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You are an attending anesthesiologist, and you are scheduled to do 8 breast biopsy cases beginning at 0730 and ending at 1730 hours. How will you manage your day?
Discussion: doeverythingrealfastanddonttakebreakstheend. So it can be in the “real world” of anesthesia. At the American Society of Anesthesiologists National Meeting each October, you will not hear a Refresher Course on how to manage a day of 8 cases in 10 hours. The slow pace of surgeons-in-training makes it unlikely most university faculty anesthesiologists have ever experienced such a day, so it’s unlikely they would lecture on the topic.
Safe anesthesia care is the most important goal of any day in the operating room. But to be outstanding in practice, you will have to be efficient as well as safe. Operating room time is expensive, and in addition, surgeons will judge you on how rapidly you work. To a surgeon, the time between when they put the dressing on one patient until they make the incision on the next patient is “down time.” They want this minimized. Surgeons as well as patients are your customers in private practice. If you do not believe this, try ticking off your surgeons on a regular basis, and see how long you have a position in any private group.
If the surgeon does each breast biopsy in 30 minutes, and there are 8 cases, that adds up to 4 hours of operating time. The other 6 hours are for the anesthesiologist and the nurse to wake the patient up, get the room turned over, and get the next patient to sleep and prepped.
Some surgeons prefer to do breast biopsies under general anesthesia, and some request deep sedation plus local anesthesia. For general anesthesia, you choose propofol for induction, with sevoflurane, nitrous oxide, and/or propofol for maintenance. A laryngeal mask airway is used for most patients. For cases done under local plus deep sedation, you may choose a small dose of narcotic, followed by a propofol infusion starting at 100 mcg/kg/minute. Oxygen is delivered by face mask.
I will offer a few labor and time saving suggestions for a rapid pace of practice:
1) When the patient moves onto the operating room table, attach and activate the automated blood pressure cuff first. While it is inflating, place the oximeter and the ECG leads. When the blood pressure cuff has finished its initial reading, you ask the patient to use that hand to hold the oxygen mask over her face. This frees both of your hands to begin the induction once the oxygen saturation reaches 100%.
2) As soon as the patient is asleep, finish the paperwork or the computerized medical records. The paperwork on a day like this one is a burden. Your paperwork errands include the history and physical, the recovery room orders, the anesthesia record, your billing form, and the narcotic form – and all these will be repeated 8 times on this work day. My advice is to simplify the paperwork or computerized forms at your facility, so that all the pertinent medical-legal information is present, but the forms can still be filled out in minutes.
3) When the paperwork is finished, get your syringes and equipment ready for the next case.
4) When the surgery ends, you wake the patient, and transport her to the recovery room. After a sign-out to the nurse there, you return to the pre-operative room to meet the next patient. Patients are often very nervous before breast biopsy, both because of the surgery, and because of the worries of the outcome of the biopsy. You attempt to ease her anxiety as much as possible, at first with your verbal skills. After discussion of the procedure and risks, you place the IV, further relieve anxiety with a dose of midazolam, and transport her to the operating room. At some private hospitals, the IV may be placed by a nurse while you are in the operating room, saving turnover time. At most private hospitals or surgery centers, someone other than the anesthesiologist will transport the patient into the operating room. This is your best chance for a short break between cases, without slowing the system down by your absence.
In a fee-for-service practice, both you and the surgeon have the same incentives: to do as many cases as safely possible, and finish the day promptly. There is an incentive to do an extra case, because every extra case is extra income. The patients definitely benefit in this system, because in addition to the opportunity to practice their healing art, their doctors are receive extra renumeration for extra work.
Anesthesia professionals who are salaried employees do not have this incentive. They earn as much if they do 4 cases or if they do 8 cases, as long as they serve out their 8-hour shift. For this reason, salaried anesthesia professionals may work at a slower pace. In an era where every labor union has mandatory lunch breaks and coffee breaks, the idea of working for 10 straight hours on 8 patients may seem unreasonable, but it does happen in community anesthesia practice. Thousands of anesthesiologists you walked at the American Society of Anesthesiologists National Meeting could give you a lecture on it. Every one will have their own advice on how best to handle a day like this one.
I’d wager that every anesthesiologist who is in a private practice would envy the opportunity to do 8 surgeries in 10 hours.
Published in September 2017: The second edition of THE DOCTOR AND MR. DYLAN, Dr. Novak’s debut novel, a medical-legal mystery which blends the science and practice of anesthesiology with unforgettable characters, a page-turning plot, and the legacy of Nobel Prize winner Bob Dylan.
In this debut thriller, tragedies strike an anesthesiologist as he tries to start a new life with his son.
Dr. Nico Antone, an anesthesiologist at Stanford University, is married to Alexandra, a high-powered real estate agent obsessed with money. Their son, Johnny, an 11th-grader with immense potential, struggles to get the grades he’ll need to attend an Ivy League college. After a screaming match with Alexandra, Nico moves himself and Johnny from Palo Alto, California, to his frozen childhood home of Hibbing, Minnesota. The move should help Johnny improve his grades and thus seem more attractive to universities, but Nico loves the freedom from his wife, too. Hibbing also happens to be the hometown of music icon Bob Dylan. Joining the hospital staff, Nico runs afoul of a grouchy nurse anesthetist calling himself Bobby Dylan, who plays Dylan songs twice a week in a bar called Heaven’s Door. As Nico and Johnny settle in, their lives turn around; they even start dating the gorgeous mother/daughter pair of Lena and Echo Johnson. However, when Johnny accidentally impregnates Echo, the lives of the Hibbing transplants start to implode. In true page-turner fashion, first-time novelist Novak gets started by killing soulless Alexandra, which accelerates the downfall of his underdog protagonist now accused of murder. Dialogue is pitch-perfect, and the insults hurled between Nico and his wife are as hilarious as they are hurtful: “Are you my husband, Nico? Or my dependent?” The author’s medical expertise proves central to the plot, and there are a few grisly moments, as when “dark blood percolated” from a patient’s nostrils “like coffee grounds.” Bob Dylan details add quirkiness to what might otherwise be a chilly revenge tale; we’re told, for instance, that Dylan taught “every singer with a less-than-perfect voice…how to sneer and twist off syllables.” Courtroom scenes toward the end crackle with energy, though one scene involving a snowmobile ties up a certain plot thread too neatly. By the end, Nico has rolled with a great many punches.
Nuanced characterization and crafty details help this debut soar.
Click on the image below to reach the Amazon link to The Doctor and Mr. Dylan:
Learn more about Rick Novak’s fiction writing at ricknovak.com by clicking on the picture below: