Boo! Being a Physician Can Be Downright Scary

You won’t find me at any haunted houses this weekend. I don’t need any costumed creeps jumping out at me when I least (or most) expect it. I’ve never been a huge fan of strobe lights, fog machines, bad makeup, or canned Vincent Price laughter.

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My day job is scary enough.

 

Some like to say that anesthesia is 99% boredom and 1% terror. They’re half right. The 99% is rarely boring. The “routine” part of my workday is usually quite busy, sometimes fun, and never boring. The terror part? I used to deny it, but as I reflect on my career, I am willing to admit that rare moments do indeed qualify as terrifying.

 

Exhibit A: The Blood Sugar is 11

 

On a ten point scale, 11 is off the charts in a good way. On a hypoglycemia level, 11 is absolutely frightful. Earlier this year, I was finishing up the placement of a labor epidural when I was called to come to the nursery. Conveniently, I was just down the hall. There was a newborn, with her tiny fingers, toes, and veins in need of an IV for an urgently needed dextrose infusion.

The nurses had made a couple attempts, but to no avail.

There was one visible vein remaining — on her left foot — and time was of the essence. I poked once with a 24-gauge IV. Nothing. Another attempt a few millimeters proximal, and I struck crimson gold. Sugar was given, the baby perked up, and a crisis was averted.

Earlier in my career, a patient undergoing a kidney transplant developed a markedly elevated potassium, as evidenced by telltale EKG changes. I treated her with the usual remedies, including dextrose and insulin. The potassium dropped, but there were new EKG changes (that telltale heart again).

A blood draw confirmed what I suspected — profound hypoglycemia — it wasn’t 11, but it wasn’t much higher. Dextrose provided a quick fix, but I’ll tell you I was quite relieved when she woke up postoperatively and could carry on a normal conversation. The heart doesn’t like to be without fuel; the brain doesn’t either.

 

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Exhibit B: Beep bleep bloop

 

Every patient under our care is equipped with continuous pulse oximetry, a technology typically employing a finger clip that approximates the patient’s level of oxygen in the bloodstream. The “beep… beep… beep” you hear on Grey’s Anatomy? That’s the pulse ox. At a normal range of 97% to 100%, it’s a high-pitched beep. As it drops, the pitch lowers. Our brains are attuned to notice even a slight alteration in pitch.

Sometimes, the drop in pitch isn’t so slight. Sometimes, the subwoofer kicks in. This is not good. Not good at all. A patient’s oxygen can drop rapidly for a few dozen different reasons, and when it does, correcting the problem is the only priority. When the O2 sats hit the floor, you’ve got seconds before the heart can start to malfunction. In minutes, there can be brain damage.

Fortunately, we have all sorts of equipment to aid us in a rescue situation. There are facemasks, breathing tubes and similar devices, and a wide variety of tools to assist us in placing those tubes in the right place. When they’re needed, they’re needed now.

When have I needed them? When called to the room of a trainee who inadvertently over-sedated a patient undergoing a minor procedure and failed to timely recognize it. When a super obese (yes that’s an actual medical term for a BMI > 50) patient proves extraordinarily difficult to intubate. When the EM or ICU physician has failed to find the larynx using every tool at his disposal. When a newborn baby has poor respiratory effort and isn’t “pinking up.” When a toddler arrives essentially DOA after a horrific car accident.

Those are just a few of the dozens of precarious situations I’ve faced over the last decade. Thankfully, I’ve always been able to do what needed to be done, and it’s not just because I’ve been well trained. I’ve relied on the assistance of many a colleague. That fact that we’ve achieved success in the past doesn’t make the next situation any easier, and the images of those patients never leave you. To my dying day, I will never forget that doll-eyed toddler.

 

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Exhibit C: Blood and Guts

 

I’ve never been bothered by the sight of blood and guts. They’re the bread and butter of what we see and do in the operating room. Mangled fingers and bone exposed from injury do make me cringe a bit, but the splayed open belly is just another day at the office. What I don’t like is when those patients try their darndest to die on you.

I work in a community hospital. Major trauma patients are flown out to better-equipped trauma centers. I have great respect for the physicians who care for near-death patients on a daily basis. Frankly, the stress would do me in. There’s a reason I work at a community hospital.

That being said, we do care for crashing patients on occasion.

The emergency belly cases tend to be one of two varieties. There is the septic ICU patient whose blood pressure has been maintained on maximum levels of several pressors, who has a belly full of dead bowel spilling all sorts of evil humors into the blood stream that tend to be incompatible with life. I wrote in detail about one of these cases in We Were Promised Death Panels.

The other is a bleeder. These patients are scarier, because unlike the dead bowel patient, this patient was probably reasonably healthy before she started bleeding. She could be bleeding from an internal process, such as a ruptured ectopic pregnancy. It might be from a spleen or liver lacerated from trauma. The cause could be iatrogenic, that is, caused by a surgical or medical mishap.

Regardless of the cause, this patient will have no blood pressure or pulse without generous and continuous intravenous fluids and blood products. When the pace of bleeding exceeds the pace at which you can replace the losses, you’ve got precious little time to obtain better access. This is when we literally go for the jugular, inserting large bore catheters into the jugular vein to allow for a steady stream of fluids and blood that can be infused at a liter a minute or more.

Once again, the teamwork makes a good outcome possible, but the continual manual labor, consuming thought process, and constant threat of a negative outcome makes these cases physically and mentally exhausting.

 

Welcome to My Scary Life

 

I could write another 10,000 words on just how frightful a physician’s workday can be, but I think I’ve gotten the point across. On one hand, I take pride in the fact that I face these scary moments on a semi-regular basis, and can handle them with at least a semblance of confidence and calm. It’s a learned behavior. To be honest, though, every scary moment comes with an adrenaline rush that’s impossible to dismiss. Some physicians live for it; I live to avoid it.

There will be at least a few more moments of terror before I set aside the laryngoscope. I can accept that, but if I could finish out my career without another scary moment, I would retire a happy man.


 


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43 comments

  • Wow PoF. Thanks for dismissing any thought I may have had that an anesthesiologist meant you walked around with a clipboard calculating the dosage of sedatives. I’ll add it to the long list of specialties I couldn’t do (I don’t know if any are left). Thank you for doing what you do.

    • Actually, that’s exactly what I do! 😉

      I do get the question a lot, though “How do you know how much to give?” It’s simple, though. How big is the patient, how old, what drugs are they taking, drink much or into recreational drugs, high strung or pretty mellow? Red hair? Then I grab a syringe, start pushing, and stop when the dose feels “just right.”

      Cheers!
      -PoF

      • S.G.

        Okay, I have to ask: My husband is 6’8″ and 250# and he has had inconsistent experience with doctors and dosages. How do you handle people who just are multiple standard deviations from the norm? Some doctors seem to adjust dosage, and some just take the 170# (?) man model. Is it more drug or doctor dependent?

        • It depends on the type of medication. For some meds, it’s based on lean body mass, others on total body mass. Different drugs have different pharmacodynamics and pharmacokinetics. They are cleared by different mechanisms and have different volumes of distribution.

          In anesthesia, we tend to titrate to effect. An important lesson we learn early in training is “You can always give more,” which is another way of saying that you can’t ungive a medication.

          That probably didn’t help, but it’s the best I’ve got. If I were your husband’s anesthesiologist, I would have an ample supply of drug drawn up and ready to go.

          Best,
          PoF

  • My wife had six C-Sections. We know the power of good and sadly bad anesthesiologists. She is a good patient, though. I am more of a nightmare. I get faint at the site of needles and am generally a nervous wreck when facing procedures. I’ve had 5 or 6 endoscopies, a colonoscopy, and my gallbladder removed. In the end, all but one went off without any real terror.

    The one was my 2nd endoscopy. I don’t actually remember any of the others as they provide a nice cocktail that, from what I understand, basically erases your short-term memory for the day. But, during the second one, I woke up in the middle and was in the process of trying to yank out the tube. My last memory is hearing someone in the room frighteningly yell, “Give him more, give him more!!!”

    For my subsequent ones, I would remind the staff of episode II and they upped the dose of my cocktail. Although, EIII freaked my wife out a bit. I was out for what seemed to her, a considerably longer time. They must have found the happy medium for the later ones. It has been a few years now. I am actually do again.

    Thank you for sharing a few or your episodes so that we can appreciate the good docs that help us in our greatest times of need. cd :O)

    • SIX C-sections? Wow. After the first 2 or 3, there are some real challenges (mainly for the OB-Gyn).

      Your experience doesn’t sound like much fun, but I do need to point out that many, if not most endoscopy suites do not have anesthesia personnel, and moderate sedation is the only safe target. That voice yelling “Give him more!!” was probably an impatient gastroenterologist directing a sedation nurse.

      Whenever I talk to a patient before a case in which general anesthesia will not be utilized, I let them know they will be comfortable, but there is a possibility of remembering something. It’s rare with the drugs I give, but when it happens, it’s not an unintended consequence. Sedatives also affect breathing, blood pressure, and heart rate, and there are reasons that we have to be prudent with our dosing. I’d rather have my patient remember the sound of my voice reminding them to take a deep breath, than to have their pulse ox go bloop while they turn a bluer shade of pale.

      Best,
      -PoF

  • Thank you for doing what you do! It takes really special people to care for the health and well being of us. It definitely puts the bloody noses and projectile vomit that sometimes comes with my job in REAL perspective! Thank you!

    • Penny, don’t sell yourself short. POF and others are heroes at work, in the moment and don’t get me wrong, most appreciated. But moms and dads are needed to be heroes every moment. So kudos to you.

      • I think Penny was talking about her work as a teacher 🙂 I appreciate all you do PoF – getting put “under” can be a pretty scary moment for us! I couldn’t imagine being under the stress you face each day! I guess it’s “all in a days work” most days for you – but that is definitely hard to imagine.

        • Fortunately, Vicki, most days go off without a hitch. I’m just trying to be honest about how it feels when things go south.

          Most days, the most stressful thing that happens is an add-on case that means I’ll miss dinner. And another that means I’ll miss the kids’ bedtimes. Then one more so I miss my own bedtime. But that’s why they pay me the big bucks. 🙂

          Best,
          -PoF

        • Oh! – Well teachers see the same kids day-in-and-day-out and also have the power to be quite heroic. My mom was a teacher and so was her mom.

    • Thanks for the love, Penny! Dealing with bloody noses and vomitus — we do have some things in common.

      Cheers!
      -PoF

  • I thought it was stressful writing safety critical flight control software. But the worst I ever experienced were a few wild rides on test flights. I can’t imagine the stress of coming up on a patient who’s life is hinged on your abilities. Kudos to you for doing the good work!

    As far as the 99% boredom part, I used to work with a Radiologist on some R&D projects. He had been an engineer that got his MD to escape engineering. But after a few years of doing that he came back and wanted to do some research in his spare time. It blew my mind that he got his MD and wanted to do engineering for fun after his day at work. He is a co-inventor on one of the patents I filed 🙂

    • I’ll bet he’s an interesting fellow. I thought radiology was the direction I might go, but I found diagnostic radiology to be 101% boring. I don’t have the attention span.

      I do get to do some cool stuff, but I have filed exactly zero patents.

      Cheers!
      -PoF

  • Nothing gets my heart rate going fast like lack of access to either vascular or airway in a rapid response or near code. The other day I had an altered hypoglycemic patient who while we were about to push an amp of D50 pulled out both of her IV accesses! Luckily she had some juicy veins and another one was placed in no time :). I would have been sweating hard trying to put a 24G in a small baby. Nice work!

    • Yeah, you’d think that epi surge would subside after you’ve been in a similar scenario a hundred times. It does subside to some extent, but I’ve acquiesced to the fact that I’m stuck with it until the day I walk away.

      Glad you guys had a good outcome in your latest round of excitement!
      -PoF

  • Yes, exactly. This post perfectly describes why I picked a relatively low-stress outpatient field of medicine. I still have to deal with some scary moments, but they are thankfully few and far between.

  • I found anesthesiology a bit to stressful for my tastes, although it was pretty cool stuff indeed. What fascinates me is the fact that we still don’t know entirely why or how general anesthesia works or what exactly consciousness is. Is consciousness subjective or objective? Where does consciousness live in the brain? Have you had any patients with anesthesia awareness? What are your thoughts on EEG or other electrical activity monitoring for general anesthesia? How many questions can I ask in a comment?

    • Five, apparently. 😉

      I have not had a case of awareness under general anesthesia, or a case in a facility where I’ve worked. It can happen, but is exceedingly rare, and usually in a crash scenario such as a stat C section or difficulty coming off cardiopulmonary bypass where the volatile gas is turned way down to help preserve life.

      What is much more common is a patient undergoing a sedation case, who hasn’t had the expectations properly explained (or had them improperly explained) who remembers something while under moderate sedation. That’s normal, but if the patient expected to be “out” they might think somebody screwed up when they recall a voice or a face.

      The BIS monitor incorporates EEG and is billed as an awareness monitor. It’s an interesting technology, but is imperfect. Beta blockers lower the reading, and it doesn’t do well with ketamine as I recall.

      Cheers!
      -PoF

  • I can barely handle getting a flu shot without wigging-out. I honestly don’t know how you doctors manage it.

    Even on my worse day at work, I don’t think I was ever responsible for someone’s death. Something like that, or the fear of it must be troubling.

    Let’s focus on the positive instead. If I recall, in the past you did say you enjoy your job (and find it fulfilling). Despite the “scary bits”, what’s the part you enjoy the most?

  • Elisa

    After recently finding your blog through the White Coat Investor, I’ve really been enjoying your posts. Being entertained while learning a few things is a happy combination for me! As I head into my on-call workday (I’m also an anesthesiologist at a community hospital) I find this post SO relatable- I too credit my job as the reason I avoid dramatic/intense/scary movies and shows. It’s ok at work in occasional doses, but I don’t need to go looking for more!

    • And I hope your call shift is relatively unexciting, Elisa. I don’t mean to jinx it, but I hope the lounge fridge is well stocked, the E.D. low key, and that all the epidurals are in place and working well by 10 p.m.

      Here’s to a pager so quiet you have to doublecheck you actually turned it on.

      Cheers!
      -PoF

  • Eric Lancaster

    As an EMS field instructor, this is exactly what I tell my cadets and students. This job is 99% boredom and 1% terror. Don’t get complacent in the boring times, and be ready for the terror.

  • TheRetirementManifesto

    Hey Doc! I almost shut down one of our factories once. I applaud those willing to face life threatening situations every day. You’re a special breed, and deserve every dollar you’re paid. If someone objects, let them be responsible for the 24 gauge IV in a baby’s foot.

    • Thank you very much, Fritz! It’s crazy to take a step back and think about all the things that seem “normal” in my job, when they’re anything but normal. I haven’t quite become immune to the potential danger that is omnipresent in the O.R. And that’s a good thing in this line of work.

      Best,
      -PoF

  • This post brought back flashbacks for me. Something I’ve come to appreciate over time in this field (anesthesia) and life in general is that nothing is routine. Surgery has become kind of like flying – something so ordinary that we forget that we’re sitting in an aluminum tube 40,000 ft above the ground or in a suspended state for a couple hours with your life in someone else’s hands. Keep fighting the good fight!

    • So true. I’ll bet you could rattle off dozens of frightening scenarios you’ve encountered in your career. The flight analogy is a good one. Air travel, like general anesthesia, is safer than driving a car, but unlike driving, involve putting your life in someone else’s hands.

      Best,
      -PoF

  • I could never do what you guys do, but I definitely give you props for sure!!

    It’s funny that I work in higher-end technology for a living and if a client’s network goes down, it seems like a stressful event. You’re dealing with life and death… you win!! 🙂

    — Jim

    • Well, there is the benefit that the crashing patient is never yelling at us to fix them right now, or else! “Every minute that you fail to insert that central line is costing this company millions!” is something I’ve never had to listen to.

      Cheers, Jim!
      -PoF

  • ChooseBetterLife

    PoF, your patients are privileged to have you.
    Those are the kinds of days when I’d rather be lucky than good, though of course I’d rather be both. And if I were so lucky, these patients wouldn’t come in on my shift…
    It’s like the guy minding his own business when Two Dudes shot him, and the GSW to the abdomen managed to miss all his vital organs–is he lucky for that or unlucky he got shot in the first place?

    • Likewise, Julie.

      Emergency medicine, surgery, and probably OB/Gyn all have a higher incidence of frightful events than anesthesia. Cheers to the work that you do! And apologies if I left off some other high-stress specialties! No, not you, dermatology. 😉

      Best,
      -PoF

  • Good post PoF. As a co-inventor on 6 patents in core science areas, I can vouch that almost every profession has its “aha” and “oh, no!” moments. While clearly not life-saving as you do doc, I tend to think my “aha” moments were at least soul-saving (even if it’s only my own soul!) 🙂 I bow down to the doctors who make life or death decisions every day and still have the sanity and sense of humor to blog about it. .

  • financialibre

    Jeez – Yes, point made! Point made! Have mercy! Uncle!!!

    A riveting read… Maybe a Robin Cook or Michael Crichton styled career path is in your future…

    Right, so this is exactly why we’re lucky to have people like you saving lives. “Treating” markets (i.e., the work of economists) doesn’t typically involve any blood unless there’s a nasty paper cut. And all the trickiness in our paper-pushing line of work rarely involves split-second lifesaving measures.

    Have a Happy Halloween…or at least not a terrifying one!

  • S.G.

    I have wondered about being a doctor. Reading through your stories is scary, and I’m sure some cases are really hard to cope with, but even the missteps are often still miracles at work. I have read the statistics about how many deaths are “caused” by doctors, but when you look the deaths are usually a bad call that resulted in death when non-intervention would have led to death anyway. The alternative to bad care isn’t usually good care, but no care. It can be hard when you fail to live up to a standard of perfection, but I assume it’s easier to work through when you are realistic about what the alternatives really are.

  • Jacob

    Hey POF,

    I was wondering what your current thoughts are on locum tenem work straight out of residency for anesthesiologists? I have considered the idea as my wife will be finishing a year of her residency once I graduate and I may decide to forego a fellowship if I can line up enough work near by. Currently only a PGY-1 so lots of time. Thanks for any help!

  • I agree with you on scary. Same can be said for sad. From time to time my wife will ask if I want to go with her to see a sad movie. I always decline. I’m already exposed to too much death and suffering at work, why would I want to go somewhere and pay someone to be exposed to more?

  • My father is a doctor and my mother was a nurse. I grew up in and around hospitals (back in the day and back home where I am from they were much more ummm….relaxed…about this stuff), and stories like this at our dinner table were pretty common. You folks do amazing things on a regular basis. I actually think that the fact that my father literally makes life and death decisions every day is one of the reasons I haven’t been able to ever be fully convinced that my job is important, that it matters. It is one of the reasons I want to achieve FIRE – so that I can explore and find more meaningful things to do with the rest of my life.

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