The Michael Jackson Edition
A doctor’s formative years are often telling. If during the first year of medical school you fall in love with gross anatomy, you really have no choice but to pursue a career in surgery. After spending a year exploring the new and fascinating territory that is your personal cadaver, dissecting along tissue planes formed or nerves stretched as an embryo, some of us just can’t see putting it all aside. Very soon, one realizes that the only physicians that need to know much about anatomy are surgeons and gynecologists. Everyone else is pretty much practicing applied pharmacology. Doesn’t matter where the iliopsoas muscle lives or if it’s your hypogastric plexus that’s pathetically paretic–write the script and see if the patient is better in a couple of weeks. If you love anatomy, if you pine for those early mornings smelling the formaldehyde perfume of your best dead friend, you’re going to be a surgeon.
Similarly, anesthesiologists are practicing practical physiologists. In the physiology lab, the subject (woof!) is attached to an array of monitors as the recently pubescent physician infuses various pharmacologic agents or inhaled mixtures of oxygen plus whatever. Agent X goes in the vein, the heart rate goes up and the blood pressure goes down. Reverse the effect with agent Y. See what happens when you add a dash of inhaled agent Z. At the end of the lab, give the happy subject a treat. Seven years later, anesthesiologists are expertly doing the same thing to people. Except for the treats.
During the formative years of every physician, but anesthesiologists in particular, one learns a great deal of respect for people physiology. People are predictable, but not perfectly so. We are men, or women, or children–not machines. Herein lies the challenge. Almost every time you give the patient your dependable drug, he responds as expected. Almost every time. It’s that “almost” that challenges every anesthesiologist. The occasional patient that responds not quite as expected, a little too emphatically or a bit reluctantly. Adjustments are titrated on the fly. The rare, but really exciting, individual that displays a completely inappropriate response, such as anaphylaxis. It is for this reason, this subtlety, that anesthesiologists are carefully trained, not born. Like the practice of surgery, it is not a skill that can be mastered by reading the textbook, even if you’re really smart. The really smart/experienced anesthesiologists know this especially well. Then throw in the fact that the patient is having the trauma of surgery that the anesthesiologist must compensate for. Some surgical procedures are more easily compensated for than others. Some surgeons are more easily compensated for (see earlier blog post “Never Say Oops in the OR“).
The practice of anesthesiology, however, suffers from one towering challenge above all; a challenge unique among all physicians. Anesthesiologists must be perfect. It’s a problem. No other physician is held to such a high standard. If you come to your surgeon with a tumor blocking your bowel, rest assured that he or she is going to do everything in his/her power to extirpate the neoplasm and restore your comfortable continuing existence. But there will be pain. And a scar or two. Perhaps you’ll have some hiccup in your ability to digest really deep dish pizza from now on, but you’re happy to be alive. Same with every other field of medicine–except anesthesia. The practice of an anesthesiologist is to take a perfectly mentating person and put him into a profound coma. But just for a while, then magically reverse that comatose state and restore the patient immediately to complete normalcy, preferably without any trace of the experience, not even nausea or a missing molar. No fair if the patient is just about the same as before he had the life-saving procedure; say, he can remember almost everybody from his high school graduating class but has a slight problem coming up with the name of that girl he married. Not good enough. The patient must awaken happy, comfortable–normal. Best case scenario, the patient emerges from anesthesia by completing the punch line to the joke he was reciting at the time of anesthetic induction three hours ago. Extra points for an exceptionally satisfying dream during the procedure. Nothing less than a perfect return to the pre-anesthetized state is acceptable.
As one can imagine, this can, at times, be a bit of a challenge. Consider the inconvenient fact that nobody who’s normal lays down on an operating table. Patients are sick, many very ill, some with years of undiagnosed/uncared-for illnesses now being subjected to the significant stress of an operation. The most stressful thing this patient experienced in the previous ten years may have been lifting the television remote control. Occasionally, the patient is horribly, critically ill. Doesn’t matter–the anesthetic must be perfect, and certainly not the cause of even the sickest patient’s demise. The surgery is allowed to kill him, but not the anesthetic.
So if you’ve ever had an operation, and you didn’t spend the entire time screaming, and you woke up pretty much thinking like your self thought before that whole operation thing: Thank your anesthesiologist. Send him a card. Or actually pay the bill. Whatever. Just don’t try it at home.
the Goat Rodeo blog 
Excellent essay. Keep up the good writing. I did not know that you were such a good writer as well as an excellent anesthesiologist. Cheers! Vinod and Sunanda Deshmukh
Thanks for reading and your kind comment.
I have had 6 major surgeries (one emergency colon resection) and I am so thankful for the anesthesiologists who took care of me. I told a family member who is an anesthesiologist that it must be very comforting for her patients to be looking into her beautiful face just before dozing off in the OR. We are so proud of her and I would like to say “thank you” to all anesthesiologists…we would be in deep trouble without you!
Well said. Thank you for your comment.
Thanks for your great comment.
Wonderful read. Best explaination of we as anesthesiologist do. Thanks.
Thanks for reading.
Shouldn’t we really be thanking the CRNA since more than 9 times out of 10 they are the ones actually monitoring us for the procedure. It must be really hard having to be the only truly perfect doctors getting your coffee and donuts while a mid level provider takes care of your patient.
Agreed. Next post “Sunday at the VA with a CRNA”. Stay tuned. Thanks for your comment.
Someone’s mad…
I on the other hand think diffrently, anesthesia is stupidely easy….the anesthiologists expertise comes in need in complex surgeries!!
I was a respiratory therapist in Quebec, Canada for ten years. And while working with over 100 anesthiologists i noticed that they actually did not taylor the anesthetic to the patient, they cared about billing codes more than starting on time…In quebec it’s the RRT that is the delgated assistant of the anesthsiologist. We are not equivalent to CRNA but have one thing in common! And it’s baby sitting the patient for hours while the MD is playing with his stock market…And give orders by phone without having the descency of checking on his patient once on a while. That is without mentioning the liberal mentality of care and not applying continuity and standard of care.
Electronic charting in the OR, meaning BPs and vital and everything else rlated to anesthesia, fluids, drugs login or out personnel….is a taboo subject around here, because it would prove that 95% of the anesthetic maintenance and emergence rather more ofter than never are done by the RRT! And also hamd written charts are the perfect way for anesthesiologist to hide their mistakes, taylor the chart to their favor…Anesthesia in Quebec does not have any transparency. Anesthesiologists are way over paid for what they actually do, and RRT are under paid for what the acually do. Anesthesiologist are money hungry making machines, they double book them selves in more than one room which is illegal here in Qc, double bill certain procedures like regional procedure incase of a re-operation without touching the previous catheter bill procedure when outside of the hospital working in a clinic while being covered by a collegue, and rectify the dates and time to avoid billing conflicts.
I can very humbly say that i can wake up a patient without pain with or without any regional anesthetics, without coughing and fighting than any anesthesiologist i have worked with… Further more when it come to deep, light or precedural sedation that we are allowed to perform by surgeon orders, we are way better at it than anesthesiologists, 3 things happened when it was them that performed sedation, Apnea, patient jupmed of then bed or cases got cancelled because of lack of time… Suffice to say Surgeons requested the RRT, we are more effecient clinically and especially technically as an anesthesiologist in Qc does not even know how to perform or troubleshoot an anesthesia machine and god help the patient if the machine is a primus!!!
RIP to my old profession, which was the best decision of my life, to leave it!!!
Thanks for your comment.
Glad you left the profession…as an anesthésiologistes from Quebec I wouldn’ t want to work with you with such an attitude…or maybe someone showed you the door?
Onceuponatime….. quite scathing… I think I have a sense of where you used to work.
What an arrogant attitude try to be a good human being
Please don’t sweep all anaesthesiology doctors with same broom stick
The difference between what you did in Canada and what I do as a CRNA is that I’m equivalent to an anesthesiologist and there are none in my facility, nor are none needed. We do everything from open and endo AAA, major vascular to plastics and everything in between except neuro and hearts.
What a terrific article. Thank you very much for posting it. I am a practicing board certified anesthesiologist with 15 plus years under my belt after residency training and I still get nervous or worried with every case and prepare for the worst. Thankfully I have the hard won skills now to make it look “easy” to the surgeon and supporting staff. I try to be humble but frankly I take a huge amount of pride in how difficult this profession can be. I love what I do and am proud to be part of a team that makes difficult things happen !
As an anesthesiologist I have two comments to add: those of us who do peripheral nerve blocks, epidurals and spinals on all ages, invasive access and must understand the potential impact of what the surgeon is operating on, on the physiology of the patient – we HAVE to know anatomy.
Personally, the anesthetic is a prescription and as such, I have many modalities to employ which I fit to the particular patient. While I have known people of differing titles who tend to do things by rote ie only one or two ways of doing an anesthetic for a particular type of surgery, I use procedures and medications to fit the patient. That is why I spent four years in medical school as well as surgery and anesthesia residency – to provide the ultimate care for my patients.
Thank you for your excellent comment. As for the need to know anatomy, I can only hide behind the excuse of writer’s hyperbole. Your example is valid, as well as that of every radiologist practicing general radiology, and others require a knowledge of anatomy; I was actually referring to the joy of anatomical dissection, but so it goes.
Your second paragraph makes an excellent point that I hope to address in an upcoming post (Anesthesia isn’t Easy-3). Believe me, I have come to learn the subtleties of a good anesthetic in very personal, painful terms. Best wishes and thanks for reading.
Thank you’re CRNA!!!