Friday, July 2, 2010

Cardiac Anaesthesia

I suspect if you get a bunch of non-cardiac anaesthesiologists together in a room after a while the discussion will inevitably get around to cardiac anaesthesia, especially if you include enough people who work or have worked in one of these centres. That includes most of us since we all had to do a rotation during our residencies.

Most of us who worked in a centre with cardiac surgery as I did at the centre of excellence, have realized what cardiac surgery is: a resource sucking monster staffed by the most incredibly arrogant individuals (including some anaesthesiologists unfortunately).

I refer to adult cardiac surgery of course. I have only the most respect for those pediatric cardiac surgeons (even more for the anaesthesiologists) who have to figure out those complex lesions. Even those ones who work when they shouldn't. I also don't doubt the necessity of a significant amount of cardiac surgery; while I don't smoke, drink plenty of dark beer and red wine, try to exercise, chose my parents well etc, I have consumed a lot of bacon and fried bread in my time which could come back to haunt me in the future.

Firstly cardiac surgery is pretty easy. You basically sew a piece of vein onto an artery 4-5 times during a procedure. I probably can't do that but I suspect in the course of a 6 year residency I might be able to. Valvular surgery, true might be a little more difficult. Cardiac anaesthesia is even easier. I trained in a centre which didn't have a separate cardiac surgery call schedule, which meant when you were on call you might have to do an "emergency" by-pass. This kept me awake for my first few nights on call. I should have slept. Back in the 1980s we used to describe a simple standard anaesthetic as "Big Syringe (pentothal)- Little Syringe (sux). When I got to do my first Saturday "emergency" CABG, the staff man gave me a Really Big Syringe (60 cc of fentanyl) which we followed up with a Little Syringe (10 mg of pancuronium) and we proceeded happily along. The art line and Swan Ganz catheter are basic skills for any anaesthesiologist and of course we now know that Swan's were actually not very useful and probably harmful.

I actually found it amusing when I actually rotated thru a 3 month cardiac anaesthesia rotation that I would go up and see the patient, look at the cardiac cath report which I would then have to relay to the next day's staff at home on the phone. I would have to recite the location of all the lesions, the wall motion abnormalities and the EF. I could have saved my breath. Regardless of how bad the anatomy and physiology, the induction the next morning consisted of the Really Big Syringe and the Little Syringe. Maybe things have changed? Naw.

A few years before I joined the centre of excellence, an academically inclined anaesthesiologist joined the department. He was one of those fellows who had done his training in multiple programs in multiple countries. This had however resulted in him never having done a cardiac case at all in his residency (apparently not compulsory then). Because at that time (and now) at the CofE, not belonging to a sub-specialty group meant a career of second classness and because of his impeccable academic credentials, he was allowed to join the cardiac group. On his first day on the job, he induced the patient using the "cardiac anaesthetic", inserted the requisite monitors and kept the patient asleep and stable until it was time to come of bypass.

Hmmmm how do we get somebody off bypass?

He went to one of the perfusionists who told him how to get a patient off bypass and went on to a glorious career as a prominent cardiac anaesthesiologist of excellence. (As a junior resident, I asked one of the senior residents how you got somebody off bypass and he said something about walking counter clockwise around the room shaking a bottle of nitroglycerin in one hand and a bottle of dopamine in the other.) That reminds me of course that where I trained we were not allowed to use inotropes to get the patient of bypass. The cardiac surgeons apparently considered the concept of their patient requiring inotropes to be an insult to their skill. This did introduce some degree of art (and occasionally deception) into getting a patient off bypass. I was amazed when I went to the CofE that the cardiac anaesthesiologists were not only allowed to use inotropes but did so with gusto. Where's the sport in that?

Cardiac anaesthesiology off course means working with cardiac surgeons who are with a few exceptions the most arrogant assholes ever to call themselves doctor. Not very smart either. They are also noted for their bad temper. I am not certain whether I have blogged about a cardiac surgeon known as F-tach for his repetitive use of Anglo-Saxon words. It actually took two anger management courses to fix him although one wonders whether any non cardiac surgeon would have been tolerated so long.

A surgery resident I trained with was home one evening when his phone rang. It was the hospital switchboard who connected him to the ward, where his staff man was apparently sitting. His staffman, ordered him to immediately come in and fill out a disability form for one of the patients. Nothing like, "can you do this tomorrow?" or "Since I'm here why don't I just fill out the stupid form?"

The hospital where I trained was a smaller centre where cardiac surgery was only done 3 days a week. This of course left lots of leeway for the "emergency" CABG. Most of these took place on Saturdays in order to take advantage of the weekend premium. Occasionally they were booked on Tuesdays or Thursdays. I remember one day our senior alpha male cardiac surgeon announced during his booked list of Monday that he really had a patient he had to do on Tuesday. To justify fzcking up the OR schedule, he described how unstable the patient was and how he had been afraid he would have to do him on the weekend (so why didn't he bump his elective case on Monday?). Anyway the plan was that the unfortunate patient would be transferred from the hospital where he was languishing in the CCU to our hospital where he would be directly admitted to the ICU and have a balloon pump inserted to off-load the heart. I happened to be on call that night and as well my wife was working in ICU. The resident on cardiac asked me if I could see the patient pre-op. We were of course expecting an ambulance transfer which was why we were surprised, when around 1900 there was a knock on the door of the ICU and the patient was standing outside, having walked over from the admitting department CARRYING HIS SUITCASE, after coming over by taxi. Nevertheless, the IABP was inserted, that the "emergency" CABG went ahead the next day.

I can't help but mention that this particular surgeon carried on an affair with one of the anaesthesiolgist/intensivists for 3 of 4 years of my residency. When they broke up, it made for some interesting dynamics in the OR and ICU.

I could go on and maybe I should, but the bottom line is that most of us really resent the sucking of OR resources into the cardiac room. This happens both during the day and also during the night. There is also the assumption that the flow in OR can be disrupted to accommodate their "emergencies" or conveniences. Nobody ever calls them on this.

There is also the issue that a considerable amount of resources are going to treat a condition which can largely be prevented or treated by much simpler measures. Back when I worked at the CofE, our department chairman made a rare appearance in the coffee room. He described an interesting dilemma. Under the bizarre funding formula in our province, our cardiac surgery team would have to do 300 heart surgeries in the next few months. In order to do this, the CofE was prepared to authorize overtime, etc anything to get those cases done and avoid whatever penalties the province would be imposing. The problem was that because of things like health lifestyles, angioplasties, statins etc. there were only 200 patients actually waiting for surgery (the CofE is capable of doing 40 cases a week). I never found out whether they met their quota. In the odd glance at the OR slate, I did notice a lot of single vessel bypasses and that the average age of patients seemed to be higher. Just a coincidence though.

At that time the CofE was erecting a temple to cardiac surgery next door. This after several glitches is finally opened. As the opening approached it became apparent that because of things like healthier lifestyles,etc that the whole centre was way too much supply for any demand and there was talk of doing non-cardiac surgery in some of the redundant ORs.

I have gone onto greener pastures at my nice community hospital of course.

1 comment:

burnttoast said...

I quit doing hearts 10 years ago, when it became apparent that to continue would require ECHO certification, and I did not want to jump thru that hoop. I also had gotten fed up with working with jerks, aka, most of the cardiac surgeons, who indeed should have been forced into anger management (Canadians are so charming). In our hospital, the nurses, techs, and MDs are supposed to just take it. Seriously. Surgeons aren't allowed to throw instruments since HIV. But foul of mouth and manner, arrogant and clinically dishonest, and some of them are incompetent as well, I do not miss the "glory" of the cardiac anesthesia at all!! And the ridiculous practice of putting in PACs on good ejection fraction CABG patients!! Impossible to justify on clinical data. But the ICU nurses want them, everyone is accustomed to them, and you can bill for it!