Monday, December 19, 2011

How May I Help You?

     Yesterday, my husband, Brad, and I decided to put up our Christmas tree. It's a fake, pre-lit one we bought several years ago. We made a special trip back to our old house in Atlanta last weekend to pick it up, and I had really hoped to have it up before evening. We decided to put it up after breakfast. Brad lugged the giant carton upstairs after we finished eating, and as he was unpacking the tree sections, I overheard him muttering, "Where is the tree stand?" I knew right then that the stand was probably sitting in plain sight, somewhere in the storage room in the Atlanta house. Despite this, we conducted a mildly frantic, perfunctory search through the plastic bins full of ornaments and decorations, and predictably, came away empty-handed.
     For some reason, getting our silly fake Christmas tree up and decorated in a timely manner has proven year after year to be a frustrating and sometimes futile task, usually complicated by a strand of lights not working. Overcoming this problem requires the systematic unplugging of each bulb in the unlit circuit and replacing it with a fresh one, and is traditionally accompanied by a fair amount of cursing. This year's snafu happened to be a missing stand. Stupidly naive in our assumption that replacing an artificial tree stand would be a piece of cake, we ventured out to Home Depot, then K-Mart and Michael's and Wal-Mart. It was a series of disappointments, and here in Rome, GA, we were quickly running out of places to look. We considered improvising with the available regular tree stands we saw, but didn't think we could make any of them work. Both of us were grumpy and hungry as we pulled up to Lowe's. Brad asked a female employee named Nan if the store carried artificial tree stands, halfway expecting to once again be told, "No, we don't" or "Huh?" To our surprise and delight, Nan launched an inter-departmental collaborative effort, which resulted in us getting our tree stand. As we stood waiting, we chatted with another pleasant employee. Although there was a rotating artificial tree stand available for $50, Nan and her team located an extra folding stand, the kind that comes in the package with the tree, and only charged us two dollars. She then phoned Barry in hardware, who set us up with an appropriately-sized turnscrew. Brad and I exchanged glances as we walked back to the car, relieved that we'd found what we were looking for, and completely dumbfounded by the excellent customer service we had just received. (And yes, I will phone Lowe's manager today to sing Nan and Barry's praises).
      This experience got me thinking about a peri-operative pet peeve of mine, the one where a patient doesn't receive an epidural or a peripheral nerve block pre-operatively because the surgeon is "ready to roll." Many surgeons don't seem to perceive regional anesthesia as an essential component of their patient's anesthetic; it's more of an afterthought. This is unfortunate, because aside from worrying about nausea or whether or not they'll wake up during or after their procedure, surgical patients are the most afraid of pain. The term, anesthesia, denotes the loss of ability to feel sensation or pain, either from intrinsic damage to a nerve, or through the administration of medication or medical intervention. As an anesthesiologist, I am uniquely qualified to strategize pain control for my patients. Regional anesthesia requires forethought and planning, as well as equipment and at least one assistant, and is usually best conducted prior to a surgical incision. It's no secret that patients who receive an epidural for a thoracotomy or a femoral-sciatic nerve block for a knee replacement require less inhalational agent and lower doses of opioids, or that they emerge from anesthesia more comfortably. Chronic pain patients tend to benefit greatly from the addition of a regional technique because their post-operative pain frequently is otherwise unmanageable. Although regional anesthesia doesn't necessarily improve surgical outcomes, it decreases the overall stress response, spares post-operative opioids, and aids in preventing acute pain from becoming chronic.
     There are a number of reasons why patients who have been deemed appropriate candidates for regional anesthesia don't receive it pre-operatively. They may have arrived late on the day of surgery, creating a delay, and in the rush to get them back to the operating room, the epidural or nerve block is omitted. Complex patients who haven't matriculated through the pre-op clinic require additional preparation, which also results in delays. Although these are typically very sick patients who stand to benefit the most from regional anesthesia, very few surgeons seem willing to wait the few minutes it takes for the procedure to be performed pre-operatively. When the OR front desk switches cases around, or gives a surgeon a second room, there is generally very little thought being given as to what's best for the patient, and this is largely because of a gross misperception of exactly what anesthesiologists do. We are not "sleepers" or propofol pushers. We are peri-operative physicians who are especially skilled in anticipating, managing and preventing pain, and our interventions do make a difference to our patients. In the recovery room, with very few exceptions, it's always easy to pick out the total knee replacement or pelvic tumor debulking patients who didn't receive pre-operative nerve blocks; they are the ones writhing in pain. Technically, it is much easier to place an epidural or nerve block pre-operatively because the patient can assist in positioning him or herself. I think it also provides a psychological benefit because patients who receive regional anesthesia already know their pain is actively being managed, before they even go back to the operating room.
     I am not anti-surgeon by any means, and I've enjoyed many meaningful patient-centered interactions with surgeons who are supportive of my recommendations. Our patients definitely take notice of this, and seem to appreciate the cooperative effort in designing and implementing an individualized plan of care; not only are we caring for them, we are caring about them. We are part of a team. What I am opposed to is the idea that patients are customers, a notion which is generally perpetrated by the business folks in hospital administrations and insurance companies. They are clearly motivated by money, and they just don't get it. They are responsible for propagating the medicine-as-business framework, which generates pressure on us practitioners to "hurry, hurry, hurry" and do as many cases as quickly as we can. How exactly this translates into "customer service" is simply beyond me. Their model of patient-as-customer reduces us to little more than fast food cashiers, negating our roles as physicians, and disrupting the important bond we share with our patients. Customers are people who purchase goods; they are satisfied because they've gotten a good deal on a sofa or enjoyed a nice steak dinner at a restaurant. Patients are an entirely different matter: they are people receiving medical treatment. They are satisfied by more intangible things like doctors who listen, nurses who care, and pain that is managed expeditiously. Even though Nan at Lowe's isn't a doctor or a nurse, she's got the right idea. She went out of her way to help us find that artificial tree stand, out of the goodness of her heart. She could have just shown us the $50 rotating tree stand, and washed her hands of us. She demonstrated genuine concern and commitment to helping us, even though her store only made a lousy two dollars from that interaction. Nan's selfless behavior is a perfect metaphor for what patients really want: they want to know they are cared for and cared about, and that is something money just can't buy.


Definition of the word, Anesthesia

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