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.]

It Can Be a Gas

While assisting on a carotid endarterectomy (wherein the main artery to the brain is clamped off, opened up, and reamed out) one time during my surgical training, I noticed the anesthesiologist was rummaging around a bit more than usual: opening drawers, drawing up drugs, checking monitors. Finally he casually looked over the ether screen and said to the surgeon, "Jack, you might want to stop what you're doing for a while and push on the man's chest."

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Shortly after I'd arrived in town, the new guy on the block, I told the anesthesiologist assigned to my impending breast biopsy in a frail elderly woman that I'd be happy to inject a bunch of local anesthetic if he thought it would simplify his anesthetic. "I don't need some pipsqueak punk telling me how to do my job," he yelled.


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In the middle of a big case during which the patient's heart had become erratic, the nurse anesthetist seemed a bit flustered. "Think you should call Dr X (the nurses always worked under the direct supervision of an MD anesthesiologist) to come in," I asked? "He's out on his boat," she replied.

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Debbie the Nurse gives the anesthesia quite frequently for the obesity surgery operations in which I participate of late. Those patients, being quite large and often having associated medical problems, present some unique intra-operative management issues, especially since most are scheduled to go home the same day. More than any of the other anesthetists, nurseoid or doctoroid, Debbie the Nurse can be counted on to have the patient awake and devoid of a breathing tube as the case finishes up.

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The patient is asleep, prepped, draped; the equipment is all ready; it's time to begin. I always ask the anesthesiologist, "OK to start?" before I make the cut, and when the reply is affirmative, I dig in. Sometimes the patient responds a bit, moving. Occasionally it's a pretty vigorous move. I hate it when that happens. (Note: I've never had a patient remember it or comment upon it.)

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During a major abdominal operation, open or laparoscopic, it's imperative that the patient is given muscle relaxants so the belly wall is nice and floppy; otherwise work is nearly impossible. Sometimes it's obvious they are tightening up: I say to the anesthesiologist, "He's getting tight." "I'm on it," is the response, usually. Better: with some docs, it never ever happens. Worse: "No way. Monitor says he's fully relaxed," comes the voice from above the patient's head. "Check the goddamn battery on your nerve stimulator, doc. He's tight as a drum."

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Tough case. Big operation, sick man. Septic, needing ventilatory support, on blood pressure drugs. I'm not sure what I'm going to find, or whether I can pull him through. The anesthesiologist says, "Right. Let's get in a few lines; I'll pop in an internal jug after you're started. Piece of cake." And he sets about his business, gets the man off to sleep without the bottom dropping out, keeps his tank full, making it smooth. What a huge comfort that is. The guy's a genius at what he does. The only tension is on my side of the screen, and it melts away as things progress. The man's gonna make it. I can breathe easier, even ask the anesthesiologist how his kid's doing in school. At the end I -- as usual with the guy -- thank him for a great job.

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"The blood looks really dark," I say. "Everything OK up there, Ralph?...Ralph?" I look over the screen. Ralph isn't there. "Where the fuck is Ralph," I ask. "Tell him to get his ass back in here." That's what did it. That's when the rest of the docs in my clinic agreed with us surgeons that it was time to hire our own anesthesia team. Which we did. They're a phenomenal group who, unlike the other group when they were the only game in town, make a continuing effort to remain excellent. (The other group soon did, too. Ralph ain't with them anymore.)

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I'm struggling to see. It's late at night, there's a limited crew, no one extra to scrub in for a few minutes to hold a retractor. "Give it to me," John says. I position the handle of the retractor so he can grab it, layered behind the sterile drape; John gives a good yank and holds it while I finish my suturing, eyeing his monitors, doing the rest of his job at the same time. John spent a couple of years in surgical residency before he got wise and became an anesthesiologist. Nothing ever fazes him. He's sweet as can be to the patients ahead of time, gets scared kiddies to eat out of his hand; he's the one the others call when they can't get the tube in. Everything he does, he makes look easy. I love having him do my cases. Except that he's so handsome and ripped, the nurses are overtly gaga over him and sometimes I have to remind them to pay attention to me. He did my anesthetic when I broke my ankle; my son's when he tore his ACL. We named our new surgery center after him when he died of melanoma, leaving a wife and two young kids. He'd come to me for the biopsy that gave the bad news.

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In response to my post requesting suggestions, Enrico asked about the relationship between surgeons and anesthesiologists. It's a good subject. I'm working on it.