Saturday, August 11, 2012

Selective Memory, Intentional Disinformation

     Yesterday started out just like any other work day...well almost. My alarm went off at 0530, jarring me from a deep sleep. Immediately ascending from the yin-yangy cool warmth of my comfortable bed where Spartacus lay sleeping, I brewed myself a caffe latte, and sat down for a brief moment at my computer to check my email, Facebook, BlogCatalog, and finally, my online banking service. Noticing that the direct deposit monthly income from the house I'm renting out hadn't yet cleared my checking account, I logged onto my rental management company's site to further assess the situation. I haven't been super happy with my role as a landlord; I really just want to get rid of my old house. Although I'm receiving monthly income and the house isn't sitting idle, I'm still losing money. Aside from not breaking even on my mortgage payment, I'm paying $100/month for yard service and $75/month for pest control at that property, as well as maintaining a rather expensive home warranty. In my opinion, the tenants living there are enjoying a pretty sweet deal. What frustrates me beyond belief is the fact that these tenants don't seem willing to take on any minor responsibilities, such as ensuring that the air conditioner filter gets changed every couple of months, nor does Excalibre, the rental management company who receives a respectable 7% commission from me, monitor or initiate this type of maintenance. It leaves me wondering exactly WTF are they doing for me that I couldn't do myself?
     Three weeks ago, I'd emailed the property manager to inquire about whether the tenants have been changing the A/C filters. Filters cost $8-10, and replacing them is a simple task. As hot as this summer has been, common sense dictates that regardless of whether one rents or owns, one does what's necessary to prevent a catastrophic interruption in air-conditioning here in the deep South. The problem I run into, trying to understand how these folks operate, lies in using myself as an example. Prior to moving back to Atlanta last spring, Spartacus and I were also renters, and because we both realize that nothing comes for free, we took it upon ourselves to perform routine maintenance chores, such as changing HVAC filters, vacuuming the refrigerator coils, and removing the calcium deposits which routinely clogged up our faucets. For us, these tasks were part of good stewardship: we treated our rental as if it were our own. Anyway, in response to my email regarding the filters, I immediately received a message informing me that the tenants were now complaining about "overflowing gutters with stuff growing out of them", and that there was also a hole in the brickwork at the side of the house they wanted fixed. This really infuriated me. It was as if being asked to do something to ensure their own comfort while living in MY house imposed upon them somehow. If you ask me, that's the definition of entitlement. Why did these idiots allow the gutters to reach the point of overflowing in the first place, when all they had to do was notify the property manager that they needed some attention? I thought I was paying Excalibre to stay on top of this kind of thing. Overflowing gutters lead to roof leaks...doesn't everybody know that?
     The property manager got a couple of estimates for gutter cleaning and the brickwork repair, which totaled around $300. Since Spartacus also uses Excalibre on his leased property, I asked him whether I'd be billed directly for these repairs, to which he replied verbatim, "No, it will come out of the tenants' deposit that was initially withheld." This explanation made perfect sense to me, so I thought nothing more about it. Yesterday morning, when I was reviewing my profits and losses on Excalibre's website, I noticed that the amount they were paying me this month was $300 less than last month. "This must be some sort of clerical error!" I thought. I finished my coffee while emailing the property manager to inquire why the repairs weren't being deducted from what I thought were reserve funds on my account. Since I was running late for work, I showered in haste and slapped on some make up. As I was getting dressed in our room, Spartacus opened his eyes, which I interpreted as an indicator that he was awake. I told him about the Excalibre situation, seeking confirmation that the information he'd previously given me about the reserve funds was indeed correct. He blinked a few times, hesitating before dropping the bomb:  "No, any work that's done is deducted from your monthly rental income." BOOM! This prompted a ridiculous "he said, she said" argument from which we still haven't quite recovered. I mean, where else would I have gotten the reserve fund idea? Ah, selective memory...ain't it grand?!
     Fuming as I made the 35-minute eastward trek to work, especially after having received a text message from Spartacus, accusing me of being inconsiderate for awakening him with my urgent question, I was deluded by an ironic sense of security with which I reassured myself, "Welp! This day certainly can't get any worse." I arrived just as our first colonscopy patient was having her IV (intravenous line) started. After interviewing and examining her, I checked out 15 vials of propofol, now infamously known to the general public as "the Michael Jackson drug," and mentally prepared myself for a pleasant morning of GI (gastrointestinal) anesthesia. "It's going to be a good day!" I thought, glancing at the schedule while drawing up a few starting syringes of propofol and lidocaine. Indeed, it did look like an easy, breezy day. Aside from the fact that all the patients in my room were age 57 or under, and presumably healthy, the GI docs and the nursing staff at this facility are great fun to work with. I don't mind traveling the 20-plus miles out of Atlanta to work with these folks; the camaraderie makes it all worthwhile.
     We sailed through the first four cases, well ahead of schedule. I've recently been working on perfecting a technique for suppressing the coughing and gagging which occurs in patients having upper endoscopies (EGD, or esophagogastroduodenoscopy, where a flexible camera is passed orally into the esophagus, stomach, and small intestine), and it was working beautifully. Here's what I do. I give a 100 mg bolus of lidocaine, followed by about 40-50 mg of propofol, slowly titrating in enough propofol to keep the patient breathing spontaneously while ensuring a deep level of sedation. No coughing, no gagging, and no apnea is about as close to nirvana as an anesthesiologist can get. Two colonoscopies, an EGD, and a combined EGD-colonoscopy (known as a "double-dip") later, we were ready for our second double-dip of the day. Our fifth patient was a guy in his mid-40s, who was a bit rough around the edges. His appearance was disheveled and unkempt-looking, with greasy long hair and a very large bushy beard, a physical attribute which raises concerns over potential problems in managing a shared airway. Aside from being a smoker, he was healthy. He was quite nervous about his procedure, which isn't all that unusual. The GI doc was seeing another patient in his office between cases, so I wheeled our patient back to the procedure room where it's nice and quiet, thinking a friendly chat about his anesthesia would help allay his anxiety. After placing him on monitors and a little oxygen, all of which are standards of care for propofol sedation, he began asking lots of questions about which anesthetic agents would show up on a drug screen. I reassured him that, unlike other narcotics, propofol wouldn't interfere with his work-related drug screening. One of the beauties of using propofol sedation for GI procedures is that it virtually eliminates the need for benzodiazepines or opioids, providing an unparalleled depth of hypnosis which rapidly disseminates once the anesthetic is terminated, with minimal residual CNS (central nervous system) effects. He wanted to know much anesthesia it takes to "put someone under" for a procedure like the one he was about to have. I told him that it depends upon various factors, such as one's alcohol intake and concurrent illicit drug use, as well as the use of pain medications or any drugs, such as anticonvulsants, which rev up one's liver enzymes. In general, the presence of any of these pharmacologic entities are guaranteed to increase one's anesthetic requirements. I was greatly relieved when he told me he rarely ever drank alcohol, but found it odd that in the same breath, he asked if it would be OK for him to "have a drink" with dinner. BIG red flag, but I gave him the benefit of the doubt. People who lie about their drinking and drug use always declare themselves under anesthesia; it's a simple matter of pharmacokinetics and pharmacodynamics.* Warily, I informed him, "No, you'll be advised not to drink alcohol for 24 hours after your anesthetic." Just then, the GI doc popped into the room; we were ready to get started.
     Although the milligram dosage of propofol required for an EGD-colonoscopy varies among patients, based on their co-morbidities and medications, it is also somewhat dependent upon the proceduralist's technique. From my personal observation and experience, the dose typically ranges between 230-370 mg, which amounts to two vials of propofol. Normally, following 80-100 mg of propofol, a young, relatively healthy person will look heavenward, closing his eyes as he lets out a big yawn, after which he'll begin snoring. I won't bore you with the details of the 20 minutes of sheer terror we endured with our thrashing, combative, self-professed teetotaler, who consumed 1200 mg (six vials) of propofol during his short procedure and was still fighting, except to say that he managed to contaminate our only end-tidal CO2 filter with bloody secretions, rendering it useless for our next three cases. In this scenario, I was victimized by selective memory's evil twin, intentional disinformation. Clearly, I'd been lied to, as nothing in this patient's history added up to 1200 mg of propofol. What people who willfully conceal details about their drinking and drug use don't seem to understand is that when anesthesia is added to the mix, it can kill them. It doesn't just injure them, it ends up affecting everyone else, like the poor recovery room nurse who had to put up with our patient's unsolicited groping, and the subsequent patients whose cases were delayed by 45 minutes as we frantically searched for another CO2 filter, while attempting to sterilize the one that had been needlessly contaminated.
     It's funny how my job as an anesthesiologist whips everyday situations into perspective. Over the years, Spartacus, who is a network engineer, and I have exchanged tales of what happens when things go "south" in our respective professions. In the world of information technology, operator error that produces a big network outage might be grounds for termination, but customers don't die as a result of not being able to swipe their credit cards. On the contrary, my job is a matter of life and death, requiring perhaps an even higher degree of vigilance for user errors. Every patient is a both an innocent and a suspect. Similar to the nature of communication in the aviation industry, my work requires the transmission of information that is accurate and precise. There are very few fudge factors and little to no wiggle room in anesthesia. In considering the events of the last 24 hours, I'm aware that although I don't bring my personal life to work, some aspects of work do come home with me, such as the expectation that statements are backed by knowledge, and hopefully, truth. I suppose you could say I'm intolerant of deception of any kind. From my perspective, hearing "I don't know" is rarely ever a problem; it's "I think I know" that'll burn me every time.

*pharmacokinetics: what the body does to the drug; pharmacodynamics: what the drug does to the body


  1. Sounds like you had a tough day there. However, I can share your mental pain going through the two major scenarios here...

    I have 3 real estate properties which were all managed by property management companies. I had made loss on all 3 properties and made peace with myself. It is best for others to worry about the annoying fine prints of maintenance like fixing stuff or coordinating with bureaucratic organisations. After all, I can claim these costs for the tax return and rely on others to "maintain" the properties.

    Speaking of the drama at the work, I feel sorry for you. For all I know about alcoholics, it is best to multiply all their reported drinking to 10 folds... In the medical world, it is probably best to think negatively since all medico-legal problems derived from "not being completely negative and pessimistic" towards patients...

    Your humour on gastrointestinal anesthesia is very funny. I had a good crack at it!

    1. Thanks, James. Three real estate properties would just about put me over the edge! You are absolutely right about multiplying the reported drinking and about maintaining a high index of suspicion...I am beginning to think it's human nature, the desire to please the doctor, that drives this dishonesty with one's medical history. Glad you enjoyed the post! :-)

  2. Good description of your day. I know all too well the scenario in the Endo suite; had a few 1200 mg cases. Don't bother too much with the CO2 monitor much, EGD cases are pretty much mouth breathers anyway. I rely on my ancient, trusty precordial for those; I hear the secretions before they hit the cords, and to reassuring heart and breath sounds are like being back in the womb...keeps my sphincter tone normal.

    1. Mike, Great to hear from you! I still have my precordial stethoscope lying around somewhere. Would have loved to have learned anesthesia "back in the day" before SpO2 and ETCO2. Like surgical examination of the acute abdomen, I fear keeping a finger on the pulse is becoming a lost skill.

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  4. Ugh. You clearly needed to vent! It's amazing how many different types of people (and tenants) there are out there. Some feel entitled, some just don't know how to maintain a house. As for your patient, it's a shame some people aren't honest, letting their pride compromise their treatment. I love how you say every patient is both innocent and a suspect. I'm sure that is true in more than one line of business...and life!

    1. Janene, that was one therapeutic post! I hate having to be skeptical about my patients' histories, but maintaining a healthy index of suspicion is the only way to keep them safe!