Visit Other Things Amanzi for this week’s edition of Grand Rounds. This surgeon is a great writer, and this week’s entries are over the top. I feel honored to be included, and look at this preview of some of the amazing photos that he included:

This is a baobab tree!

December’s Pain Blog Carnival is now up at How To Cope With Pain. New bloggers are always welcome, and I’m grateful for my inclusion.

Thank you, T. at Anesthesioboist, for your validating article. Hopefully more and more people will become acutely aware of how we are all being hijacked.

And finally,

Thank you, as always for all of your comments, and for reading my blog. Happy Trails to you all in the coming year, and I wish you always the best of health.

Not the best news for the New Year, but something that we all need to be aware of and get a little outraged over, just the same.

I have already written before about how Propofol is your friend and mine. Now, some insurance companies have determined that its use is medically unnecessary for colonoscopies. This is a bad and ill-informed decision on a number of counts.

Propofol is a drug with a quick onset and quick metabolism. What this means for YOU is that it will start working practically immediately, and last for the duration of your procedure, without any long-lasting after-effects. It causes no nausea or vomiting. It wears off quite fast. In small, titrated doses, it causes no respiratory depression.

Of course, colonoscopies can be done without Propofol; in fact, before the inception of this drug, colonoscopies were performed with various combinations of narcotics (think fentanyl, demerol) and benzodiazepines (think valium, versed), or without any sedation at all. They still are performed this way in many doctor offices and centers. My advice to all of you is to never opt for no sedation at all. As for the narcotic/benzo option, well, yes they work, but not without hitches.

Colons are long, tricky organs, with many twists and turns. Not so easy to navigate a 5 foot snake-like instrument through. A still, flaccid patient makes this a much easier endeavor for the colonoscopist and patient alike, and can often determine a successful or unsuccessful procedure. A comfortable patient has a relaxed abdomen. Narcs and benzos must also be given in incremental doses, like Propofol. Unlike Propofol, they do not wear off quickly, and narcs can cause nausea and vomiting (frequently) and respiratory depression. When narcs and benzos are combined, they pack a one-two punch, working synergistically together and often unpredictably. They also do not as reliably provide patient comfort like Propofol does.

Please give me Propofol for my colonoscopy.

Propofol needs to be administered by someone both very knowledgeable about how it works and very skilled in handling situations that may arise due to Propofol administration. Situations like airway and/or hemodynamic compromise. When an anesthesia provider gives you your drugs for your colonoscopy, YOUR heart, blood pressure, oxygen saturation, and breathing are constantly monitored for the duration of the procedure. Your anesthetist has no other responsibilities than watching over you to ensure a safe and effective anesthetic for the colonoscopy.

The insurance companies do not want to pay the anesthesia fee for these procedures. They would rather have YOU receive your sedation for this procedure by either the colonoscopist or one of his/her designated nurses (RNs) working with him. The same people who will be quite busy looking for any irregularities in your colon, biopsying lesions, removing polyps, filling out paperwork, applying abdominal pressure to assist in navigation of the large colon and otherwise involved in the procedure. All this, and administer incremental sedation while watching for and treating any side effects as a result of the drugs being given.

I’ve been involved in giving sedation for colonoscopies going the narcs/benzos route, and the Propofol route. The latter route has 100% reliable endpoints - namely, a sleeping, relaxed, comfortable patient. The former route is unpredictable and frequently provides inadequate, sub-par sedation.

Colon cancer is the our nation’s third largest cancer killer, after lung and protrate cancers. Getting people to have their colonoscopies for screening, let alone for symptoms, is Job One in both the prevention and treatment of this disease. Patients wake up after their colonoscopies with Propofol in disbelief that the procedure was even performed.  Do you have any idea what kind of great PR this is for the person who may feel a wee bit scared of having a colonoscopy done?

Please give me Propofol for my colonoscopy. And don’t take away my anesthesia provider, either.

Check it out at BrainScramble’s blog!

This week’s Grand Rounds, volume 4, number 14, is being held at medGadget, with a special collection of blogger links shared for the Christmas day edition. Enjoy the gift of great medical blog-reading.

Speaking of sharing, may I direct your attention to In Sickness and In Health? Barbara’s blog is always stimulating and thought-provoking, frequently stirring; this time she has graciously offered 5 highly engaging links as her gift to all of us for the New Year. They will wow you, make you laugh, and warm your hearts. Thanks, Barb - they made me feel good, and made my day.

Speaking of links, may I offer to you a highly addictive travel geography game to tickle your memory and challenge your knowledge of locations around the globe. Visit The Traveler IQ Challenge and see you far you can get - I’ve made it to level 10, but not without a struggle!

It’s that most wonderful time of the year, and I am gearing up for my annual Christmas call marathon. I go in to work at the hospital on Christmas eve day, and go home the morning after Christmas. Yeah, yeah, it’s about 48 hours, give or take, but it’s a worthwhile thing to do, and I enjoy it. You see, I do not observe the holiday, but it sure is important to most of my coworkers.

The Operating Room is a bittersweet place to be during Christmas. We see only the true emergencies, as most people do not want to spend their holidays as a patient, let alone needing to have surgery. So, in general, the patients are a little sicker or needier than our normal larger volume of patients on any other given day. A lot of surgery that is done during the year is considered “elective” - this means that there is no urgency to have the procedure done. Surgery on Christmas day is unexpected, uninvited, and immediate.

What kinds of cases do we typically see on Christmas? At our institution, over the years, the more common procedures have included:

repairing bone fractures due to cold weather mishaps

acute appendix and gall bladder attacks

trauma due to violence or motor vehicle accidents

organ transplants

We have had very quiet Christmases too. When there is no work, we eat, watch DVDs, visit patients, sleep, eat some more. It’s always a crap shoot - we never know what will happen. Our hospital offers a free Christmas meal for employees, which is mediocre at best. Usually, we’ll just order out Chinese food, and have a big buffet.

Christmas in the hospital is especially hard on patients and their families. Memories of happier times, yearnings to return to a better state of health, to return home - it is not easy for these people. Hospital staff go out of their way to try to bring the holidays inside. Units are decorated cheerfully, Christmas music can be heard on the various floors, and visitors abound. Food trays are appropriately themed and garnished. It seems like there is a heightened sensitivity by all personnel to the misfortunate who must spend their Christmas within the confines of an institution.

One of the things that I’ve noticed that brings many smiles to patients at this time of year is the movies on TV that have come to be recognized as classics for Christmas. Films like It’s a Wonderful Life, White Christmas, and Miracle on 34th Street can be seen on patients’ television screens throughout the hospital, and I believe these movies bring a lot of extra joy and distraction to patients who are stuck in the hospital during the holidays, and help to bring a little of what’s going on out “there” in “here.”

So, I leave for work on the 24th with my duffel bag fully packed and ammo in hand - favorite food/drinks/snacks, some good reading, warm blanket and favorite pillow, phone charger, DVDs. I am prepared for the worst, hope for the best, and take whatever catnaps I can. It’s a good feeling to go in and help, and it’s a really good feeling to go home when it’s over.

The warmest and brightest of Christmases to all who celebrate!

Buckeye Surgeon has done a fantastic job as host of this edition of SurgeXperiences. Stop by for a real insider’s view. Thank you for including me, Dr. Buckeye.

This past Saturday I was covering obstetrics, better known as OB, attending to the needs of women in various stages of labor and delivery.

A woman in the throes of labor is a force to be reckoned with. In between contractions, she is an expectant mom, filled with worries and concerns, generally cooperative and conversant. During a contraction, though, she morphs into an unrecognizable being and ceases to communicate with intelligible words. It is in this milieu that we usually first meet.

“Hello, my name is Terry. I’m your nurse anesthetist and I was told you would like an epidural.”

“Stop talking and just put it in!”

“I just need to ask you a few questions first, and then explain the procedure and obtain your consent.”

“If you don’t put the expletive deleted epidural in right now, I will expletive deleted.”

I love my job. Really, I do. Thanks to my academic training and finely-honed technical skills, I can help soothe another person’s anguish. That makes my work very rewarding.

Placing an epidural is a methodical procedure, requiring sterility, accuracy, knowledge, and refined technique. Every step taken along the way has a reason and a rationale. It is all about patient safety. There are no shortcuts. 

Under the very best of circumstances, I have inserted epidural catheters in about 10 minutes. One absolute requirement of the patient during this procedure is to maintain body stillness during insertion. This can be a tall order for a laboring parturient. In fact, it is sometimes near impossible for some moms, their contractions are that bad. Oftentimes, the anesthetist, RN, and patient’s personal support person serve as coaches to help keep the mother motionless and “breathing-focused” during the epidural insertion.

But what a worthwhile team effort it is, when the remarkable transformation occurs once placement of the epidural is confirmed. Our laboring mother now smiles, makes eye contact, and even speaks full sentences. Her face brightens as her body says thank you. She is now freed up to enjoy her labor or just relax.

I have often wondered out loud on more than one occasion how we as a human race progressed this far to the 21st century with epidurals as an option during labor and delivery only for the past 50 to 60 years.

It’s up and cleverly running at

Trick-Cycling for Beginners.

I have never haiku’d. Can you?

There is nothing more instantly gratifying for an anesthesia provider than relieving someone’s pain. This can be both the lure and the catch that reels in so many nurses and physicians that go into this specialty.

When patients are asleep for surgery, we deliver some of their analgesia proactively, in anticipation of the expected pain; and some of the medications are administered reactively according to patients’ unspoken autonomic responses.

In our textbooks there exist tables that offer predictors of how much pain to expect from the various operative procedures. But most seasoned anesthetists will tell you that analgesia administration becomes intuitive, although not written in stone.

This is one example of why giving anesthesia is both a science and an art.