What it’s like to be a female anesthesiologist…

To promote the series #asawoman started by @nataliecrawfordmd (from Instagram)
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Throughout medical school, residency, fellowship, even now in private practice… patients have often judged a book by its cover. They’ve thought I was their nurse, volunteer, high school student or college student shadowing, almost everything but the person who will lead their anesthetic care. While this can seem deflating given all the extra work and studies one puts in to become a physician, I’ve changed my mindset re: my patients’ initial thoughts on me.
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First of all, thank goodness they think I’m super young! I have my mom’s genes and beautiful skin to thank!! At this rate, I hope I start to look 30 when I hit 50. When patients ask my age, I happily oblige them with a bold 39. Then I see a look of relief over their faces. I, of course, ask them how old they think I am….and I get the range of: just graduated college to mid-20s. Awesome!! I use it as a bonding moment and icebreaker with my patients. Sometimes with the right patient, I joke with them that it’s my first day… it usually entertains a good laugh. Then, I go into an overly technical schpeel on risks/benefits of anesthesia, expectations, PACU recovery. This typically solidifies to the patient that it’s not my first day on the job. Additionally, many patients tell me in the PACU that they feel better than their prior experience or better than their expectation and are quite grateful for my care.
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There are a lot of men in my anesthesia group. Sometimes, after I introduce myself to the patient, they’re shocked that a woman anesthesiologist would be delivering their care. In this day and age, I’m shocked that a lot of patients still assume that a male physician will oversee their care. When caring for female patients with this mentality, I purposefully address a gentle and vigilant anesthetic plan. With my male patients with this mentality, often times they’re happy to talk about the “happy juice” cocktail they’ll get and some much deserved relaxation knowing that I will carry a watchful eye over their surgery and anesthetic.
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Lastly, since becoming pregnant with my first and currently pregnant with my second… I feel I have a better understanding of the worried/concerned parents who are at the bedside to be with their child about to enter surgery.  Oftentimes, the parents think I’m young and want to know where I trained and when I graduated.  I offer them this info, and continue speaking to the patient (their child) about their concerns or questions.  I make sure the parents know everything that will go on re: anesthetic plan, how the patient will feel in recovery and risks/benefits of anesthesia options.  I TAKE MY TIME with the parents and the patient.  While my age and gender often work against me (even though it shouldn’t!), I make sure the controllable worries by the parents are addressed.  I speak to the parents after the surgery.  They go into the recovery room and see their child (older than 13 at our hospital) comfortable and recovering.  While I can’t change my appearance (nor would I want to…), I can change perceptions of women physicians.  We are every bit as capable of everything our male colleagues can do.  In addition, we tackle pregnancy, motherhood, businesses, and everything in between.  #asawoman As A Woman, I feel more empowered now than ever before.

Women in Anesthesiology

American Medical Women’s Association

American College of Physicians: Women in Medicine

Bias, Bravery, and Burnout: The Journey of Women in Medicine

Interested in Medical School? Start Early.

A friend of mine’s son is just about to graduate from high school.  He’s interested in medical school, and his mom asked me what advice I would give to help him pick a college knowing that he has an interest in medicine.

Keep in mind: I am not a counselor or an advisor.  I am a physician, and this is what worked for me.

My advice:

  1. If you’re interested in medicine…. start early.
    • The college and medical school application process are getting more competitive.  Students are bright, prepared, and eager.  Let’s start with the basics.  Are you sure you’re interested in medicine?  Like really interested?  Sure, the media portrays some glamour lifestyles for physicians… but it’s not all glitz and glam.  You’ll put in at least a decade of extra work vs. your peers who get a job right out of college.  While they’re building their nest egg, you are not.   
    • Luckily, I stumbled upon my interest in medicine at an early age when my family practice physician encouraged me to pursue it.  He proved to be a great mentor as I was able to shadow him and really get a feel of his day and what he does.
  2. Once you’ve decided medicine in your passion… solidify that decision.
    • Volunteer at the hospital.  Observe your physician.  Volunteer to help people.  If this excites you, you’re on the right track.  Put yourself in situations where you can get involved in medicine.  Read and research what medical school is like.  Reach out to a medical school and see if you can get more information: chat with a medical student, find out if anyone needs help with a research project.
  3. Do well in school.
    • This is a must.  Applicants are incredibly competitive and intelligent with tons of extracurriculars on their resumes.  Get good grades.  Do well on your SAT/ACT and then do well on the MCAT.  Your grades and your test scores are the most basic comparison tool for schools to compare applicants.  Doing well gets you noticed.
  4. Get involved and signup for extracurricular activities.
    • Once you’ve put in the work for good grades and test scores… get involved.  This could be anything: sports, clubs, arts/music, babysitting/caring for loved ones, volunteering, job in a lab, travel/cultural growth.  The key is to show that you’re well-rounded and multifaceted all while achieving the good grades.  Once the colleges and med schools have seen your test scores, they’ll next use your extracurricular activities to help separate out the different applicants.  The key is maintaining good grades while all these other activities are happening.  AAMC fact sheet for medical schools.

If you’re in high school and interested in medicine:

  • Get good grades and do well on SAT/ACT (consider college prep courses to help)
  • If you’re able to take honors classes or AP classes and do well, definitely sign up for these.  It’s another way to separate yourself from other applicants.
  • Volunteer at your local hospital and/or doctor’s office
  • Get a job at a research lab or hospital
  • Get involved in extracurricular activities
  • Talk to your high school counselor about career paths
  • Attend career fairs (my school offered a career night in medicine where we got to go into the operating room) and college fairs on getting into medical school
  • Ask a college pre-med what they’re taking and how to do well in college
  • If you’re torn between two schools on your college list, consider taking a good look at the college that may also be linked to a medical school.  There’s a good chance that some of the medical school professors will be teaching some of the upper level physiology or anatomy college courses.  Some of the professors may also sit on the admissions committee to medical school.  Lastly, it may be easier to get involved in clinical research or scientific studies that the medical school professors are working on… and that would be a great way to introduce yourself to medical school staff as well as get a stellar recommendation letter to show off your work ethic and dependability.

If you’re in college and interested in medicine:

  • Get good grades and do well on the MCAT (consider prep course to help)
  • Get a major in something you’re interested in (you do NOT have to be a pre-med major… you just have to take the pre-med prerequisites to take the MCAT and apply for medical school).  Even though I majored in biomedical science (a pre-med major at Texas A&M), I would have done biomedical engineering if I had a do-over.  Science and math have always been my interests…the engineering major would have given me a nice background beyond my pre-med major.
  • Talk to your college counselor/advisor early (freshman year)
  • If you get into an honors program in college (usually based on your SAT/ACT scores), go for it.  Typically the honors classes are smaller and are a fantastic way to build report with your professor as well as get deeper into the subject matter.  Plus, being in the honors program will further help you standout on your application to medical school.
  • Volunteer at the local hospital.  Although you may start out as a volunteer, see if you can get into the OR (operating room) as well as outpatient clinics.  This will expose you to a wide variety of practices: surgery, anesthesiology, pathology, internal medicine, family practice, OB/GYN, specialties, etc.
  • Get involved in extracurricular activities in college.  There are a ton of clubs and interest groups in college.  If you don’t find one you like, start your own!
  • Need a job in college?  Consider getting one in the research lab or at a medical school or in a hospital.
  • Consider doing summer school to get some credits out of the way.  When I was in college, 12 credits was a full-time student.  I always took 15 credits because I thought I could handle it.  (Now I cannot recommend the following…) My junior year in college, I signed up for 21 credits to see if I could handle a medical school work load.  It was a tough semester, but I did it and got a 4.0.  I wouldn’t recommend that route because you need to focus on grades… but it worked for me.
  • Apply to a lot of medical schools (in-state and out-of-state).  I grew up in Texas and at the time they had a Texas match with 7 medical schools.  I only applied to the Texas (in-state) medical schools because I knew that was all I could afford.  Keep in mind your debt burden: a $9,000/yr education vs a $30,000/yr is a big difference.  I chose an option that made the most sense to me — I didn’t want to be in debt forever.  In fact, I highly recommend reading this book: The White Coat Investor: A Doctor’s Guide To Personal Finance And Investing.  If I had that available to me, I would’ve read that in high school… re-read it in college… read it again in medical school… and read it again throughout life.  Yes, I’m constantly revisiting this book because it is that good.
  • Interviews: honestly, I can’t remember if I interviewed for medical school or not (geez that makes me sound old!).  If you do have interviews… put your best foot forward and practice interviews with your friends/parents/professors/etc.  Be positive, engaging, and professional.  Interviewers DO judge a book by its cover.
  • Once you’ve applied to medical school, sit back and wait for your results to roll in.  Honestly rank the schools you would like to go that caters to your learning style/goals/etc.  My medical school (UTMB) was one of the first in the country to incorporate systems-based learning and problem-based learning.
    • Systems-based = learn subject material based on the different organ systems vs. separate anatomy, physiology, pharmacology, pathology, etc.  (I learned based on the cardiovascular/gastrointestinal/genitourinal/neurological system, which included the anatomy, physiology, pharmacology, pathology, etc related to that system.  I thought it was a more intuitive way to learn medicine) .
    • Problem-based learning involved small groups where we would discuss medical cases, labs, clinical problems, etc.  It was a nice environment to express yourself as well as work together in a team.  This is how the real-world works where you talk to your colleagues to work through various medical issues.  It supports professionalism and engages a teamwork mentality.
  • Lastly, thank the people who helped you get here.  It’s easy to overlook your mentors, friends, professors, and family.  As you enter the medical school/medicine world, your family will learn along the way that you made a commitment to a profession that will take priority over them.  You will miss weekends, evenings, date nights, holidays, anniversaries, etc.  Not only will you sacrifice a lot to get to medical school… you’ll continue making sacrifices once you’re out practicing medicine in the real world.

AAMC fact sheet for medical schools

My Training:

My Job:

HeartWare vs. HeartMate LVAD

A couple of weeks ago, I took care of a patient who desperately needed to get better from acute CHF.  At that time, we placed the patient on an impella… but the next day, it was deemed that he needed ECMO to reperfuse his organs.  After a week on ECMO with continued impella support, ECMO was titrated down and off while maintaining 3.9L/min flow from the impella.  During the wean off ECMO, the patient had been extubated and was mentating clearly and interacting appropriately.

Fast forward a couple days after getting extubated, the patient was ripe for an LVAD.  But which one? (We ended up placing the patient on HeartWare LVAD).

YouTube: LVAD 101 – Anatomy & Physiology

YouTube: LVAD Pathophysiology


HeartWare

heartware-hvad-7x4

HeartWare brochure

YouTube vid of HeartWare (no sound) ; Vid of HeartWare with detailed explanation

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HeartMate II

heartmate-index_1

HeartMate II website

YouTube vid of HeartMate II


Summary

  • Cost-effectiveness: HeartWare > HeartMate II (UK NHS study, April 2014)
  • LV Geometry: HeartWare = HeartMate II (J CT Surg, 2013)
  • Stroke & GI bleed risk: HeartWare > HeartMate II (J Card Surg 2013)
  • Risk of device failure: HeartWare < HeartMate II
  • ENDURANCE trial: Randomized patients eligible for DT 2:1 to the HeartWare centrifugal flow LVAD versus the HeartMate II axial flow LVAD. The trial did reach its primary noninferiority endpoint of stroke free survival at 2 years (55.0% in the HeartWare patients versus 57.4% in the HeartMate II patients). Of note, a change in the design of the HeartWare device during the trial (sintering of the inflow cannula) appeared to decrease the incidence of pump thrombosis. Overall, the stroke rate was higher in the HeartWare arm whereas device malfunctions requiring exchange or urgent transplantation were more common in the HeartMate II arm. Data analysis suggested that better blood pressure control in the HeartWare arm may decrease the stroke rate and a second cohort of patients is being enrolled with more attention being paid to blood pressures management.

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Ventricular Assist Devices: Impella

“There’s an emergent case coming for impella placement.”

Impella?  I’ve read about these devices and I’m familiar with managing patients on LVADs as well as providing anesthesia for LVAD placement.  But, I’ve never done an Impella on a critically unstable patient.

YouTube video describing the purpose and placement of the Impella

Cath Lab Digest: Overview of Impella 5.0

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Anesthesia & Analgesia; January 2012. Echo rounds: The Use of TEE for Confirmation of Appropriate Impella 5.0 Device Placement.

From A&A Echo Rounds

 YouTube video similar to our axillary artery conduit (we had to go left sided bc of a prior AICD in the patient’s right chest) for Impella 5.0

JCVA, June 2010. Review Articles: Percutaneous LVAD: Clinical Uses, Future Applications, and Anesthetic Considerations.

Left Atrial Occlusion Devices

Our hospital is starting to do more left atrial occlusion devices for people who have afib and aren’t able to tolerate blood thinners. Currently, two types are offered by our cardiologists: Watchman procedure (endocardial) vs Lariat procedure (epicardial).

Lariat

It look and acts similar to a lariat or lasso.  An external guide wire with a magnet at its tip is introduced outside the heart towards the left atrial appendage (LAA). Another wire with a magnet at its tip is introduced from a groin vein and it traverses the interatrial septum to sit at the most distal point inside the LAA. The magnets “connect” and the lariat is introduced along the external guide wire and essentially lassos the LAA.

Lariat procedure
Watchman

A large occlusion device is inserted via a groin vein and traverses the interatrial septum into the proximal (base or largest opening) left atrial appendage. The device gets deployed and successfully occludes the LAA.

Watchman

PPT on Watchman from Boston Scientific

Is one better than the other?

Endocardial (Watchman) vs epicardial (Lariat) left atrial appendage exclusion devices: Understanding the differences in the location and type of leaks and their clinical implications.  Pillarisetti J, et al. Heart Rhythm. 2015.

CONCLUSION: The Lariat device is associated with a lower rate of leaks at 1 year as compared with the Watchman device, with no difference in rates of cerebrovascular accident. There was no correlation between the presence of residual leak and the occurrence of cerebrovascular accident.

Anesthesia

For these cases, we typically have a good flowing peripheral IV and intubate these patients for general anesthesia. There’s a fair amount of TEE required for placement and verification of correct positioning of the device. Both procedures require transseptal access. Watch for hypotension as there is a risk for pericardial effusion.

TEE for Lariat

TEE for Lariat


TEE for Watchman

Watchman TEE

Echo Essentials for Endoluminal LAA Closure: April 2014 Cardiac Interventions Today

The WATCHMAN Left Atrial Appendage Closure Device for Atrial Fibrillation: J Vis Exp. 2012; (60): 3671

Anesthesia and Transesophageal Echocardiography for WATCHMAN Device Implantation: December 2016Volume 30, Issue 6, Pages 1685–1692.

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From JACC: Cardiovascular Interventions
PDF Article

Percutaneous Left Atrial Appendage Closure
Procedural Techniques and Outcomes

3D Echo inside the Cath Lab – A must in LAA Closure. London, 2016.

ECHONOMY:Tools for Echocardiographic Calculations

YouTube: LEFT ATRIAL APPENDAGE CLOSURE PROCEDURE : Role of Transesophageal Echocardiography

YouTube: TCTAP 2015 SHD Live Case Session: LAA Closure

YouTube: How to image the inter-atrial septum using 3D-TEE “RATLe-90 maneuver”

YouTube: TOE in LA Appendage Assessment by Jason Sharp

**ASEcho.org 2017**

WATCHMAN:
 
Baseline TEE:
·       Full Scripps TEE protocol
·       Measure the LAA at the following views:
o   0°, 45°, 90°, 135°
·       Report the LAA maximal orifice, as well as the LAA dimensions at each angle using the following Xcelera drop-downs under “Left Atrium”:
 
·       Comment on presence or absence of atrial thrombus or “smoke”
·       Optional: Comment on LAA shape (ie: cauliflower, chicken wing, windsock, cactus)
 

 

Intra-Procedural TEE:
·       Comment on presence or absence of atrial thrombus

·       Report the LAA maximal orifice using the following Xcelera drop-down under “Left Atrium”:

·       Enter LAA device size and implantation date under the “History” section in Xcelera
·       Comment on the presence or absence of a residual leak using the following Xcelera drop-down under “Left Atrium”:
 
·       If a residual leak is present, comment on the size (mm) of the leak using the following Xcelera drop-down under “Left Atrium”:
 
·       Iatrogenic ASD with direction of shunting
·       Comment on any post-procedure pericardial effusion (compare to baseline)

 

 
Post-Procedure Discharge TTE (pt. in hospital):
·       LIMITED 2D TTE to rule out pericardial effusion (unless order specifies otherwise)
·       Spectral Doppler for respirophasic flow changes if an effusion is present

 

 
45-Day, 6 Month, 1 year and 2 year F/U TEEs:
·       Comment on presence or absence of atrial thrombus
·       Comment on the presence or absence of a residual leak using the following Xcelera drop-down under “Left Atrium”:
 
·       If a residual leak is present, comment on the size (mm) of the leak using the following Xcelera drop-down under “Left Atrium”:
 
·       Carry over LAA device size and implantation date under the “History” section in Xcelera

·       Comment on Iatrogenic ASD with direction of shunting, if still present

Paravertebral Block: basics and cancer recurrence

 

From J Anaesthesiol Clin Pharmacol. 2011 Jan-Mar; 27(1): 5–11.
Why do paravertebral blocks?
Paravertebral blocks and decreased cancer recurrence
Paravertebral block techniques
From NYSORA

But wait… what about the potential side effects/adverse events from a paravertebral block?

Why not do a TIVA with propofol and dexmetetomedine and local anesthesia via surgeon?  Where’s that study to compare?

** Update **  July 20, 2016 –> What about the PEC 1&2 Blocks as well as Serratus block?

Prolonging blockade with adjuvants:

TAVR Team: conscious sedation vs. general anesthesia

Today, we had a guest speaker Christian Spies from Queen’s Hospital in Hawaii who spoke on his experience with his TAVR team and conscious sedation vs. general anesthesia for these patients.  More specifically, we are speaking of the transfemoral route.

Keypoints:

  • Patient selection is key (consider for COPD; bad for OSA)
  • Short surgical time for monitored anesthesia care (MAC)
  • Decrease invasive monitoring (no PA catheter,+/-CVP)
  • No difference in hospital LOS or 1 year mortality rate
  • Move from TEE to TTE if MAC
  • Be prepared to convert MAC to GA (can be difficult in already tenuous patient in a crowded space under the drapes)
  • MAC agents: dexmetetomidine, propofol, ofirimev
  • Decrease pressor use
  • Develop an algorithm for MAC vs. GA and patient selection

From goinggentleintothatgoodnight.com

For my own lit search:


***Update May 1, 2018***

We at Scripps Memorial Hospital in La Jolla do most of our transfemoral TAVRs via conscious sedation assuming appropriate patient selection.  These patients still tend to be the inoperable patients not cleared for open heart AVR (aortic valve replacement).  My techniques and choices for setup have changed over time as I’ve had a chance to fine-tune my plan based on prior experiences with TAVR.  Patients typically come to the hybrid room with a 20g PIV placed by the pre-op RN.

My Setup:

  • 4 channel Alaris pump:
    • dexmedetomidine @ 0.7 mcg/kg/hr until incision –> 0.4 mcg/kg/hr until valve deployment –> off
    • norepinephrine @ 2 mcg/min (titrating on/off, up/down as vitals suggest)
    • Isolyte (IV carrier fluid) @ 200ml/hr until valve deployment –> 50ml/hr
  • Cordis neck line
    • Initially, I would have the interventional cardiologist setup a femoral venous line since they’re getting access to the groin.  However, the cardiologist would use that femoral line for emergent ECMO cannulation and I would lose my venous access and have to depend on a measly 20g PIV.  Nowadays, I try for a short 14g or 16g PIV.  If I can’t get one, the patient gets an awake right IJ cordis for large venous access.
  • Hot line fluid warmer with blood-Y tubing: this is for hookup to a large PIV or cordis line
  • Right radial arterial line
    • I started only placing right radial arterial lines because there was a case of a dissection and I immediately lost my left radial arterial line and couldn’t do pressure monitoring.  I insist on only using the RIGHT radial for my arterial monitoring.  Do not let the cardiologist only give you arterial monitoring based on their femoral arterial access.  It will only give you intermittent monitoring and there are critical points leading up to the deployment where you need CONTINUOUS arterial monitoring.  Therefore, I’ve found the right RADIAL arterial line best for continuous monitoring.
  • Facemask for continuous oxygen at 10L/mim with ETCO2 monitoring
  • For trans-subclavian/axillary approach vs. transfemoral approach TAVR, I’ll put in a supraclavicular block right after Cordis/large-bore PIV venous access for patient comfort while still utilizing conscious sedation/MAC.

My Technique:

  • When the patient gets to the room, transfer patient to OR table.  Start IV fluids @ 200ml/hr.  Cases that go well are about 2 hours from start to end.
  • Facemask O2 at 10L/min.
  • Start sedation: precedex/dexmedetomidine @ 0.7 mcg/kg/hr.  Some patients may receive 1-2mg midazolam x 1 and 25-50mcg fentanyl for radial art line placement.
  • Place right radial art line with lidocaine for skin numbing.  Place PIV with lidocaine.  If unable to get access for PIV, prep neck –> sterile gown/glove/drapes for U/S guided Cordis placement with lidocaine.
  • OR staff preps patient.  Antibiotics prior to incision.
  • At incision –> precedex to 0.4 mcg/kg/hr.  25-50mcg fentanyl PRN discomfort. 10-20mg propofol push for discomfort if needed while large sheath placed for valve deployment.
  • Crossing valve –> BP changes.  Manage with volume or levophed.
  • Valvuloplasty
  • Don’t treat over-drive pacing too aggressively when the valve is deployed.  Typically, once the new valve is in, a little volume will help normalize the BP.
  • Once valve is deployed, turn precedex off.  No other sedation or BP meds needed.  Change IVF rate to 50ml/hr.
  • Patient heads to PACU awake, interactive, and comfortable.

What techniques do you like to do?  Any suggestions on a different approach?