The Ether Way

Donation after Cardiac Death: Is mostly dead slightly alive?

"There's a big difference between mostly dead and all dead. Now, mostly dead ... is slightly alive."

-Miracle Max, The Princess Bride.(1)

In Jainism, a gentle devout sect of Hinduism, the sanctity of life is taken to an extreme. Jains are vegetarians. The most devout Jains will not eat fruits and vegetables that are harvested; they prefer to eat produce that has fallen naturally from the vine or tree.

Which brings us to the euphemistic "Donation after Cardiac Death," or DCD. For those of you who have wandered into this blog, a little history. In 1968 a Harvard committee headed by Henry Knowles Beecher (Harvard Professor of anesthesiology) defined Brain Death. This led naturally to the notion that with proper consent, the organs from such unfortunate ex-individuals (individuality being lost once the person died) could be of utility to society and potential organ recipients. These potential donors are the poor folks who have fallen off the vine of life, but for whom some organs still possess vitality. But, there were problems, the main one being that as the industry advanced, there just weren't enough organs to meet the burgeoning demand.

So, the transplant industry, with transplant surgeons and organ procurement organizations (OPOs) in the lead, set aside decades of careful philosophical and ethical reasoning behind brain death in favor of a utilitarian formulation; they lowered the bar for donation...

We have met the enemy, and he is us....

I'm back...

A year or so ago, I was walking down the OR corridor between cases, and a surgeon I had known for fifteen years pointed at me and said sharply; "come on; what are you doing wandering around? - take the patient back!" I was momentarily confused, since we weren't working together that day. It was good that I was disoriented for that brief moment, because it gave me pause before the anger rose in me; a pause long enough that I suppressed whatever growl would have otherwise erupted. I was four steps away by the time I figured out that he had forgotten who his anesthesiologist was for that day, and he thought I was it... (and I use "it" intentionally). When I passed by a couple of minutes later, he simply said "I thought you were my anesthesiologist." Maybe a little sheepish, but then again, maybe not. And I thought, "he treated me like he treats the nurses..." Here's an amusing account of a sociological study on why surgeons behave like surgeons...

Good Anesthesia Matters!

The anesthesia world is spinning up to a tizzy over the upcoming theatrical release of the movie "Awake." For those of you living "off the grid", Awake is a story about a poor victim who has the extraordinary misfortune to be subjected to cardiac surgery awake/paralyzed. None of us have seen this movie, but advanced word is the anesthesia folks aren't favorably depicted.

I am really, really looking forward to its release. For a lifetime, I have wholly devoted myself to my craft; medicine and anesthesiology. While I have not minded being in the background behind my surgeons, I have, over thirty years, grown tired of the surgical attitude that what I do is trivial; of course it is, because if it weren't, well, they'd be doing it themselves, wouldn't they?  And if I and my colleagues had been made of better stuff, we would have gone into surgery.  What a load of nonsense.

One slip of the surgeon's knife, and a patient's meaningful life is over. Just so, one mistake with a syringe of vecuronium, and a patient is dead, or perhaps, worse than dead... The truth is, if I don't practice smartly and on form, patients will suffer and perhaps die in ways both obvious (aka "Awake") and subtle (ie high blood glucose leading to higher post-op infection rates) It's about time everybody understood it. It doesn't help when colleagues (especially CRNA's, I note over the years) minimize what they and we do; "oh you're going to take a little nap while your (big strong) surgeon operates on you." I even avoid the use of the word sleep to describe what I do. I usually say "sleep is what you do at night. It is free and natural, but if your surgeon were to attempt to operate while you are asleep, you would wake up in great pain. What I provide is drug induced unconsciousness, not unlike a temporary coma. You will not wake up until I reverse the process. It is a safe procedure in my hands, and I will stay with you the entire time to maintain this state and see you safely through." I have no tolerance for anybody who suggests that I am scaring patients like this; it is simple truth, which is the stuff of informed consent.

For every patient that  says "oh, doctor, anesthesia is soooo important," I have ten patients who believe that I belly up to the table with a syringe of clear stuff, inject it, and walk on to the next room, or out for a cup of coffee... ("who was that masked man? I don't know, but he left this bill pinned to my dickie...")

A little patient apprehension about their upcoming anesthetic is a good thing-it's appropriate.  And if the patients get the idea that who is giving their anesthetic; their education, dedication, compassion and diligence,  matter to their outcome, well, then, so much the better. Because it's true.

Where I come from, there' was a saying; "a good surgeon deserves good anesthesia. A bad surgeon needs it." I can't remember all the times I've had to hold a patient together physiologically while the surgeon tried to work his way out of a nasty situation. I have auscultated the hearts of 20000 patients to avoid missing that once-in-a-lifetime patient with critical aortic stenosis who would otherwise die on anesthesia induction (I've found 2). I've sniffed around thousands of diabetics for a whiff of the coronary artery disease that might progress to a fatal perioperative MI. I've sat on the floor of the holding area hundreds of times looking up at anxious three year olds and their parents, quickly forging a rapport that I could leverage into a less scary induction.

I can deal with healthy patient fear; it just takes a little time, some patience and explanation. I hope that every patient for the rest of my career has the good sense to ask me what I'm going to do to keep them alive, and how I'm going to prevent the excruciating agony of their being awake "under the knife", and then I hope they look me in the eye as I explain it all, to be sure they see a soul they can trust.

And if anesthesia leadership on both sides of the aisle (AANA and ASA) settle for some bland reassurances about anesthesia diligence and try to undermine the message of "AWAKE"  by pointing out the inevitable inaccuracies they will find in the movie, than they (and we) ought rightly to be banished to the back benches of the medical pecking order.

And if Aspect medical makes a few more bucks on their BIS monitors along the way, so be it; their box isn't perfect, but it isn't bad, either...

I say, "bring it!" I'll be there on opening night with a big bag of popcorn to assuage my vicarious anxiety...

on Memory and Reminiscence

We have, in the next place, to treat of Memory and Remembering, considering its nature, its cause, and the part of the soul to which this experience, as well as that of Recollecting, belongs.  -Aristotle 350 BC

The clinical Anesthesiologist's interest in memory and its formation is that of a lmberjack to the forest. Anesthesiologists are clear-cutters, ad not typically too engaged in the niceties of the eco-system. In this case we might reasonably be forgiven, since the failure to abolish memory during a general anesthetic is at least a therapeutic failure and at worst, a terrible (actionable) trauma for the patient. Fortunately for us, memory formation/consolidation is eliminated far more easily than movement, which means that the anesthetic depth (related to the concentration of anesthetic) required to keep the patient "still for the knife" is much greater than the concentration required to interrupt memory formation. So far, so good. An interesting digression; movement during surgery can be initiated from the spinal cord in the absence of any brain activity. (Think of A chicken running around its  head cut off; well, maybe don't...) We know this from experiments involving isolated head and body perfusion experiments, (not human!) where the body and the head are separately anesthetized. So when the surgeon yells "the patient is awake," the wise anesthesiologist knows that non-purposeful movement under anesthesia does not imply awareness, (but certainly doesn't preclude it...)

Of all animal traits, the three most philosophically intriguing are awareness, consciousness and memory. Of these, memory is certainly more derivative; Invertebrate worms demonstrate memory (they can learn) without any sense that they are conscious or aware. The taxonomies of memory, while being the subject of heated intellectual conflict, all seem rather comfortable, even intuitive, to the casual spectator. Memory is most superficially parsed into short-term and long-term, which we know have different physiological mechanisms (we know this in great measure due to the work of Dr Eric Kandel, which won him the Nobel). When you remember a phone number long enough to dial it, you are using short term memory. This involves chemical changes in synapses. If you remember your home address and telephone number from last year, you are using long term memory. That involves changes in synaptic connections. Long term memory gets sliced and diced lots of different ways, based mostly on our human classification of cognitive function. Explicit memory is memory which is subject to conscious recall (like the name of your high school sweetheart, or your anniversary). Implicit memory is not (for instance, riding a bicycle, recognizing a face or voice). Explicit memories are further sub-divided along various functional lines; intellectual memories, memories of events, etc, etc. WIkipedia has an unusually good introduction to the science of memory.    Here also, is a link to a video introductory lecture on the neurobiology of memory from the MIT Distributed Intelligence project:  http://mitworld.mit.edu/stream/146/

Contemplating Quality.

"It was all those people in the cars coming the other way. It's just that they looked so lost," she says. Like they were all dead. Like a funeral procession."

 

Robert Pirsig. Zen and the Art of Motorcycle Maintenance.

I've been thinking a lot about quality lately. For two decades, I have accepted the industrial definitions of quality advanced by Deming and his disciples, and the evidence based outcomes-driven practice style that this model drives. I and my colleagues have written about limitations resulting from a slavish devotion to this model; the stifling of innovation being one  and the reliance on weak data and the devaluation of individual experience being another. While my leadership responsibilities have kept me focused on measurable outcomes as a context acceptable to all stakeholders, I observe a frustrating flatness creeping into the medical enterprise and I have come to believe that it derives from what I now call "spread-sheet medicine," and its major driver, "quantitative quality." Quantitative quality is the narrowly focused equating of quality with clinical outcomes; morbidity/mortality  and costs.

This quantitative fixation is a classical notion, best defined by the aphorism "If you can't measure it, it isn't real." Of course, that's nonsense; just ask any musicologist or art historian. Romantic tradition understands that there is non-quantitative Quality, and that it is vital to a meaningful life. Opposing the quantitative quality is this other view of Quality; the artistic or romantic view; let's call this "values quality"

I prefer to think of quantitative outcome assessment in medicine as "effectiveness" rather than Quality. It is an important component of medical quality but it is by no means the only consideration. This is not a trivial distinction. Like all discussions or disagreements, how you frame the debate defines the results. Management people say, "you can't manage what you don't measure..." They are highly motivated to limit the scope of quality to things they can "get their arms around," in order that they may discharge their fiduciary responsibilites to hospital owners and payers. The masters of industrialized health care; the money men, aren't interested in values-quality. As a US Senator once counseled me, "The marketplace won't pay for compassion." Nor in my experience, will they acknowledge the legitimacy of any intangible values; unless, of course,  it's their turn in the bed.

Clinicians, on the other hand, find the quantitative quality paradigm to be artless; or as my 17 year old would say, "it's soul-sucking." It's not that it's not important. It is. But, while being necessary, it is not sufficient. Quantitative quality may drive systems of care, but it will never inspire caring. And, as Pirsig points out, without caring there can be no true Quality. But our dislike of being managed; of being part of the "machine," is not in itself sufficient justification for seeking to modify the paradigm. We have to have a better reason than that if we expect to persuade ourselves or anybody else that it's time for deep reconsideration.

Strength for the Journey

Westley: Why can't I move? Why am I up against this wall?
Fezzik: You've been mostly-dead all day.

-The Princess Bride

In some unfortunate folks, the "arch" of the aorta becomes diseased. The layers of the aorta split apart;  a separation which spreads under the pounding of blood ejected from the heart. Over time (sometimes quickly) it can result in stroke, catastrophic heart attack, or sudden bleeding into the chest as the split advances to the branching arteries leaving the aorta for their target organs. This is called an aortic arch dissection. Alternately, the aorta can weaken, bulging like the bubble of an inner tube into an aneurysm which, if it ruptures, is almost always rapidly fatal.

If the proximal arch, the segment between the heart and the blood vessels branching off to the head and brain, is involved (type 1 dissection), the treatment is urgent surgery to replace that section. If the dissection involves the aortic valve at the proximal end (close to the heart) the valve is usually replaced as well. At the distal end (away from the heart) branching blood vessels perfusing (feeding) the heart, brain and head are sometimes involved; these then, have to be disconnected, and anastamosed (connected) to the woven dacron or gortex artificial tube which is used to replace the sick aorta. In order to do this, the circulation must be stopped; no blood flow at all...

Impaired physicians-administrative issues

"Out of timber so crooked as that from which man is made nothing entirely straight can be built"
Immanuel Kant, 1784.

In the 1980's, Michael Swango, a physician trained in Illinois, was convicted of intentionally poisoning co-workers and spent five years in prison. Despite this, after his release he managed to forge documents enabling him to acquire residency positions at various academic hospitals, where he murdered an estimated 30 patients.

In 1986, Congress passed a law entitled "The National Healthcare Quality Improvement Act." (HCQIA) The main purpose of the act was to create a national database of physician incidents, the National Practitioner Data Bank (NPDB) to block the migration of incompetent and impaired physicians, like Swango, from state to state "under the radar" of institutional scrutiny.  Despite imperfections and dificulties, the HCQIA has withstood the test of time, surviving two decades essentially unchanged.

We are all well versed on its' reporting requirements; (i.e. suspensions longer than 30 days, privileges "voluntarily" relinquished under investigation, judgments or settlements greater than $5, etc). It also indemnifies physician leaders who participate in peer review from legal liability for their "good faith" efforts, From the facility/medical staff perspective, a helpful (and sometimes vexing) aspect of the law is the requirement of institutional confidentiality. The reasons for this provision are clear; it balanced out the otherwise oppressive aspects of the law for practitioners, afforded affected practitioners a semblance of privacy pending resolution of their due process appeals, and decreased the motivations of competitors and enemies to make baseless allegations for business advantage.

the common dark of all our deaths...

-On the Road, Jack Kerouac

I have been involved in surgery for thirty years, and I am amazed daily that people will willingly submit to it. There is no greater example of the triumph of hope (and trust) over fear. A wise surgical professor at Wisconsin once lectured to our class that “an operation represents the substitution of surgically induced pathology for the patient’s own pathology, in the hope that the surgical pathology will be better tolerated.”

As I write this, I know that tomorrow, I will be caring for a patient in whom a neurosurgical colleague will be placing deep brain stimulators for Parkinsonism. The patient will be somebody who has such severe, medication resistant, brain-mediated joint rigidity and muscle tremors that going out to dine is more-or-less out of the question. Most of the people so afflicted avoid being seen in public at all. He will come to us, willing to undergo brain surgery while wide awake, in the hope that we can alleviate his disability. Sometimes the results are miraculous. Sometimes not.

So called "functional" or awake, neurosurgery is performed for a variety of reasons. Usually, it is because the procedure requires the active participation of the patient in pinpointing areas of the brain; speech, motion and such. Normally, I have a cart full of drawers full of vials full of clear liquids with magical properties that allow me to modulate (and most typically abolish) my patient's perceptions, memory, and consciousness, and thus, overcome their pain and suffering during surgery. But I don't get to use them here. (Well, the liquids would be magical, except our understanding destroys the magic; "Mark Twain's experience comes to mind, in which, after he had mastered the analytical knowledge needed to pilot the Mississippi river, he had discovered the river had lost its beauty." -Zen and the Art of Motorcycle Maintenance, Pirsig. (see also Sleep and Death are brothers).

Impaired Physicians Part III- Clinical Competence, a Moving Target

Of all impaired physician issues, incompetence is the toughest to manage. The "dry lab" component of competence is obvious; required didactic certifications must be maintained, CME's must be completed, licenses must be active, minimum case numbers must be documented. The problem arises in the crucible of clinical practice. Like everything in life, physician competence resides on a continuum, from inspiring to notorious. Competence changes with time; sickness or senescence, improvement with experience or intercurrent training, and importantly, shifting standard of care. To make matters more difficult, competence can be contextual; I might be an outstanding neuro-vascular anesthesiologist, but weak with liver transplantation. So, how to judge?

The answer is outcomes. As in  evidence based medicine, good outcomes are the proof of good practice. Competence is generally considered adequate from an institutional and leadership perspective if bad outcomes don't "fall out" in Quality Assurance activity. There are sentinel events (major complications) or patterns of lesser complications that serve to focus leadership scrutiny on the affected practitioner. Here is a situation where once again, insight is key.

Impaired Physicians Part II - Insight

There are two psychological traits that are important to the successful practitioner; empathy and insight. Empathy allows us to identify with the suffering of others; it motivates us to perform at a high level. Insight allows us to process uncomfortable realizations regarding our ineffective, harmful or embarassing actions. "Good judgment comes from experience, and experience comes from bad judgment;" but only if there is motivation to get it right, and insight to allow honest assessment of when we do (and don't) get it right.

Unfortunately, neither empathy nor insight are required to succeed in medical school and residency. In training, empathy can be replaced by fear; fear of disapproval or dismissal. And insight can be replaced by external direction; the non-insightful are frequently good at following instructions. At least, those that aren't (true sociopaths and the like) don't usually make it into medical practice.