappearingJohn said...

I enjoyed both posts!

I haven't been in many surgeries (well, at least while awake!) and sadly, in every one I've been in, the surgeon and anestheiologist have been adversarial at best. In one case, they didn't even know each other until they shook hands before scrubbig.

I love to hear the stories of the opposite...

Anonymous said...

From a patients side. While I'm no expert at surgeries, I've had a few..9 to be exact..The easiest time for me following surgery, were the ones where the antethesiologist met with me prior to surgery. He asked questions and knew that I get very sick following surgery. Those are the ones, that start off by ordering zantac and other stomach meds first. They already know how I have reacted to prior surgeries and are prepared for it.

The strangest surgery I ever had was at one of the really big hospitals, where you WALK yourself into surgery and climb onto the operating table.

Once I was already in surgery, on the table, and NO surgeon! He had called (I was his first of the morning) and told them to wait (1) minute and take me back. He would be there..They took me back, everyone else was already in there and NO surgeon...OMG, It was atleast 30 minutes before he got there. It was ok because everyone else, gasman, assistant, nurses were all talking and making jokes with me..The Gas man kept walking over to the door to see if he was there yet.The last words I remember hearing, after he announced that my surgeon had finally arrived, as he was givng me meds through my IV , was the nurse, saying..."ELVIS....Is in the building!"

Sid Schwab said...

disappearingjohn: I suppose there's an extent to which the anesthesiologist is generic: in many hospitals, it's whoever shows up, and the surgeon figures if he can put him to sleep and wake him back up, who cares. But it really is a pleasure to work with people you know, over and over. Lots of little things go much better.

anonymous: the idea of a patient going off to sleep without the surgeon at least saying hello to him is disgusting, as far as I'm concerned. Walking into the OR, however, is not. Nothing like a little leg action right before surgery, far as I'm concerned. In situations where the patient was already in the hospital, I'd ask the floor nurses to walk him around the halls before sending him down to the OR.

beajerry said...

Nice post, doc.
As a nurse, it seems we get along much easier with anesthesiologists than with other types of docs.
I don't know why.

keagirl said...

We used to call it MAFAT (Mandatory Anesthesia Fuck Around Time)in residency.

I have to say that being in private practice has opened my eyes to more efficient anesthesia. There is minimal MAFAT now.

Empress Bee said...

doc you just write beautifully. and i had the good ones in my surgery, i was a very lucky girl. both the surgeon and the anestheiologist were wonderful, it made all the difference in the world. bee

jclarkv said...

You've heard of the three A's of being a successful anesthesiologist?
1. Availability
2. Affability
3. Ability

...in that order.

The Angry Medic said...

Heh. Because anaesthesiologists don't have to DO their job well, as long as they're so lovable they get along with everyone, right?

The ones who are really good at their job command almost as much respect as the surgeons, in fact. On one of my surgical attachments I had the pleasure of working with a really affable gas man who had been operating with the surgeon for decades, and their working relationship was exemplary. It was only later that I found out the gas man was the same one who put my mum under during my delivery all those years ago! I turned out only slightly brain-damaged, so he must have been quite good :)

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enrico said...

Most sandmen I got to know were quite forgettable. The anesthesiologist I came to know well (for good reasons) had a steel Craftsman cart that he'd roll from room to room which contained all his gear (minus the DEA box of course) because he insisted on having HIS gloves, HIS tape, etc. because the stock stuff would always get misplaced or whatever. He was no shrinking violet--Dr. A. had as much command in his domain as any surgeon, but, in most cases, twice the affability.

Most important in the cart was the massive CD collection with the cherry boombox attached to the top (this was before iPods of course). He prided himself on having whatever anybody wanted for tunes, and took the time to ask the patient if they wanted any specific type of music during induction.

It's the little things...

Intelinurse2B said...

I am scheduled to observe for an entire day in the OR in the next few weeks. I'm looking forward to this as I can now observe some of the interpersonal stuff with a more informed perspective.

Enrico, the traveling DJ, a.k.a anesthesiologist is a hilarious mental pic.

Alexandra Lynch said...

Very fascinating and interesting...thanks for writing this up and sharing it.

I'm always happy to see a new post from you.

Janice said...

I had surgery in May. My surgeon was late and so I just observed while I was in pre-op. I saw an anesthesiologist who was really concerned about another patient's condition and wanted to talk to the patient's cardiologist before surgery to make sure he knew what was going on with her and that he authorized the surgery. The surgeon told the anesthesiologist if he didn't get the patient into surgery immediately, she wouldn't have surgery that day because he had a full schedule. The doctors argued. It got very heated and all of this in front of every patient in the pre-op area. It was incredibly inappropriate, in my opinion. I was so happy that doctor was not my surgeon. He was more concerned about his schedule than the patient's safety.

Julia said...

I've had an anesthesiologist handling me 3 times (all at the same hospital, no less, how boring of me!), and the one I remember best is the one who was handling my case when I was giving birth to my twins.

First of all, early that morning (for me, anyway), a pitocin drip was started. Not so bad. Then after 2 or 3 hours of that, someone came along to rupture the amniotic sac. She told me that the anesthesiologist would be in shortly to give me an epidural.

Now, pitocin drip alone isn't bad, ruptured amniotic sac alone isn't bad (I've had it both ways), but the combination of the two is the most hellishly long pain experience I've ever gone through. (But maybe I'm a wuss.) So I really, really, REALLY wanted that epidural.

And when the anesthesiologist came in, he told me he just needed one bit of information from the last blood draw they'd done on me. Then left.

And came back to tell me I couldn't have the epidural due to a low platelet count. (AARRRGGGHHH! You'd think they could have checked on this BEFORE coming at me with that hook, but NOOOOO!) He explained why it would be a bad idea do to an epidural on someone with a low platelet count -- and then promised that when it came time for the delivery, he would do everything in his power to help make me more comfortable.

So when I went into the OR for delivery (vaginal, but they always do twin deliveries in the OR in that hospital for several reasons), he was there, and at one point, it was so bad that all I could do was clutch at the two hands holding mine.

And then I realized that one of them belonged to the anesthesiologist, and that at that moment, the only thing he really could do for me was hold my hand -- and he was holding my hand.

(I ended up getting a spinal after twin B did something that complicated his delivery, and I would rather not have a spinal again, as I threw up from it later. But it beats being able to feel the doc rumaging around in your womb trying to find the feet of the kid who's just decided he is no longer going to be a vertex presentation and so will be hauled out feet first instead. And I've just scared some poor woman into childlessness, haven't I?)

Anonymous said...

You sound like some kind of disgruntled unhappy surgeon. As a practicing anesthesiologist for 20 years, I have worked with a few of your kind. You think the world revolves around you. Get this pal, THE WORLD REVOLVES AROUND THE PATIENT, not what is convenient for you and your schedule.

I and my partners have cancelled countless surgery over the years to the patients benefit......cardiology evaluation preop, medicine etc.

Glad your retired, you sound like a miserable bastard

Sid Schwab said...

Well, well. I think you must have stopped reading before the last couple of paragraphs. But it's ok. There's two sides to the ether screen. If you'd taken a bit more time, you'd have seen the amount of respect I have for good anesthesiologists. And, believe it or not, they for me.

And you might be interested to know I NEVER had a case cancelled for the reasons you listed. Why? Because I knew what preparations to make, and what the gas-men needed. Which is why, in fact, I got along famously with all but a non-precious few: the ones who weren't all that good.

mrh said...

Too bad you wake up so angry...
I bet you ruined so many potentially happy moments for you family.

Sid Schwab said...

mrh: not sure what you mean. However, I refer you to my comment above yours.

brahms said...

I guess your 15 minutes is more important than a proper evaluation by an anesthesiologist. We do more than just touch some flesh you see. We know that you don't give a damn about optimizing patients. You should have hired a CRNA - in fact, why don't we just let CRNA's take over - would that be ok with you? Its definitely ok by me because I'm done with dealing pricks like you.

Sid Schwab said...

brahms: nice to meet you. Did you notice the addendum at the end of the post? In retrospect, as one can read, I don't like what I said, either. On the other hand, it's nice that you've found a way to avoid working with people you don't like. I never managed that one.

Perhaps it's different in Wichita. The group I worked with (they were my partners, in a large multispecialty clinic, and we got along extremely well, with only a couple of exceptions) hired several CRNAs. They did an excellent job and I was always happy to work with any of them.

Zach said...

Stick to your guns! You said nothing that was unfair, in fact you made an effort to mention that anesthesiologists likely had similar issues from the other side of the relationship. Few who have ever set foot in an OR in a occupational capacity would deny that there are some anesthesiologists who are less organized than others and who slow things down.

Felix Chesterfield said...
This comment has been removed by a blog administrator.
Sid Schwab said...

Sorry, but that last comment seemed like a spam ad to me, so it's gone.

Anonymous said...

Nice post. My recent experience with surgery: the doctor didn't talk to me beforehand (or mark the arm to be operated on), the anesthesiologist told me I couldn't ask any questions (though I did meet with him previously and asked most of my questions then), and when I expressed surprise when it was mentioned I would have a catheter the anesthesiologist told me that I could leave if I didn't like it. Fortunately everything turned out well, but pre-surgery was a bit traumatic.

Sid Schwab said...

Wow. Well, I guess that proves that assholes can make it through med school. Shameful.