The Ether Way

on Memory and Reminiscence

We have, in the next place, to treat of Memory and Remembering, considering its nature, its cause, and the part of the soul to which this experience, as well as that of Recollecting, belongs.  -Aristotle 350 BC

The clinical Anesthesiologist's interest in memory and its formation is that of a lmberjack to the forest. Anesthesiologists are clear-cutters, ad not typically too engaged in the niceties of the eco-system. In this case we might reasonably be forgiven, since the failure to abolish memory during a general anesthetic is at least a therapeutic failure and at worst, a terrible (actionable) trauma for the patient. Fortunately for us, memory formation/consolidation is eliminated far more easily than movement, which means that the anesthetic depth (related to the concentration of anesthetic) required to keep the patient "still for the knife" is much greater than the concentration required to interrupt memory formation. So far, so good. An interesting digression; movement during surgery can be initiated from the spinal cord in the absence of any brain activity. (Think of A chicken running around its  head cut off; well, maybe don't...) We know this from experiments involving isolated head and body perfusion experiments, (not human!) where the body and the head are separately anesthetized. So when the surgeon yells "the patient is awake," the wise anesthesiologist knows that non-purposeful movement under anesthesia does not imply awareness, (but certainly doesn't preclude it...)

Of all animal traits, the three most philosophically intriguing are awareness, consciousness and memory. Of these, memory is certainly more derivative; Invertebrate worms demonstrate memory (they can learn) without any sense that they are conscious or aware. The taxonomies of memory, while being the subject of heated intellectual conflict, all seem rather comfortable, even intuitive, to the casual spectator. Memory is most superficially parsed into short-term and long-term, which we know have different physiological mechanisms (we know this in great measure due to the work of Dr Eric Kandel, which won him the Nobel). When you remember a phone number long enough to dial it, you are using short term memory. This involves chemical changes in synapses. If you remember your home address and telephone number from last year, you are using long term memory. That involves changes in synaptic connections. Long term memory gets sliced and diced lots of different ways, based mostly on our human classification of cognitive function. Explicit memory is memory which is subject to conscious recall (like the name of your high school sweetheart, or your anniversary). Implicit memory is not (for instance, riding a bicycle, recognizing a face or voice). Explicit memories are further sub-divided along various functional lines; intellectual memories, memories of events, etc, etc. WIkipedia has an unusually good introduction to the science of memory.    Here also, is a link to a video introductory lecture on the neurobiology of memory from the MIT Distributed Intelligence project:  http://mitworld.mit.edu/stream/146/

Contemplating Quality.

"It was all those people in the cars coming the other way. It's just that they looked so lost," she says. Like they were all dead. Like a funeral procession."

 

Robert Pirsig. Zen and the Art of Motorcycle Maintenance.

I've been thinking a lot about quality lately. For two decades, I have accepted the industrial definitions of quality advanced by Deming and his disciples, and the evidence based outcomes-driven practice style that this model drives. I and my colleagues have written about limitations resulting from a slavish devotion to this model; the stifling of innovation being one  and the reliance on weak data and the devaluation of individual experience being another. While my leadership responsibilities have kept me focused on measurable outcomes as a context acceptable to all stakeholders, I observe a frustrating flatness creeping into the medical enterprise and I have come to believe that it derives from what I now call "spread-sheet medicine," and its major driver, "quantitative quality." Quantitative quality is the narrowly focused equating of quality with clinical outcomes; morbidity/mortality  and costs.

This quantitative fixation is a classical notion, best defined by the aphorism "If you can't measure it, it isn't real." Of course, that's nonsense; just ask any musicologist or art historian. Romantic tradition understands that there is non-quantitative Quality, and that it is vital to a meaningful life. Opposing the quantitative quality is this other view of Quality; the artistic or romantic view; let's call this "values quality"

I prefer to think of quantitative outcome assessment in medicine as "effectiveness" rather than Quality. It is an important component of medical quality but it is by no means the only consideration. This is not a trivial distinction. Like all discussions or disagreements, how you frame the debate defines the results. Management people say, "you can't manage what you don't measure..." They are highly motivated to limit the scope of quality to things they can "get their arms around," in order that they may discharge their fiduciary responsibilites to hospital owners and payers. The masters of industrialized health care; the money men, aren't interested in values-quality. As a US Senator once counseled me, "The marketplace won't pay for compassion." Nor in my experience, will they acknowledge the legitimacy of any intangible values; unless, of course,  it's their turn in the bed.

Clinicians, on the other hand, find the quantitative quality paradigm to be artless; or as my 17 year old would say, "it's soul-sucking." It's not that it's not important. It is. But, while being necessary, it is not sufficient. Quantitative quality may drive systems of care, but it will never inspire caring. And, as Pirsig points out, without caring there can be no true Quality. But our dislike of being managed; of being part of the "machine," is not in itself sufficient justification for seeking to modify the paradigm. We have to have a better reason than that if we expect to persuade ourselves or anybody else that it's time for deep reconsideration.

Strength for the Journey

Westley: Why can't I move? Why am I up against this wall?
Fezzik: You've been mostly-dead all day.

-The Princess Bride

In some unfortunate folks, the "arch" of the aorta becomes diseased. The layers of the aorta split apart;  a separation which spreads under the pounding of blood ejected from the heart. Over time (sometimes quickly) it can result in stroke, catastrophic heart attack, or sudden bleeding into the chest as the split advances to the branching arteries leaving the aorta for their target organs. This is called an aortic arch dissection. Alternately, the aorta can weaken, bulging like the bubble of an inner tube into an aneurysm which, if it ruptures, is almost always rapidly fatal.

If the proximal arch, the segment between the heart and the blood vessels branching off to the head and brain, is involved (type 1 dissection), the treatment is urgent surgery to replace that section. If the dissection involves the aortic valve at the proximal end (close to the heart) the valve is usually replaced as well. At the distal end (away from the heart) branching blood vessels perfusing (feeding) the heart, brain and head are sometimes involved; these then, have to be disconnected, and anastamosed (connected) to the woven dacron or gortex artificial tube which is used to replace the sick aorta. In order to do this, the circulation must be stopped; no blood flow at all...

Impaired physicians-administrative issues

"Out of timber so crooked as that from which man is made nothing entirely straight can be built"
Immanuel Kant, 1784.

In the 1980's, Michael Swango, a physician trained in Illinois, was convicted of intentionally poisoning co-workers and spent five years in prison. Despite this, after his release he managed to forge documents enabling him to acquire residency positions at various academic hospitals, where he murdered an estimated 30 patients.

In 1986, Congress passed a law entitled "The National Healthcare Quality Improvement Act." (HCQIA) The main purpose of the act was to create a national database of physician incidents, the National Practitioner Data Bank (NPDB) to block the migration of incompetent and impaired physicians, like Swango, from state to state "under the radar" of institutional scrutiny.  Despite imperfections and dificulties, the HCQIA has withstood the test of time, surviving two decades essentially unchanged.

We are all well versed on its' reporting requirements; (i.e. suspensions longer than 30 days, privileges "voluntarily" relinquished under investigation, judgments or settlements greater than $5, etc). It also indemnifies physician leaders who participate in peer review from legal liability for their "good faith" efforts, From the facility/medical staff perspective, a helpful (and sometimes vexing) aspect of the law is the requirement of institutional confidentiality. The reasons for this provision are clear; it balanced out the otherwise oppressive aspects of the law for practitioners, afforded affected practitioners a semblance of privacy pending resolution of their due process appeals, and decreased the motivations of competitors and enemies to make baseless allegations for business advantage.

the common dark of all our deaths...

-On the Road, Jack Kerouac

I have been involved in surgery for thirty years, and I am amazed daily that people will willingly submit to it. There is no greater example of the triumph of hope (and trust) over fear. A wise surgical professor at Wisconsin once lectured to our class that “an operation represents the substitution of surgically induced pathology for the patient’s own pathology, in the hope that the surgical pathology will be better tolerated.”

As I write this, I know that tomorrow, I will be caring for a patient in whom a neurosurgical colleague will be placing deep brain stimulators for Parkinsonism. The patient will be somebody who has such severe, medication resistant, brain-mediated joint rigidity and muscle tremors that going out to dine is more-or-less out of the question. Most of the people so afflicted avoid being seen in public at all. He will come to us, willing to undergo brain surgery while wide awake, in the hope that we can alleviate his disability. Sometimes the results are miraculous. Sometimes not.

So called "functional" or awake, neurosurgery is performed for a variety of reasons. Usually, it is because the procedure requires the active participation of the patient in pinpointing areas of the brain; speech, motion and such. Normally, I have a cart full of drawers full of vials full of clear liquids with magical properties that allow me to modulate (and most typically abolish) my patient's perceptions, memory, and consciousness, and thus, overcome their pain and suffering during surgery. But I don't get to use them here. (Well, the liquids would be magical, except our understanding destroys the magic; "Mark Twain's experience comes to mind, in which, after he had mastered the analytical knowledge needed to pilot the Mississippi river, he had discovered the river had lost its beauty." -Zen and the Art of Motorcycle Maintenance, Pirsig. (see also Sleep and Death are brothers).

Impaired Physicians Part III- Clinical Competence, a Moving Target

Of all impaired physician issues, incompetence is the toughest to manage. The "dry lab" component of competence is obvious; required didactic certifications must be maintained, CME's must be completed, licenses must be active, minimum case numbers must be documented. The problem arises in the crucible of clinical practice. Like everything in life, physician competence resides on a continuum, from inspiring to notorious. Competence changes with time; sickness or senescence, improvement with experience or intercurrent training, and importantly, shifting standard of care. To make matters more difficult, competence can be contextual; I might be an outstanding neuro-vascular anesthesiologist, but weak with liver transplantation. So, how to judge?

The answer is outcomes. As in  evidence based medicine, good outcomes are the proof of good practice. Competence is generally considered adequate from an institutional and leadership perspective if bad outcomes don't "fall out" in Quality Assurance activity. There are sentinel events (major complications) or patterns of lesser complications that serve to focus leadership scrutiny on the affected practitioner. Here is a situation where once again, insight is key.

Impaired Physicians Part II - Insight

There are two psychological traits that are important to the successful practitioner; empathy and insight. Empathy allows us to identify with the suffering of others; it motivates us to perform at a high level. Insight allows us to process uncomfortable realizations regarding our ineffective, harmful or embarassing actions. "Good judgment comes from experience, and experience comes from bad judgment;" but only if there is motivation to get it right, and insight to allow honest assessment of when we do (and don't) get it right.

Unfortunately, neither empathy nor insight are required to succeed in medical school and residency. In training, empathy can be replaced by fear; fear of disapproval or dismissal. And insight can be replaced by external direction; the non-insightful are frequently good at following instructions. At least, those that aren't (true sociopaths and the like) don't usually make it into medical practice.

Impaired Physicians

The public imagines that doctors protect each other. The reality is far more complicated. Medicine, at least hospital medicine, is a fishbowl. If Doctor Y turns up for rounds with a black eye on the fifth floor, we are likely to hear about it (in gossipy tones) in the OR that same morning. Think of a hospital as a big cubicle barn without the barriers. Nevertheless, disciplining physicians is tricky business.

First, my credentials. I have served as Chief of Staff at two hospitals, and have been in hospital leadership for two decades. I have had death threats against me and my children, almost certainly as a consequence of physician disciplinary activities during my time as chief of staff. I have been involved in dozens of disciplinary actions at all levels, and in retrospect, I've been generally satisfied with outcomes for patients and physicians.

"There's a lot of stuff goes on."

  -Tony La Russa


A favorite anesthesia blogger, T of Anesthesioboist, recently compared anesthesia to cooking. Not an inapt comparison, but I've always thought anesthesia was most like...baseball. There are the obvious reasons (I'm a guy, I was a baseball fan, baseball is like all of life..); no, wait-hear me out on this one.

Anesthesia is like playing right field.

Firstly, batting is like an anesthesia induction or emergence (or like coming off bypass); it is an acutely intense activity which requires complete concentration on multiple rapidly changing variables in the midst of distraction, if one is to be successful. It is an intensely physical activity (go ahead-try to manage a cardiac induction with a broken finger or sprained ankle) with relatively narrow tolerances. Hitting and anesthesia are completely honest activities; there is no pretend, and little that is relative; either you got it right or you didn't.

The maintenance phase of anesthesia is like playing right field; although it looks relaxed, it's anything but; peering in for signals as to positioning, scrutinizing the batter's stance for clues to his intentions. Examining the baserunner's positions; who's fast enough to tag up and beat a throw, who's slow. Ignoring or engaging the crowd. Preparing to move to a hit ball...every pitch is an exercise in focused watchfulness and pre-positioning. That's the price of playing in the big leagues. And being a "gold glover" means virtually never committing an error; One mistake in a thousand plays is barely good enough. The chances that any given pitch will result in the need for decisive action by the right fielder are low; maybe routine fly balls two or three times a game. Once every five or ten games maybe a big move; shag a fly and a long accurate throw to the cutoff man. Once or twice a season, the game hinges on your move; hero or goat? And if you get it right, the pitcher might come by in the locker room and thank you for saving the game; or, more likely, he might be too busy talking to the press about "his" win.

Whack-a-mole!

No mysticism today, but a meditation nonetheless. I have in mind the once-again confused state of matters for the patient with cardiac disease presenting for non-cardiac surgery. When I left off in my thinking, snug (and smug) in my self-assurance, it was January 2005. Life was good! Eagle and Fleischer (and all the rest..) had published, in 2002, a lovely practice guide stratifying risk by extent of procedure, severity of risk factors, and had even published a sexy little flow chart suggesting how to proceed. To make matters even better, intervening publications highlighted the protective effects of Beta-blockers, statins (who knew they had an acute protective effect?), and the interesting observation that many post-op MI's smolder (elevated i-troponins for hours or days) before they burst forth. (At least, that's one of the off-hypothesis impressions I took from this data.) McFalls et al did their remarkable study (CARP) in the VA system (where else in America could such a thing be done?) where they took a bunch of veterans with known coronary artery disease of sufficient severity to warrant intervention (CABG or PCI), and randomized them to either have their hearts fixed before abdominal or thoracic aneurysm surgery, or after. No kidding-you can look it up! Here. No differences in outcomes! No differences!(They eliminated critical aortic stenotics (Duh!) and Left mains (hmmm.) Lots of letter-to-the-editor chatter about this study, as befits a work of this breathtaking hypothesis and conclusion. You'll have to read them yourself...