Clinical Case for Discussion: You are an attending anesthesiologist in private practice, in your first year out of residency. Your schedule for the next morning includes a 60-year-old, 350-pound male with ankylosing spondylitis and congestive cardiomyopathy for cholecystectomy. You turn off the lights the night before at 10 p.m., and cannot fall asleep, as you are worried about the case. What do you do?
Discussion: During my first year in private practice, one of my senior anesthesia colleagues, ripe with gray hair and receding hairline, stood outside of his operating room at 7 a.m. I bid him good morning and he said, “It is a good morning, despite the usual anxieties that come with what I’m about to do.” I asked him to explain, and he said, “Every day I come to work knowing that something could go wrong, and my patient could be harmed, and it could change my life forever. That gives me anxiety, which I have to cope with every day.”
Anesthesia textbooks are thick with information on how to assess patients preoperatively, how to perform anesthetics, and how to manage postoperative medical problems. You won’t find much guidance on how to handle your own anxieties as an anesthesia provider.
What are chances that you will have a perioperative death during your career in anesthesia? In a recent published survey, 84% of anesthesiologist respondents had an unexpected perioperative death or serious injury of a perioperative patient during their career (Gazoni FM, et al, The Impact of Perioperative Catastrophes on Anesthesiologists: Results of a National Survey, Anesthesia and Analgesia, Jul 7, 2011). A majority of these respondents indicated that they experienced guilt, depression, anxiety, sleeplessness, fear of litigation, fear of judgment by colleagues, anger, and reliving of the event. Five percent experienced use of drugs or alcohol and 12% considered a career change after the event.
During my 25-year career as an attending anesthesiologist in private practice, I’ve had two unanticipated patient deaths. Both were awful events for me, and had me reeling for some time. The first was a male in his 70’s for an open abdominal aortic aneurysm repair. The case occurred at a local community hospital, six months after completing my Stanford training. As the vascular surgeon closed the abdominal incision, the patient went into pulmonary edema, dropped his cardiac output and arrested. The resulting unsuccessful CPR, followed by the conversations with the surgeon and the patient’s family, were gut-wrenching experiences. Because I was new at the hospital, I’m sure there were individuals who doubted my abilities and competence. The post-mortem diagnosis was myocardial infarction. The case went through peer review, my management was not challenged, and no one blamed the anesthesiologist. But I remember that one day after this patient died, my first patient was a sickly 90-year-old. If my hands weren’t shaking that morning, my confidence was.
The second death was an elderly insulin-dependent diabetic end-stage-renal-disease patient who was having an upper extremity arterial-venous fistula revision for dialysis access. At the conclusion of the case, I administered protamine to reverse the heparin, and the patient’s oximeter stopped beeping. Her automated blood pressure cuff readings became unobtainable. It took me several moments to figure out that she had no discernable pulse either. Her only working monitor was the sinus rhythm on the ECG, and that soon deteriorated into ventricular fibrillation. We could not resuscitate her. The post-mortem assessment was anaphylaxis to protamine. This case occurred in the third year of my private practice career, and again it shook my confidence for a while.
Anesthesia practice can be lonely. During university training, each anesthesia resident has an attending to back them up and emotionally hold their hand through both easy and difficult cases. When you finish training and enter the next phase of your career, you have to work alone. In the middle of the night, you may be presented with an extraordinarily sick patient and you may be the only anesthesiologist for miles around. In some practices you will work in freestanding facilities, and again you will be the only anesthesiologist for miles around.
What about the Clinical Case above, where you are the first-year attending anesthesiologist who can’t sleep because you’re worried about the difficult airway, the morbid obesity, and the congestive cardiomyopathy in your patient for the next day? What are solutions to the anxieties an anesthesiologist experiences? I’m no psychiatrist, but here’s my advice after having toiled in the anesthesia arena for 25 years:
1) You’re often going to feel anxious, and that’s normal. Expect it.
2) Learn as much as you can during your residency, so you emerge from your training with confidence. Not cockiness–“Man’s got to know his limitations,” as Dirty Harry famously said in Magnum Force–but you need to be confident.
3) If you’re truly worried or in over your head, remember how reassuring it was in residency to have an ally. Call another attending the night before for their opinion on a difficult case for the next day. Call for help before you start a challenging case regarding a difficult intubation or a complex anesthetic induction.
4) Cultivate a strong emotional support team of people, inside and outside of the hospital. You’ll need them.
4) If you run into ongoing insomnia, depression, or fear, seek professional help. It’s well known that anesthesiologists are vulnerable to chemical dependence. Treating your own insomnia or anxiety with fentanyl or Versed or propofol will be a dead end.
The same anesthesia attending I referred to in the first paragraph once told me, “There are three ways an anesthesiologist can end his career. He can: 1) die in mid-career, 2) quit because he can’t handle the stresses of the job any more, or 3) walk away and retire on their own terms when they choose to.”
Let’s hope each of us gets to choice number 3!
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: