Anesthesia Observership

[doctor712]

Hello All,

Wanted to take a moment and post about an experience that began today. While I'm not an MD, I hope you don't mind the thread initiation here this one time.

After asking to shadow an Anesthesiologist at my local hospital, I was thrown into the Medical Student Observership program at the same hospital. It was the only way they could get me in, today I started.

Over six months, while working at P&S in NYC a few years ago, (non-trad here) I shadowed Anesthesia, mostly Peds Anes. After day one I was sure I wanted to be an Anesthesiologist. After the last day, I was sure to the 10th power.

So, going into today's experience, I was just hoping to see something new while keeping my eye on the ball and taking premeds. Turns out the Anesthesiologist I shadowed works much more in the Pain Clinic than the OR. So, the day was filled with Interscalene blocks, epidurals (including one cervical), consults etc. This doc did his Anesthesia Residency and Pain Fellowship. It was amazing to see this completely other side of Anes that I really only read about.

What I'm getting at is that I think allllllll you anesthesiologists are absolutely amazing for what you do, and that the level of skill and knowledge you possess is second to NONE. I've seen the Mitral Valve Repair and the CV Surgeon and the brain op and the Neurosurgeon, who are amazing in their own right, but you guys are more amazing to me. Without this field, there are no others. I'm sure I'll get the reply that all here wish patients and other docs would feel the same way, and I'm aware of the road that lies ahead for me in this regard. As aware as I can be.

So, unlike the Peds Anes. surgeries, today I learned all about epidurals. After seeing five, I could tell (obviously not by touch, but by looking) when the MD had loss of resistance, how he played with the syringe to get it, and when it happened. I also learned about the three different approaches to the epidural space. I saw a couple Owls. A few dogs. Learned that the spinal cord itself stops between L1-L2, WHO KNEW? One blood patch. Saw the anatomical differences in the spines of a 19 y/o and an 80 y/o. Fascinating. And learned a BIT about something called Plechia Medialis Dorsalis (sp?) and how the block doesn't cross the midline. The doctor told me to remember this, and I swear it wasn't 10 seconds before I dropped the term. Why does that HAPPEN!? The first procedure of the day was an interscalene block and I had JUST read up on the procedure on a med school website, the landmarks, etc, for this VERY moment. Only to absolutely freeze up and lose ALL the info the moment I saw the marking's on the pt. neck. Also learned that "back in the day" sacral epidurals on OB patients were obviously done without xray guidance and that sometimes, since the babies heads were so close during labor, the needle was injected to deep, and the baby was killed. Maybe, if permitted, I'll post a question about Peds deaths if the forum permits. As I do have ONE question for all you Ped Anes out there...

The point of my day wasn't to learn, per se, but it's great that I picked up tid bits that will, of course, be pounded into my head 800x by the time I'm an MS-III. What this experience does for me is reaffirm my feelings that I'll be an Anesthesiologist in the end. This post sounds almost giddy for a father of two who is very successful in his own career, however, I hope you can remember the feeling. You guys are IT for me and you deserve a shout out.

Lastly, there were a few questions I wanted to ask my MD, and I did ask away ALL day today. But of course, I didn't want to overwhelm with, "Well, how come..." questions. So, was wondering if I could lay a few on you here in the hope I get a little future colleague love?

1) When Versed was given, it seemed to lower only systolic BP. My own observation. Does this sound right, and can someone tell me, in general terms, why this happens? Why a sedative wouldn't lower BP overall?

2) When the contrast or block is given in the epidural space, why does it only diffuse out proximal to where the needle is inserted, rather than in "both" distal and proximal directions?

3) CSE. If you puncture the dura and give that injection, then when you give the epidural next, isn't then there a brand new hole that would allow the epidural injection to go right into the spinal injection site? Wouldn't this be potentially dangerous dosing wise? CSEs are done all the time, so maybe someone can explain how the epidural medicine does not simply go into the new hole from the spinal injection.

4) Do ALL patients deny prior drug use? This one is rhetorical.

5) Why did it seem, to the eye, that everyone got the same amount of medicine for the epidural injections? First it was lidocaine 1% local, then bupivicaine .25%, then a steroid I can't recall, really small bottle, etc. Seems the same doses were given to the 300lb 40 yo as the 105 lb 19 y/o. Is this because these medicines only treat local inflammation? Don't these two patients metabolize medicine in different amounts considering one is 3X the size of the other?

If only O-chem were this interesting!!!

Continued success to all the SDN Anesthesiologists.

D712

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[Noyac]

Thanks for the kind words.
I'll try to answer some of your questions here
1) When people are anxious (stress) it is the systolic that increases more than the diastolic. Therefore you see a greater response with sedation in the systolic. The increased volume of blood ejected at each heart beat during stress causes systolic blood pressure to increase, perhaps to 180 mm Hg. However, because blood flows very rapidly out of the arteries diastolic pressure remains relatively unchanged or may even decrease. This is very obvious with exercise when the muscle aterioles are dilated.
2) It follows the path of least resistance. I'm sure you know this and that you are asking why is the least resistance lateral. I'm not really sure that it is. When I was doing pain mgmt I don't recall the contrast only going lateral. It seemed to go caudad and cephalad as well. It also depends on the needle placement. Was the needle placed midline?
3) I don't believe that the hole is large enough to allow anything to pass since the tension of the dura "should" help to close the hole. This is why we get very few headaches from CSE's with the pencil point needle (no actual cutting of the dura). And if I remember right, the pressure in the spinal canal is greater than in the epidural space therefore the tendency is to leak out, not in.
4)Yes
5) Because we are not smart enough to figure out the dosing from individual to individual. But really, someone here must have a better explanation than me for steroid dosing but steroids are not based on weight. They are not even dosed on lean body mass. They are dosed by intervals with the actual mg's being the same.

On a side note, you want to impress you pain doc, then tell him not to put any local (bupivicaine) in the epidural space. It is a temporary benefit if at all and has been connected to the vast majority of complications of epidural steroid injections.

 

[doctor712]

thanks for all the information, noyac.

2) yes, the needle was placed midline. i might have explained it wrong, but i meant the contrast always seems to go superior/higher/north of the needle. never south. maybe it's placement and angle like you said. tomorrow, i'll wait for an xray that shows this obviously, and ask.

3) hadn't thought of pressure and tension. makes perfect sense. now that you explain it...

5) That would go along with the MD telling me that the max epidural numbers in a year would be three because of the steroid used. Something about 80mg per Kg per year, with the avg person weighing about 80KG. Thus one dose = 1:1, 3 1:1 doses at the most per year.

Extra Credit: Sure, but I will ASK rather than tell the MD about Bupivicaine with the steroid in epidural space. But if he kicks me out on my tuchas, I'll be needing your home number!!!

thanks again, will report back my MDs logic in using the local in epidural space. can't wait for tomorrow!

D712

 

[Noyac]

thanks for all the information, noyac.

2) yes, the needle was placed midline. i might have explained it wrong, but i meant the contrast always seems to go superior/higher/north of the needle. never south. maybe it's placement and angle like you said. tomorrow, i'll wait for an xray that shows this obviously, and ask.

2) As best I can remember, when injecting anything into the epidural space the solution travels 2 interspaces cephalad for every 1 interspace caudad. Meaning it travels north twice as much as it travels south due to pressure differences and space. If he is only injecting a few cc's then you will only see it going cephalad.

if I am wrong, someone here will be more than happy to correct me.

 

[doctor712]

Noyac: as promised I asked MD about bupivicaine into epidural space. Said he uses it because (I paraphrase) of self extinguishing pain. Said that even though the block only lasts a little bit, when the block is over and nerves have sort of reset, calmed down, if/when the pain returns the hope is that it will be at a lower level due to the rebooting of the nerves.

Learned about ganglion block this am. Difference between L4 L5 and S 1 leg pain presentation. Pt came in today and was asked who referred him: Dr Pain. His pain doc. . Spine surgery this afternoon.

N.b I like when my MD intros me as a visiting professor. Not sure if the joke is on me or the pts. Nobody questions it. I'm 6 4 with salt n peppa. Or maybe it's my swagger.

 

[jetproppilot]

Cool CV !!
Your passion is evident.
Best of luck to you.

P.S. whats the show you wrote for?

 

[doctor712]

Thanks, JPP!

I PM'd you.

 

[doctor712]

Hi Gang,

Final update for the week! I'll spare everyone the details of the rest of the week. So, the observation is really amazing, was in the OR today instead of Interventional Pain Clinic. Missed the first induction because I was rounding on patients starting at 7am (blast). I was really looking forward to it because the first patient was having a C7 herniated disk repair and the approach was anterior/superior to the clavical, the chords needed to be moved aside and I thought the case would be cool to watch. But I saw the tail end anyhow. Even though I was observing Neurosurgery today, it only took me 45 minutes before I could slowly make my way to the COOL side of the curtain...and the fun began.

Told my personal journey to the Anesthesiologist who I hadn't met before and he quickly asked me if I knew what he just injected into the patient. I told him Neostigmine is a reversal to the paralytic (I'm sure I could have been more eloquent) and he said good job for a pre-med and told me he'd take any and all questions. Nice fer daddy!

So, today I learned about Succinylcholine and Hyperkalemia. I had heard about this when I was shadowing Peds Anes at P&S. That if a child is unsymptomatic with a neuromuscular disease, and you give Succinylcholine, you can cause Hyperkalemia. Most 80 y/o aren't asymptomatic for MDA so that leaves the kids. (I always thought it was MHyperthermia with Succs and kids, but I'm still learning). So, Succs is not typically used in Peds patients. But that's academic medicine and maybe this isn't the case in PP...

So, since I was on the topic of Hyperkalemia I asked a hypothetical about a Trauma patient and Hyperkalemia. I once heard K is released by muscles during trauma. So, my question was simple: Can Succs be used to paralyze trauma patients? Here was the highlight tidbit of the day: The talk went to Spine trauma and how following spine trauma, Sux can be given, if immediate. But not a week later. But a year later is Ok again. MD taught me that the acetylcholine receptors, immediately after spine trauma, haven't been "looking/searching/wanting" acetyl (succs) long enough to open wide and say "Give me lots and I'll over react." So it's ok just after spine trauma to give Succs. But, say a week later, when the Acetyl receptors have been hurt, and damaged, and haven't felt Acetyl, they will overreact in a BIG attempt to get whatever Acetyl/Succs they can. And that's bad. Cardia/MI etc. A year later, when the receptors know all hope is lost, they quiet down and Succs can be used in Spine trauma patients again. This MD was fantastic with his explanations. That is if I retained this properly.

But then we touched on (this is one spot I know I'm REALLY fuzzy on...) how in patients that might have high K, if Succs is given, you can Hyperventilate the patient causing more CO2 buildup, which is an Acid, and (DARN) um, Hydrogen Ions and cells, and Acidosis/Alkalosis...um, all I remember is that: with hyperventilation you can cause more K to be pushed back into the cells upon buildup of the Bicarbonate (CO2). I'm not sure why/when this would be used, maybe in a patient with an already elevated K that would benefit from a little dose of K going back into cells, but I'll learn one day...God willing.

Speaking of Hyperventilation, the MD hyperventilated the patient toward the end of the case. I guess this is a little trick to get them to want to spontaneously breathe on their own as I remember from HS physiology, I think, that CO2 buildup triggers the body's reflex the breath. Yes?

I was given a birds-eye view during Fiberoptic intubation. I should've started the story here actually, right? I'd never seen a Fiber optic at P&S Peds. Of all the time I'd spent there, it's all done without. Maybe that's because they are teaching students. This MD thought maybe that was the case. He said if he can come up with a reason to use FOptic, he does.
I think he must have a 95% fiberoptic rate. I was all ready to answer questions about upper airway anatomy. Naso/Oro pharynx connect posterior to the palate, which is 2/3...but before I could blink, the MD was telling me, "As long as you follow the tongue, you'll always get to the epiglottis." Hadn't looked at it like that, but yeah, that's where the tongue ends, right? So, through, into trachea, further then I thought he would go,
I thought it was only about 10 cm, but he went down to where I could see the mainstem split, maybe he just went there to show me, I don't know.

I know it's foolish, being that he's CLEARLY visualized chords and trachea, but I was expecting him to listen to chest sounds. The MD at P&S did this no matter what (indeed, he never did fiber optic in front of me, but still he seemed to pound the importance of this in no matter what). I guess it's a good lesson to learn. No twitch stimulator was placed. I asked why, the response was bleh. The case, btw, was a Coccygetomy. Interesting. Neurosurgeon had to work right where the colorectal MD usually works.
Many jokes were made and the Surgeon was in good spirits.

Also, I asked the MD what he induced with, Inhalational + Propofol? He said
he was giving O2 by mask only. So, only IV induction. Why? He said Inhalationals give him headaches so he doesn't use them to induce.

I also asked him about how he draws Meds. I mean, that's step one, right?
I saw him mixing up, maybe Neostigmine with Glyco(XYZ). Something about one eliminating the side effects of the other. He did it so quick I had no chance to follow how he left 2ccs empty...I'll learn.

Back to Epidurals at 5pm. Learned a little tidbit I had been wanting to ask MD this week: why only the air syringe for loss of resistance when he approaches the epidural space translaminally? Answer: the Ligamentus Flavum (did Jerry lewis name that ligament? FLAAAAyvum!!!!) is thicker more medial, laminal approach, so there is a true Loss of Resistance. Through the foramen, it exists, but it's really thin, so, not a good technique. ROCK ON!

Also, can someone help here. I know a little about pre-oxygenation, washing Nitrogen from lungs and filling with O2. The MD pointed out the Et02 and said when that reaches up to where the OTHER (???) level was, she was nice and pre-oxygenated. 95 and 95%. What was that other number? It wasn't her Saturation, was it? It was the small number that reads out just below Et02. He said when those match, she's pretty good.

Also, because this patient was prone for surgery, and he wanted her nice and asleep for flipping her back over after the procedure was done, and not too awake prone, that she was still asleep for a bit longer than he expected.
Cut off anesthesia a little later. Anyway, we were watching her slowly awaken, and he said to me: this is really Stage 2, not awake, and if you extubate her here, "you can get into trouble, remember that." So, can someone tell me the levels of sleep/awake that the MD was talking about here? Are there certain visual clues to look for that classify stages (i.e. coughing/gagging/pulling on tube, eyes, certain reflexes?)

The MD said he's cancelled 2 cases in 5 years at this hospital where all Anes MDs are on salary. I write MD because it's quick for Doctor. Could be DOs, no disrespect. He said in academic, it happens all the time. I mention this because it's been discussed on Anes forum. He said why get a chest xray if it's going to find a lung mass when we're operating on her thigh? She still needs surgery for thigh! Whereas in Academic medicine he said the story would go, "Oh, she's 65. No Xray? Wow, cancel. We need to make sure she's optimized."

Well, I hope you've enjoyed my little one week pre-med-med-student rotation in Anesthesia/Pain Management. On a great note, a Pain Doc took me aside after I spent time with him yesterday, and said, "Here's my card. You'll be applying soon, right? I'm sure you'll be needing letters of recommendation and I'm sure you'll be around here more. Keep in touch." I thought that was just fantastic and very generous. I tell ya Docs don't let me down. Fellow TV writers: can't say the same.

If I could set up a tent, I would.

Sooner than later.

D712