Tuesday, March 15, 2005

why we need to turn down the howard stern and start talking in the OR

i was reading an interesting article on when anesthesia fails

he mentions briefly about how in certain spinal procedures the neuro monitoring requires anesthesia levels be adjusted. when i read that my heart sang, because in my former life i was a board-registered neurodiagnostic technologist, and this little-known issue was my whole life.

i worked for five years around southern california doing intraoperative monitoring during various brain and spinal cord surgeries. there was so much time spent arguing with surgeons and anesthesiologists over gas levels during surgery, which often ended up being just a masturbatory gesture because they couldn't see how their levels of inhalational gases left my signals weak or non-existent. in the end, when we failed to communicate or agree on how to proceed, the patient suffered because they weren't getting the best standard of care during a sometimes very risky procedure. i was always frustrated because the anesthesiologists just needed to shut up and do what i told them to do, and for some reason they didn't like being told that.

which is why i knew i needed to get the fuck out of my dusty corner of the OR and get over to the sterile side of the room. they'll listen to me then, those bastards.

but i digress.

somatosensory evoked potential (SSEP) , motor evoked potential (MEP) , EEG and EMG monitoring used during surgical procedures can be very useful when done properly (here's an article on intraoperative monitoring 101 for those interested). the problem is, to be maximally effective there must be complete cooperation between patient, surgeon, tech and of course, anesthesiologist. it's not just a matter of keeping inhalational anesthetics within a range that will lend itself to accurate assessment of signals. because the techniques are varied for different types of procedures, the surgeons also need to be aware of which modality will be used and what their role is in assisting the tech.

for instance, during procedures in which pedicle screws are placed, EMG can be used to verify that the screw is not in contact with any nerve roots. it's simple enough in theory: place recording electrodes on muscles that correspond to the dermatomal levels in question, then take a monopolar stimulator (or a nasopharyngeal EEG electrode for the creative), contact the screw hole or screw itself, and send a small current through. if there is a muscle response below a certain threshold, the tech can tell the surgeon that they might want to re-place that screw. the surgeon must know how to place the stimulator and be in constant communication with the tech about what level is being stimmed, and whether they have dropped the stimulator on the ground, again. pedicle screw stim also requires that there be no muscle relaxants on board. since this is often done concurrently with SSEPs, the anesthesiologist must now make sure that both inhalationals and muscle relaxants are within the range to ensure a true positive or true negative result. being anesthesiologists, they don't like that. so they yell, make snide comments, ignore my requests, or lie to me, which is kinda dumb since 1) i can read the gas levels on the machine and 2) it's not hard to tell when someone is paralyzed when you are testing their neuromuscular junction.

i understand their position- it makes their job much harder and increases the chances of the patient having some bad memories of the surgery. but it's important if the surgeon wants to make sure their patient won't have post-op nerve pain or worse from a mis-placed screw. everyone benefits from a good outcome, and everyone gets the shaft from a bad one. which is why you'd think the surgeon, who has a vested interest in their patient not waking up with pain or neurological deficits, would help us out here and maybe advocate for the tech to the gas man in the evnt of any trouble. but you'd be wayyyy wrong there. even though they often are annoyed by their drug-pushing colleagues, a little tech buzzing around them having the gall to ask for a little fucking help here is much more annoying.

circulating nurses, scrub techs and slimy instrument reps weren't much help either, preferring to ignore me unless my shit was in their way.

thus, although pedicle screw EMG is ideally a five minute test, i never had as many problems with any other modality than with this one. and on top of all the screaming going on, something technical always went wrong: a cord was too short, or not plugged in; 60Hz interference in the room completely obliterated the EMG signal, so everything was sequentially unplugged until the offender was found; the stimulating or recording electrodes didn't work; or as mentioned before, the fucking surgeon dropped the stimulator.

communication during surgery is critical. i know that seems like an obvious statement- but with the cavalier, military-style attitudes inherent in the OR, it was frowned upon for a lowly tech to direct anything, even if it was required for us to do our jobs properly.

in an effort to change this and increase communication between neurodiagnostic tech and the physicians that loathe them, a wonderful colleague of mine (a complete hardass if there ever was one) developed this: The Los Angeles Anesthesia Friendliness Scale.

LAFS was a great way to kill two birds with one stone: get the anesthesiologist to do what you need them to do, and use it to feign interest in their specialty and all its crazy sleepytime drugs. they like that because it makes them feel important and special after being yelled at by surgeons all day. when you make them feel special, they will become your best friend and then everyone is happy.

i must end this by saying that even though anesthesiologists made my life a daily hell for five long years, i can forgive them now that i'll never be stuck behind their stinking machines ever again. you can go back to your wall street journal guys, cuz i ain't mad at ya!

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