Bad work habits 1

This being the New Year and resolution time, I feel I should confess some bad habits that I have acquired. I have no intent of changing them but talking about them makes me feel good.

I leave the room while patients are asleep.

Not just when I have a resident and we don't have anesthetic assistants or nurse anesthetists in Canada. From time to time I just get up and leave the room!

This is the cardinal sin of anaesthesia. From day one of our residency it is beaten into us, thou shalt not leave the room. Sleeping, staring up at the ceiling, talking to people with your back to the patient are okay. Reading is slightly frowned upon (I will comment on that in the future).

Our medical protective association considers this such an egregious violation of the standard of care that they will settle any case where this happens out of court. The courts have over the years taken a very dim view of this. Even the criminal courts have taken a dim view of this; about 15 years ago an anaesthesiologist who had a patient die while he was out of the room taking a phone call spend 6 months in jail. This by the way didn't prevent him from getting another job and as far as I know he is still working somewhere.

Now I only go out of the room when I have to, I minimize the time I am out of the room and I try to pick "safe" times in the case. I will give you examples of when I leave the room.

1. Bathroom breaks.

When my kids were younger they brought home all kinds of nasty viruses from daycare and school. This usually resulted in my having to sprint to the nearest toilet every once and awhile. I also confess to having a weak bladder. I am sure I should never have been offered a residency in anaesthesia. I compound this by drinking way too much coffee. I used to work in a teaching hospital. Unfortunately residents no longer think letting staff anaesthesiologists pee is educational. Of course many of my bathroom breaks were sudden and unscheduled.

2. Finding equipment and drugs.

Even after 18 years as a staff anaesthesiologist I still don't anticipate very well what I am going to need or the piece of equipment isn't in my cart and I didn't check. I could ask the nurse to go fetch the equipment but I learned at the CofE how useful that is. Usually I know where I can find it and can get it quicker myself.

When I was a resident, I was in my last year and the staff was "letting" me do a AAA by myself. For some reason we did not keep more than 1 litre of fluid in the room at that hospital and while there were bags and bags of crystalloid in the hall, it had been beaten into my that I could not leave the room, so I asked the nurse to get me another litre. She promptly went to the intercom and paged the staff back to the room. When he arrived quickly figuring something had gone wrong, she told him "I am not spending the entire case fetching things for him (pointing at me)"

3. X-rays

OR nurses and X-ray techs believe that anaesthesiologists are immune to the effects of radiation. At least that is why I think they never bring in an X-ray gown for me. Therefore if they are only shooting a few shots I generally step out into the hall. Actually one of my near misses occurred doing just this. I had taken over a case from someone else, it was an ortho case and they were doing X-rays at the end of the case so I wandered out into the hall for a few minutes. When I came back in the room, the heart rate was 20. I never figured out why that happened but I could be in jail right now.

4. Food and coffee

Cases frequently run over lunch. Infection control frowns on eating in the rooms. Actually I quite frequently fervently eat my sandwich in the room. I have on occasion got nurses to bring coffee and a muffin into the room for me (I paid of course).

5. Recovery room

You take the patient into recovery room, he is completely stable, you go out pee, have coffee eat, chat to your next patient put him to sleep and ....that is inevitably when your previous patient starts to circle the drain. The courts have said, "Thou shalt not leave thy patient". My conscience says I should weight the risks and do what is best. Of course if I think my patient in the OR is stable and can be left I will go to recovery. I have done this a few times in a career, fortunately not often.

There was a case quoted where someone left his patient in the OR because his patient in recovery had arrested. While he was in the recovery room, his patient in the OR arrested. He was undoubtedly unlucky or a really bad anaes. The judge no doubt prompted by "expert witnesses" said that what he should have done was bring the patient from the recovery room into the OR. In what universe did they live in?

Anaesthesia is of course the one specialty where the dogma of total dedication to one patient only applies. During my residency, I had to do six months of internal medicine. I remember several times where I was with a sick patient I felt I couldn't leave and was called for a more trivial problem. I usually explained that yes I would be by sometime but that it would not be for a while because I was with a sicker patient. This was usually followed by a phone call from the nursing supervisor ordering me to attend the other case and in one case a letter. (I never somehow figured out how to lie and say, yes I'm on my way).

Anyway it would do the profession good, if we got off our high horse and went from a total prohibition of hallway time to a harm reduction strategy. We could say in what cases it is acceptable to leave a patient, for how long and what type of contingencies we should use (tell the nurse?, tell the surgeon?).

Meanwhile I continue to live on the edge.

Operating on no sleep

We in anaesthesia do not work after being on call. This has always been a topic of derision among our surgical colleagues.

I was having supper with the former OR director at my former hospital a few months ago. The OR director is the poor sucker who is responsible for the smooth running of the operating room. This poor individual tried to do his best for over a year frustrated by the OR administration who wouldn't take his advice and his own Department who wouldn't back him up so he quit and went back to just being an ordinary anaesthesiologist and we went without an OR director for over a year until we found someone stupid or optimistic enought to do the job.

Anyway my former hospital does a lot of transplants. For various reasons most of these occur at night. There are reasons for this. You have some poor soul in ICU who is beyond hope. At morning rounds the decision is made to abandon life support and think about organ donation. By the time all the necessary tests have been done to establish brain death and all the relative have had their last visit, most of the day has passed and we are in to evening which is when the "harvest" starts. This means that the liver, heart and lung transplants don't start until close to or after midnight.

This of course means that if we can potentially have 1 heart transplant, 2 lungs and a liver all going on at the same time. That means that 4 sub-specialist anaes are working all night. These services are not staffed so that the anaes. is off post-call, however most individuals have no interest in working the next day. Therefore however is the OR coordinator is supposed to find 4 anaes to fill in the next day. Although there are a number of part-timers who can be called on, this can be a problem. After such nights there is usually a massive shuffling of lists which is annoying to those POAs in the department.

Surgeons however, like the alcoholic who believes he is witty and sexually attractive when drunk, still believe they can operate competently on no sleep.

My colleague was faced with this problem one morning of trying to find anaes. to work. He looked at the list and saw that one of the cardiac surgeons scheduled to work that day was also one of the individuals who worked all night. He spoke with the individual, a paediatric cardiac surgeon, who assured him that he intended to do his elective list, even though he had worked all night. So my colleague shuffled rooms and cajoled people and the surgeon was able to do his list.

The surgeon's elective case which was a paediatric patient and a re-do died on the table. My colleague still wonders whether he should have just cancelled the list.