Correspondence can bring many things. Recently there has been a lot of mail, much of it from friends and family with discussions of life, projects and goals. I even had a request for money recently from a needy soul that could not be turned down. What I wanted to share today was a series of communications from this last week that has occupied my mind for several days. Maybe after reading these you too will pause and consider what a gift we have been given to serve and learn from our patients. Their contribution to us is tremendous and must never be forgotten. This is a sacred trust that I am appreciating with a new understanding. Thank you Jim for that. It starts with a letter from Jo. I find her vignette interesting and instructive but what comes later is beyond instructive. Let’s see what you think.

Hey David, here is a funny story,

As student nurse anesthetists we are fortunate to have some common sense especially since we have some critical care background and have actually touched patients. Anesthesia physician residents often do not have this luxury. They get thrown into an operating room because they have graduated form medical school and are expected to perform. While SRNAs are guided on how do things should be done in the operating room for a long time.

Recently I heard a story about a M.D. resident that was interesting. The surgical case involved a patient scheduled for a total knee replacement with an epidural catheter and an Laryngeal Mask Airway (LMA). A Nurse Anesthetist enters the OR to send the physician on a break. The patient is breathing 38 breaths per minute and chewing on the endotracheal tube. The physician states, “Oh that’s new this must have just started”. Propofol is then slammed intravenously and B/P drops precipitously and then the low blood pressure is then chased with ephedrine trying to bring the blood pressure back up.

There is a lesson to be learned here. You can’t blame the physician resident because many times when they are new in their training they do not have sufficient oversight. The patient obviously needed something other than slamming propofol – possibly a dose of narcotic and not hypnosis. The epidural was infusing but did the patient get a loading dose up front? These things may all effect how the patient was tolerating the surgery. What I have seen clinically is that when epidurals catheters are working well you need far less opioids and less volatile agent as the MAC is lowered. These patients usually wake up very comfortable.

The morale of the story is to feel good about the education that we receive as nurse anesthetists and feel proud to be apart of this prestigious profession of Nurse Anesthesia. Remember that 65% of all rural anesthesia is given by Certified Registered Nurse Anesthetists (CRNA’s). Some day you might be taking care of me or my loved one and I want the best and most competent anesthetist on the job.

Jo

At first I glanced over this note from Jo and scribble a few notes to myself while reviewing the many interactions that I have had with residents. Jo is a dear friend of mine – however I find that her reasoning incomplete. At least there is more here that is bothering me that I can not mine fully. She states correctly that patients with epidural catheters require lower MAC and less opioids then proceeds to disparage the hypnotic and suggest that the patient needs additional opioids? I began thinking that the idea of giving more opioid for a light patient is the wrong choice and her criticism of the resident could take a different slant. For me the propofol is not a wrong option but the lack of vigilance by the resident deserves comment. So ran my thoughts. To confirm my suspicions I ran off a note to a friend, we’ll call him ‘John’, a long time anesthetist back East. I was dealing with the trees and not the forest. My thoughts continued at that time this way:

John,

…I was not there in the OR and all of this is second hand information but an interesting discussion about CRNA SRNA and Resident relations mainly. We all have our prejudices I guess. For me the physicians do just fine and receive extensive training. At times in the beginning of their training there may be things that happen that are not the best practice. Who is to say that Student Nurse Anesthetists do better really? Personally I do not find it profitable to compare providers but to look for a best practice regardless of the practitioner. John, I thought you might get a kick out of this story and look forward to your comments on the scenario. Hope all is well with you and that your scheduled surgery goes well. I am wishing you all the best from Los Angeles.

David.

The response I received back has been lingering in my mind for the past few days. When I started the NurseAnesthetist.org/ web site my goal was to try to put together something with content that would be both instructive and entertaining while showing what it is like to be a nurse anesthetist student. John goes beyond my expectations.

Hi, David

I have many thoughts tumbling through my head at this stage of my career. As to the story your friend related, I find your take on it to be the more reasoned. Yes, the average SRNA is probably much more oriented to the care of the patient, by virtue of the nursing background. This stereotypical SRNA is also more clinically astute because s/he’s been on the front lines, watching actual patients get better or get worse and die, so s/he has earned to look at everything, make no assumptions, and always to keep that “sixth sense” activated whenever s/he is responsible for a patient. Those hard-earned lessons from the ICU on a 12-hour night shift do stand the SRNA in good stead.

And it’s probably true that the average MD trainee at whatever stage of her/his training is probably less experienced and clinically seasoned; more educated in basic sciences than the average RN (notice I said “more” educated which doesn’t necessarily equate to “better” educated). But a friend of mine long ago put it this way: “Good nurses know a lot about medicine while good doctors know a lot about nursing”. When I look back to the people who had the most influence on my developing anesthesia career (and it’s STILL developing) I find nurses who took it upon themselves to be very educated (and very WELL educated) and physicians who had that common sense and humanitarianism that is stereotypically viewed as the hallmark of nursing. What each had in common was a curiosity that motivated their learning, a humility that taught them that their learning would never end, and an empathy for the suffering patient who was at once her/his sacred responsibility and greatest teacher. The other thing they had in common was my enduring respect; you see, I’ve seen callous CRNAs and empathetic and truly altruistic physicians. We must be careful not to be guilty of that error which we decry in others: judging an individual by the letters behind the name and not the character attached to the person.

As to your friend’s assessment of what was needed, we all know that anesthesia is a complex specialty. From first principles, the patient should never have been allowed to come to such a state, under the care of an anesthesia provider, that the patient was chewing the tube and breathing 38 breaths per minute. The rescue of the patient from that unacceptable state can take many forms, some better than others. The bolus of propofol was a “fast” answer. Fast is important, but one must be careful not to overshoot lest one have to engage in the “dueling drugs” scenario as your friend described chasing blood pressures all over the place. You made another astute observation: “I wasn’t there…” This is a very mature approach to analyzing anecdotes about cases; you know that not everything that happens can be reduced to marks on an anesthesia record, and that even the most careful observer is biased to some extent.

I have a feeling that neither you nor your friend would have gotten yourself into the situation of needing to rescue the patient from inadequate anesthesia. In a couple of jobs I’ve had in the past, we’ve had trainees rotating through the anesthesia department. Now, I’m always careful about generalizations, and the following observation is given with the very large caveat that generalizations are poor tools to explain things. That said, I noticed that there were in general two “styles” exhibited by anesthesia trainees. One style was more “high tech” and the other more “high touch”.

One manifestation of this was the manner in which the trainee monitored the patient. Some stood with their backs to the patient and watched a bank of monitors. These tended to miss things that a more experienced onlooker would see evolving before they manifested themselves on the monitors. These were the “high tech” ones. Many were very intelligent — far more so than I — and usually more educated as well. As a generalization, these were doctors. Others gave their primary attention to the patient, and looked to monitors as a secondary information source, to validate their clinical impression of the evolving anesthetic. Most of their time was spent seated or standing in close proximity to the patient, their backs to the monitors. Sure, this has elements of a false dichotomy, but by and large, these latter were nurses. They didn’t treat numbers, they treated patients. And they usually “picked up” things before the “things” became “problems”.

Sometimes the “high touch” crowd couldn’t even characterize what it was that was about to go wrong. Usually the “high tech” ones could recite the “book learning” about what had just gone wrong. If you haven’t found this out already, in anesthesia it is frequently the case that we are too smart too late. You’ll also know the daily reality of something I once read: Most great discoveries are presaged not by the exclamation “Eureka!” but by “Gee. That’s strange….”

The only good thing that came out of Jo’s experience is that you are talking and thinking about it and learning from it. The occurrence of inadequate anesthesia in this patient — the failure of our specialty, the patient’s trust betrayed — became, if you will, a “chance experiment” in the laboratory that is your learning. No Institutional Review Board would ever have approved of the situation into which this patient had been allowed to deteriorate, even for the pragmatic good of your learning. But it happened. Remember, “stercus contingit”. You have been handed a learning opportunity, purchased at a very high price by your patient. Learn from it, get all you can out of it. And, as you progress in your career and teach others, remember the debt you owe to that patient, in whose care an error was made, allowing you to learn from the remediation — and yes, even the “cover up” — of the error.

Here is where I have a huge problem with many physicians with whom I’ve worked. There’s an attitude of entitlement. “I earned this degree. I got out of training with six figures of student debt. I am owed”. No. Wrong, wrong, wrong. They are who they are, they know what they know, and they have what they have, because of an unending string of patients who held still for their first clumsy attempts at the laying on of hands, who suffered at their mistakes as they repeated lab tests and painful procedures, who died at their imperfect hands — at all of our imperfect hands. David, I submit to you that this is a debt that can NEVER be repaid; the currency to satisfy such a debt has never been minted, nor could it be.

I recently had a physician make some comments to me in passing. I think he meant to encourage me; I’m not sure. He commented on my skill at regional anesthesia, especially in the massively obese parturient with whom we’d just dealt successfully. I described how I’d evolved in my skill to a peak several years ago, and how I’ve had to refine my skills as my senses and strengths change. I used to palpate everything, and my sense of touch was my paramount one. As I age, my tactile sensation has diminished, and I rely more on vision. And even that is failing as I approach my seventh decade of life. But I continue and I do my job well and carefully. He expressed surprise when I told him how old I am — that surprises everyone because I’m blessed with a youthful appearance. Then he told me that he doesn’t intend to work past the age of sixty, not at all while I intend to work until it would no longer be safe for my patients for me to continue to do so. I’ll know when that is, and a carefully selected group of people with whom I work will validate that judgment. Only then will I pursue a lesser career, and I will leave with reluctance and with regret for that huge unpaid debt, with gratitude for every patient who has taught me what I know. For now, CRNA doesn’t describe so much what I do as who I am.

PS: My surgery has been put off until the 22 of this month. Several things have to be in place for it to take place, one of which is some sort of fibrin glue to be used in the repair. I am blessed to have tissue that doesn’t act its age, and a “sports medicine” orthopedist who normally limits his practice to athletic injuries in genuine athletes. He’s agreed to apply his skills for an old man who fell on the ice, whose “athletic” prowess is confined to paddling canoes and kayaks to photogenic places, or slogging along on a mountain bike or cross-country skis to places that aren’t crowded, and whose major competition is against entropy — and gravity. His method includes aggressive rehabilitation. It will return me to my “playing field” sooner, and ease the overwork my absence will impose on my partner and our already thinly-stretched locums. That’s important to me.

Thanks for your kind good wishes. I’ll keep you posted. In the meantime, work is busy, and that’s great therapy.

Today I received such a sweet note from Gina my friend from USC that I had to post it. We have been in the nurse anesthesia program now for about a year and a half together and in the last couple of months have not seen much of each other. All of the students are scattered about doing specialty clinical rotations currently and only get together for Journal club once a month.

At one point last year Gina and I were together at Arrowhead Regional Medical center and we became quite close.

Here is her note:

David,

Got your message today and sorry I missed your call. I’m just now trying to get my Medatrax caught up for the week. Wondering how you’re doing these days. It is strange not seeing one another every week, but that is progress, isn’t it? We’re very close to the finish line, or so it seems. How are things going in OB? Any problems getting your numbers? Dr. Gold seems to think that is a concern there. I was looking over the schedule to see where you are and it appears as though you have a nice few months ahead of you. Of course that last month at LAC is going to kill you. You know what I say; better you than me!!

Children’s is worlds better than I had imagined. It is clean and efficient, much like Arrowhead, which you will like. The attendings are for the most part, into teaching. The morning conferences and Grand Rounds are a nice review. The hours are not as long as I thought. The anesthesia is simple and it is not a rotation I would recommend trying to get too fancy with. Of course my objectives for the rotation are very simple; 1) don’t kill anyone and; 2) get to the point where I am reasonably comfortable when a baby or child shows up in my OR. And to that end, I think I’m getting there. It’s good and important experience. Of course the bad side is that you are dealing with kids who have really horrible diseases, who endure pain daily, who are scared when you take them away from mommy, and who wake up crying. The parents are weary and desperate. My heart is broken daily. I hug my son a bit tighter these days when I get home.

Tell me how you are doing and where your thoughts are these days. Any thoughts about where to work when all this craziness is done?

I look forward to seeing you Monday, my dear friend. Be well.

Gina

So there you have it! Gina would probably laugh out loud if she knew that I posted her letter she is such a stickler for details. One thing is abundantly clear – she is a great soul. I did reply to her mail and include it here for historical purposes.

Gina,

Thank you for the great update. You are a great soul and appreciated very much. Your wisdom comes through everything you say. Its like the old saying about the trees and the forest except that no matter what you do I see the forest of wisdom in who you are. Maybe I am just an old philosophical fool but it makes sense to me anyway.

For the latest on me you can always check out my revised web site the “Average Man” at the new URL http://averageman.org/

You may get a kick out of this site actually. Many have asked me why I chose the moniker of the Average Man. When I try to answer the question the topic of the “Ordinary” man always comes up when I am thinking of “Exceptional” man – used in the universal sense. When they are thinking of “Ordinary” I am thinking of the potential that is in every one of us just waiting to be exposed. Most people don’t get it but those that do are the ones I speak to. As an example, I did a search in Google for an “Average Man” and came up with a site for Gandhi in which I found this:

Mahatma Gandhi was an average man – at least, that is how he regarded himself. He laid no claim to be either a saint or a mahatma. He declared with humility:

“I claim to be no more than an average man with less than average ability. Nor can I claim any special merit for such non-violence or continence as I have been able to reach with laborious research. I have not the shadow of a doubt that any man or woman can achieve what I have, if he or she would make the same effort and cultivate the same hope and faith. Work without faith is like an attempt to reach the bottom of a bottomless pit.”

These words were not the expression of a pretentious modesty. They reflected Gandhi’s fundamental conviction that each one of us can achieve that which he had achieved – and more. For Gandhi, life was a permanent experiment with truth. He walked his talk – and where his walk did not coincide with his talk, he changed either his walk or his talk.

“I claim to be a simple individual liable to err like any other fellow mortal. I own, however, that I have humility enough in me to confess my errors and to retrace my steps. I own that I have an immovable faith in God and His goodness and unconsumable passion for truth and love. But, is that not what every person has latent in him?”

So Gina dear friend maybe you will be able to understand what it is to be an Average Man and know who I am. Most likely due to the fact that you certainly have touched the center of your own latent potential. Certainly I claim no greatness just the average goodness that is in us all.

Your friend David.

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