Friday, July 3, 2015

Reflections on a quarter century

25 years ago today or maybe it was yesterday I gave my first anaesthetic as a specialist.  I remember it was an oral surgery list.  I also remember my first patient was a Pediatric patient and I remember thinking how it was a good thing I hadn't looked carefully at the list the night before because I might not have slept well knowing I was doing a kid first.  Fortunately that child and the two other patients I did that day did well.

The child I would have induced with Halothane before starting an IV, giving a muscle relaxant (probably vecuronium) and intubating after which I would have maintained him with N2O, oxygen and halothane.
The two adults I would have used Alfentanyl, thiopental to induce and either succinylcholine or vecuronium to intimate.  I would have maintained with nitrous and oxygen and either isoflurane or enflurane.  Because the surgeon may have wanted induced hypotension, I may have used curare as my muscle relaxant.  Morphine would have been given for analgesia and I probably gave droperidol as an antiemetic.  Interesting how many of the drugs I used then are either no longer available or have fallen out of favour.

My machine would have been a Boyle machine.  No electronics, no software, driven by compressed gas and just as safe or safer than the $100K behemoth I use today.  To switch fron the bag to the ventilator, you manually disconnected the bag and connected the ventilator hose, remembering to close the APL valve.
The anesthetic circuit was the Bain circuit, with its necessary high gas flows which meant you went thru at least 1 bottle of isoflurane a day.  The circle circuit which had fallen out of fashion was just coming back into fashion.  Circuits were changed every case but there was no filtering.

Monitoring was with EKG, NIBP, pulse oximetry, and  ETCO2.  The latter two had only recently been mandated as standard.  There was no expired gas monitors.  Most of us figured that by dialling in a certain percent, we got a certain end tidal gas concentration.  Pulse oximetry had not been mandated in recovery yet.  Our recovery had one or two pulse oximeters which they put on whoever they figured needed it the most.

A significant number of patients were admitted the night before surgery which meant seeing them the night before after your list  and coming in Sunday evening.  At our hospital then, the person on call saw all the pre-ops which meant 10-20 patients on Sunday evening on top of doing emergency cases and I remember rounding at 2300 some nights. (When people complain about the pre  assessment clinic I remind them of this, but so few people remember having to do this that it doesn't work any more.)

Cholecystectomies, appendectomies, and hernias were still done open.  The laparoscopic cholie appeared early in my career ( initially three hours of farting around followed by an open cholie), the others later.
Over time things changed.  Propofol was introduced early on.  At first pharmacy refused to supply, then rationed it; I got into the habit of mixing it with Pentothal, I called this mixture President's Choice propofol.
Muscle relaxants came and went, rocuronium came and stayed, less so cisatracurium and pipicuronium. Curare disappeared soon after I started.  Pancuronium hung on until recently.  Atracurium and vecuronium, introduced while I was a resident are gone.

Sevoflurane and desflurane appeared in the mid to late 1990s.  I still don't think they are much better than halothane and isoflurane which have also disappeared from use.  So has enflurane.

The laryngeal mask airway was introduced early in my career.  Who remembers mask anaesthesia?  That was how we did short cases like D+C s and cystoscopies, holding the mask with one hand, and writing up the chart with the other.  Some of our older colleagues even did longer cases and had elaborate set ups with the black mask strap and tongue depressors to free up their hands.  (Periodically a resident comes across the mask holder and asks me what it was for).  The LMA has mostly supplanted the ETT in many of the cases I used to intubate although I am still a lot more conservative that some.

When I started well over half of Caesarian Sections were done under general.  Now GA is reserved for special exceptions and dire emergencies.  Some commentators are now saying we don't do enough GAs. Unfortunately in my time the section rate has increased from 15-20% to 30%.

My malpractice premiums were $9000 (14,600 in 2015 dollars) that first year.  I currently paid $8600.  I would like to think that this is because we are all better anaesthesiologists but I credit the pulse oximeter for most of this.

One constant in my career has been the drive to cut costs.  For the past 25 years, the mantra has been that health care costs are spiralling out of control.  With that logic they should now be consuming 200-300% of the total provincial budget or GDP however you want to express it.

One major change in anaesthesia and in medicine in general has been the increase in obesity.  On my fellowship oral exam, I remember being given a case of a morbidly obese lady presenting for a D+C.  I see at least one such lady every time I do the Gyne list.

Two things I thought were inevitable when I started have not come to pass.  Today as I have for the past 25 years, I charted on a paper chart.  Lots of places have an EMR; in my chronic pain practices I use an EMR at some but not all sites, but if you offer me good odds that I will not be exclusively charting electronically before I retire I will take them.  Secondly I am still billing exclusively fee for service.  I gave this 5 years maybe, when I started.  I will take the same odds that I will be billing fee for service until I retire.

Since my first day I have moved cities once and lived in 3 very different neighbourhoods in my current city.  I have fathered a second child, and watched 2 boys grow up.  I have gone thru 4 dogs.  I became an accidental chronic pain specialist.  After working unhappily at the C of E I now enjoy my life at my medium size Catholic Hospital.  I have gone into and survived administration.

When my wife learned I was blogging on this, she asked if I was nostalgic or whether I was happy with the way things had changed.

I am nostalgia for the way I felt during the first few weeks in practice when everything was a novelty, and you realized that after 4 years of training, you had made the right decision and you were competent at it.  You never get that feeling back.  I feel nostalgic for some of the people I first worked with who helped me out.  I also feel nostalgic for the little town in Atlantic Canada where I first worked for 2 years before I went to the Centre of Excellence.  I don't know how many times in the first few months, I wanted to call them and ask for my job back.  All in all I still think that the move was for the better.

Have things gotten better?

I do like the short acting drugs we have now although they are not always a short acting as we would like them to be and sometimes because we don't respect them we get into trouble.  Like the recent article in Anesthesiology suggesting that a significant number of patients still get discharged incompletely reversed from their intermediate muscle relaxant.  Pancuronium and curare we knew lasted a long time, so we used them sparingly.  If the surgeon complained about bucking while he was closing, we didn't give another dose.  It may be a good thing that patients are more awake post-op, however I wonder how whether the recovery room nurses appreciate the awake, anxious, painful patients we now drop off as opposed to the sleepy ones we used to.  No matter what anaesthetic you use, discharge is driven by things like policy, availability of porters and when the patient's ride shows up on time.  When I recently had a colonoscopy with sedation, I liked being able to walk out 15 minutes after the end of the procedure (I told my wife, "I've driven in worse shape then this.")

The greatest advance in anaesthesia is the pulse oximeter.  The ETCO2 is also a useful monitor and one I am glad to have.

With the medical system in constant crisis, I often wonder whether we are worse off.  I sometimes think that we are like the frog in the pot of water that is slowly being heated, and don't realize that we are being boiled alive because it is so gradual.

I like history and one of the advantages of growing old is to look back on how things have changed (and how things have not changed) ; how dogma becomes heresy and how heresy becomes dogma.

Looking forward to the next 25 years.



5 comments:

Jordan said...

Great look at your career here. It's amazing how much of the medical field has changed - and yet some things stay the same! Thanks for sharing your insight here on it.

newton juma said...

Quite a deep reflection on career well taken. Newton@KU School of medicine

OldfoolRN said...

Precordial stethoscopes were the anesthesia monitoring device of choice in my day. For a look at what was state of the art 40+ years ago in nursing, please see my blog at oldfoolrn.blogspot.com. Your blog is very interesting.

Bleeding Heart said...

I had forgotten about the stethscopes. Precordial stethsocopes were routinely taped to children's chests at the beginning of the case and we had the audiology department custom-make ear pieces. Later Anaquest makers of isoflurane gave us purple ear pieces. I may still have mine in a drawer somewhere. Esophageal stethoscopes were used in adults.

Mafeitz Mamat said...

Love the reflection. I hope you don't mind me sharing this post on my blog. A definite good read for my students :)