Author: Nanadadzie Ghansah

Am I Asleep

Recently a patient asked me if being under general anesthesia was like being asleep. Well, the answer I gave him was not wholly true and for good reason. Let’s explore that.
There are three states of decreased arousal – a coma, sleep and general anesthesia.
A coma is a period of prolonged unconsciousness due to injury to the brain. A comatose patients typically lies still with eyes closed, unresponsive to physical stimuli. At the start of the comatose state, patients may withdraw from painful stimuli or even grimace but as the coma deepens, even these reactions may vanish. EEG (electroencephalogram) shows low frequency, high amplitude waves.
Sleep is a state of very decreased arousal that is controlled by centers in the hypothalamus, brain stem, and forebrain. It is necessary for a human’s well-being. Humans cycle between two phases of sleep – REM (rapid eye movement) sleep and NREM (non-rapid eye movement sleep).
REM sleep last about 90 -120 min and is characterized by dreaming, erections, inability to move and high frequency, low amplitude waveforms on EEG.
NREM sleep has three phases and has low frequency and high amplitude waves on EEG. Restfulness is achieved in this phase of sleep. There are parts there is muscle activity and parts where muscle activity is rather low.
Lastly is general anesthesia. This is a reversible drug-induced state of unconsciousness, amnesia, analgesia, and being motionless. EEG shows low-frequency high amplitude waves. There are four phases of general anesthesia – light, intermediate, deep and profound phases. Surgery is usually performed between the intermediate and deep phases. A profound phase is achieved for procedures where the brain needs to be protected or to stop intractable seizures. As anesthesia deepens, the waves on EEG go from a decrease in number and amplitude to a flatline in the profound state.
So which state is general anesthesia closer to?
You guessed right – a coma.
General anesthesia is a reversible drug-induced coma. The sites in the brain that seem to be affected in a coma are the sites most anesthetics work to effect unconsciousness. For example, propofol induces unconsciousness by it’s effects in the cortex, mid-brain, thalamus and brain-stem. These same areas have been noticed to be affected in comatose patients.
A patient in a coma does not react to pain, just like a patient under general anesthesia, at least when the depth is adequate. Under general anesthesia a limb can be amputated, the appendix removed or even a hip replaced. Now try that in a patient sleeping at night.
Sleep refreshes. General anesthesia does not. Now, pure propofol anesthesia seems to have that refreshing effect. It has been found that propofol can help recover from sleep deprivation.
Sleep also has cycles, something that general anesthesia and the comatose state do not have.
The changes seen on the EEG during sleep differ from those seen the comatose state and under general anesthesia.
So I guess it was understandable that I did not tell the patient the whole truth. Imagine being told before your anesthetic as a lay person that you were going to be placed in a coma! With the kind of patients we see, I bet more than half of them might flee. I’d rather they believe they are going to have a nice, long nap. Ignorance is at times truly bliss.

This Thing called Wisdom

“The desire to reach for the stars is ambitious. The desire to reach hearts is wise.” – Maya Angelou

Certain recent events in a land close to me yet ever so far has made me think of the word “Wisdom” all day. This thing called “Wisdom”…..what is it?
It is defined as “the capacity of judging rightly in matters relating to life and conduct; soundness of judgement in the choice of means and ends; sometimes, less strictly, sound sense, especially in practical affairs.”

Throughout history, it is a virtue that has always been sought by many and yet few seemed to posses. The Greeks even had a Goddess for it – the beautiful Athena. The Christian Bible says one gets it by fearing God even though I know some rather foolish people who fear God! The Quran says wisdom is given to whom Allah wills – Allah must be stingy! Psychologists try to measure it and anyone who seems to have gobs of it becomes an oracle. So what is this ephemeral quality called wisdom?
Well, wisdom seems to have to do with life. Now life is both biologic and interactional. Biologic in that a body has life and is alive. Interactional in that we live by interacting with others and our environment. A deep understanding and discernment of the environment is knowledge that enhances this interaction. In the same way, a deep understanding of the self and of other humans enhances life and it is this deep understanding of the self and of others that I think constitutes wisdom.
Per my argument, wisdom is then a thorough understanding of the self and of others. It is a deep understanding of the human condition, the human psyche. A knowledge of one’s strengths and weaknesses and appreciation of what makes humans tick. Our fears, hopes, egos, desires. The wise person understand these human traits really well.
So a wise person exploits his/her strengths and always seeks to minimize the influence of inherent weaknesses, then inasmuch as they are aware of their strengths, the wise will be the first to point out their limitations and seek help for those things in which they are weak.
In dealing with others, the wise person attempts to harness the others’ strengths even as he/she reduces exposure to their weaknesses. This is very much the opposite of what most unwise people do – exploit the weaknesses of others. The wise know that that ultimately never ends well.
A wise person lives by the Golden Rule – treat others as one wishes to be treated. (That is why maybe the Bible says “The Fear of God is the beginning of wisdom).
A good illustration of my theory is offered by the biblical story of the Judgement of King Solomon. Solomon was king of Israel probably from 970 – 931 BC and reputed to be the wisest king that ever lived. The story involves two women who lived together. They both had recently delivered. One slept on and suffocated her baby. On waking up and realizing her baby had died, she hid the body and then claimed the other woman’s baby was hers. This led to a fight and the case was brought before King Solomon. He offered to cut the baby in two and hand each woman one half. At that, the real mother asked him not to while the other woman wanted him to go ahead and divide up the baby. He handed the baby to the real mother. A deep understanding of a mother’s love helped the king make this amazing decision and illustrates his wisdom.

Thus if wisdom is a deep understanding of the human condition, then it surely can be acquired then understanding oneself and others is something than can be learnt. That is the good news. The bad news is that the majority of people do not know who they are and are unwilling to so much as understand the next person. Is it any wonder that wisdom is so scarce?
She is out there though…Wisdom is…trying hard to draw out attention…”crying out loud in the streets, at the city gate, even in the public square”…telling us to know ourselves and understand our fellow men and women…if only we would listen…

Dignity

“Dignity consists not in possessing honors, but in the consciousness that we deserve them.” – Aristotle

The Olympic Games ended tonight and I enjoyed every minute of them. I know most Brazilians in the favelas that dot the Rio landscape were unwelcome guests at a party in their own city. That is sad but a true fact of life in a world where many find themselves as unwelcome guests. In spite of all that, the games offered not only entertainment but several life lessons.
For me, one of the most compelling is the lesson taught by the dignity and poise of the US track star, Allyson Felix.
In July, due to a nagging ankle injury she suffered in April, she lost in the 200 m qualifying race. The athlete who beat her fell/dove across the finish line. Her dream to defend her Olympic gold medal from 2012 was dashed. She held her head high and consoled herself with the 400m, 4x400m and the 4x100m relays.
On Monday, August 15th, she lined up to run the finals of the Women’s 400m. Running in Lane 4, she had the chance to cross the finish line and claim a gold medal when the Bahamian star, Shaunae Miller, fell/dove across the finish line to claim the gold. Allyson was beaten by 0.07s. She was devastated but kept her head high.
Three days later was the women’s 4x100m heats. Allyson was in at the 3rd spot. Just as she got ready to hand the baton over to English Gardner, she was bumped by the Brazilian runner in the next lane causing her to lose her balance and miss the exchange. Even with that, she kept her composure and asked English to finish the race. She did and the US team appealed. They won the appeal and got the opportunity to rerun the race. They qualified and ended up wining the gold.
Dignity in the face of adversity is something few can muster. Those who do it always shine as bright as the morning sun, showing us all that it is possible.
Allyson injured her ankle in April, lost her dog in June and her grandfather in July. Still, she worked towards her goal. The 400m final loss would have discouraged many and yet she kept on. The 4x100m bump should have put the nail in her coffin and yet she had the presence of mind to tell English Gardner to finish the race.
She faced all these adversities with poise and class, always displaying a certain strength of character and dignity. That poise and dignity even translated to how she ran – graceful and effortlessly.
So what is dignity and why does it matter?
Well, dignity keeps one above the fray of life and gives mental clarity to the daily chaos. It is defined as having self-respect and a sense of pride in oneself.
Life is hard and most of the time, people and experiences seek to strip away this sense of pride in one’s self. It is up to the individual to constantly reinforce a sense of self-respect. It is worth reinforcing because it shows that even though one may not possess the honor, it is something that is deserved. So since one behaves like being deserving of the honor, sooner or later, the honor comes along. If dignity is lost, it is like saying that one does not have the honor and does not deserve it. How sad!
Thus even though she lost by a hair in the trials, lost by 0.07s in the 400m and was bumped in the 4x100m, she didn’t despair. She knew that no matter what happened, she deserved the honor and the honor will come. And did it come!
After 16 days, the games are over and life goes on. The lessons learnt this week will stay with me and should I trip and fall, I hope I pick myself up with dignity and class. Just like Allyson Felix would.

In the Simulator

There is something irreversible about acquiring knowledge; and the simulation of the search for it differs in a most profound way from the reality.”
– J. Robert Oppenheimer

A Simulator is defined as:
– a machine with a similar set of controls designed to provide a realistic imitation of the operation of a vehicle, aircraft, or other complex system, used for training purposes.
– a program enabling a computer to execute programs written for a different operating system.
Simulators are used extensively in the military, aviation, medicine and other industries for training purposes. With or without actors, they can be used to create scenarios for training. Each scenario is usually managed by the person or team who created the scenario and can be watched live and/or videotaped to be watched later for evaluation. Events in the scenario can be altered to challenge the participants.
Simulators are now used extensively in medical training. They are also required some specialties for recertification and for continuing education.
Being old-school, I wasn’t a big fan of the whole simulation thing. I believed and still do that, for training purposes, a real live scenario beats a simulated one hands down. However a real live scenario is not always available. That is where a simulated scenario is invaluable for training purposes. It is also great for testing one’s reaction and for revising training. For my recertification a few years ago, I had to spend some time in a simulator and in the process, became a believer. It surely has it’s place.
Recently, I have been thinking of taking another simulation course. As I reviewed the available options, I had a thought. We are in the mother of all political seasons. The presidential elections are around the corner and with that the debates. I thought of how we choose who we think deserves to occupy the highest office in the land.
I am sure people vote along party lines, by race, by looks (I’m not kidding!), by their stand on social issues like abortion and gay marriage and so on. Sometimes their experience may sway us. This year, it’s crooked versus crazy!
Even though what they say and promise should not be that important in our decision making, even though words are cheap, they do play a huge role. Unless it is an incumbent, no one has had the prior experience being a president so we are really dealing with the unknown.
So then I kept thinking – what if we could get our presidential hopefuls into a Simulator and have then manage some “crisis” situations?
So, back to my candidates.
We get a simulator and create scenarios that mimic crisis situations for a US President.
We get actors to play all the different parts – Congress, the Supreme Court, the Tea Party, Teachers’ Union, Putin, ISIS etc.
We get the candidates, one after the other to manage these scenarios and see how they perform.
The candidates will know to put their best food forward since the whole world would be watching. It would be impressed upon them to take the scenarios seriously.
Having been in a simulator myself, I can honestly say that it is rather difficult to mask your real abilities during these scenarios.
If they are well written and planned, they can be so real as to elicit reactions from the participants that reflect who they really are in crisis situations.
Remember Hilary’s “3-am ad” against the then Obama? Well we could simulate that.
We could simulate an economic crisis, wars, attacks, conflicts with Congress, natural disasters and so on.
It might just be a better measure than empty words and promises.

Are We to Blame

I see this in my hospital all the time and I am sure it is seen by anesthesiologists all over the US – how much sicker our patients are.
It is also evident that surgeons are pushing the envelope further and further. Patients are sometimes showing up for surgery whose short-term prognosis (don’t even consider the long term) makes one question the wisdom in a surgical intervention.
Then is the rather formidable (no pun intended) issue of morbidly obese patients who need their day in the OR.
We as anesthesiologist seem to take all these challenges in stride and in most institutions, the daily schedule is hardly affected as these challenging cases are shuffled through.
We complain about the wisdom of surgically intervening in these instances but since the show must go on, we do what we have to.
I dare to blame us though for these circumstances. Bear with me and I’ll make myself clear.
Imagine an institution where the anesthesiologist cannot manage ASA IVE cases or secure the airway in that 550 lb patient or get that patient through an exploratory laparotomy who just had a myocardial event. Just imagine!
What do you think the surgeons are going to do? Three options – take their cases elsewhere, stop taking these patients to the OR or hire an anesthesiologist who can or is prepared to do these cases.
What if this was a national phenomenon with all anesthesiologist? Maybe the sickest patients will not show up for surgery!
However, we have a specialty that prides itself in being progressive, being evidence-based and seeking to constantly improve itself.
We attract the smartest and most innovative minds.
We seek and employ CRNAs who are bright, focussed and unafraid.
The results – the ability to manage whatever the surgeons pitch at us! So they keep throwing and we as trusted batters, always hit the home run.
600 lb? Bring it on!
EF of 15%, cirrhotic and anuric? Bring it on!
Hematocrit of 15? We’ll fix it intro!

I think the realization has hit us so most anesthesiologists have stopped complaining and are just keeping on because maybe, just maybe, we are to blame, but in a good way.
No matter what we allow into an OR though, we always have to bear this in mind:
“I swear by Apollo Physician and Asclepius and Hygieia and Panaceia and all the gods and goddesses, making them my witness, that I will fulfill according to my ability and judgment this oath and this covenant…I will apply…(treatment) for the benefit of the sick according to my ability and judgment; I will keep them from harm and injustice.”