Behind Closed Doors: Surgery with an “Appy” Ending

If ever there were a physical example for proof of the argument in favor of evolution vs. creationism it would most certainly be the human appendix. What kind of spiteful, ill-humored God would purposefully place this useless and trouble-making stump at the beginning of our colon? In our ancient incarnation as ground dwelling pre-historic mammals, the appendix undoubtedly played a useful role, as it does in modern-day rodents and other such buck-toothed chewing machines. However, the relentless march of genetic progress, random as it is, has relegated the appendix, along with other vestigial structures such as the coccyx, the erector pilae muscles, and the plica luminaris to the trash heap of human appurtenances. It would be nice if the appendix minded its own business and didn’t trouble us. But like an unsolicited sales call, it troubles us to no end.

Appendicitis is inflammation of the appendix, and is a lot more common and potentially life threatening than one might think. Historically, the diagnosis of an inflamed and burst appendix was often a death sentence. Its rupture causes exposure of the contents of the bowel to the unprotected inside of the abdomen resulting in a condition known as peritonitis. This can lead to overwhelming sepsis due to gut bacteria in the bloodstream. Untreated, death will occur in relatively short order.

The first recorded appendectomy was performed in 1736 by French surgeon, Claudius Aymand, who operated on an awake 11 year-old for an appendix perforated by a swallowed straight pin. In 1804, the only person to die on the entire Lewis and Clark expedition was Sergeant Charles Floyd, due to an attack of suspected appendicitis.  At this time surgical anesthesia did not exist save for a shot of whiskey and a stick to bite on, nor did reliable surgery, and there were certainly no antibiotics to be had at any price. It wasn’t until the latter part of the 19th century with the advent of general anesthesia and more refined surgical technique that it was possible to treat and cure acute appendicitis.

About 250,000 cases of appendicitis occur annually in the United States, and the lifetime risk of an appendectomy is estimated at 12% for males and 23% for females. Thus appendectomies remain a common procedure.  In my family, both my wife and my daughter have had appendicitis followed by emergency surgery. Dana had hers in the first trimester of her third and last pregnancy. Kate had hers at the tender age of four.

As is the case in many doctor’s families, the three “Ds” of diagnosis were critical in identifying the problem. The first is “downplaying” of the complaint. “Are you dying? Cause a lot of my patients are…” is a common refrain in my house. Dana woke up in the middle of the night with vague peri-umbilical abdominal pain. “It’s just gas, go back to sleep!” I said and rolled over. Despite sitting in a warm bath for the rest of the night, Dana felt worse in the morning. She vomited and her pain had localized to the right lower quadrant of her abdomen. I said, “Maybe it was something you ate. I hope you feel better. Gotta go to work! Call me if it gets worse.” and I hurriedly rushed out the door to take care of my first case of the day. Fortunately we have an amazing friend we call Saint Gina. She is a nurse, and a super-mom, and as practical and able as they come. Dana called her to look after our boys because she was feeling too sick to get up. As soon as she arrived, Gina took one look at Dana and said, “You are going right to the hospital!”

The second “D” is “denial.” While I briefly considered that Dana’s constellation of symptoms might be appendicitis, I was far more worried about an ectopic pregnancy as that was entirely possible given her gestational age of ten weeks, a common time for such a problem.  In retrospect, it is good advice for physicians to leave the diagnosis and treatment of family members to others far more objective, and thus more competent. A surgical consult and an ultrasound revealed both a healthy intrauterine pregnancy, and a grossly swollen appendix. Therefore, the third “D” is for “dumb-ass!” which is what I felt like after the correct diagnosis was made. Fortunately, Dana underwent an uneventful appendectomy under spinal anesthesia, in order to minimize exposure to anesthetic agents to our developing fetus that eventually became our lovely daughter Kate.

As luck would have it – both bad and good – Kate would soon emulate her mother. Early one evening when she was four years old, we decided to see “Harry Potter and the Chamber of Secrets” at our local theatre. Kate had been feeling a little poorly for most of that day and was a touch irritable. For Kate, irritable meant that she smiled only 95% of the time rather than 100%, so I thought a movie would cheer her up and off we went.  She sat on my lap spellbound (no pun intended) with the film. I noticed she felt a little warm, and was aware that every time my hand rested on her stomach she stiffened. As we walked up the aisle at the end of the movie, she seemed to limp a bit. By the time we got home, I could tell she was sick. I laid her down on the kitchen table and proceeded to play surgeon. “Does your tummy hurt?” I asked. “Yes. First it hurt in the middle and now it hurts down here.” pointing at her right lower quadrant at a place called “McBurney’s point” named after the surgeon who initially described the signs of appendicitis. Textbook answer. “Does it hurt more when I press, or when I let go?”  I gently pushed then released the spot to which she pointed. She winced as I let go, and with a sinking feeling I knew we were going to the hospital. The latter sign indicates an inflamed appendix and a resultant angry peritoneum, the lining of the abdominal cavity.

It was now pretty late in the evening, and the emergency waiting room at our local hospital was totally empty. Literally, crickets chirped. Nevertheless, we sat for what seemed to be an eternity. Finally, I couldn’t take it anymore and in my best doctor voice I approached the intake nurse and said, “Listen, my daughter is febrile, has peri-umbilical pain that has localized to the right lower quadrant, has rebound tenderness and is guarding. Could we please see the doctor on call?” She looked at me; her expression narrowed, and with a voice dripping with condescension said, “My! We are using big medical words, aren’t we? Are we a nurse or something?” I resisted the urge to push her smug face in and replied in as level a Clint Eastwood voice as possible, “No, we are a doctor or something. Should I use smaller non-medical words so you understand them?”  I was being a total jerk but didn’t care. This was my daughter after all.

Once in the ER, a quick urine test was negative and a blood test revealed a high white count. Ultrasound again clinched the diagnosis.  Kate was a trooper through it all, bravely enduring a urethral straight catheter and a needle poke for a blood sample without so much as a whimper. Because our local hospital had neither pediatric surgeons nor pediatric anesthesiologists, and I felt more comfortable on my home turf, I arranged for a friend, Mike Harrison, one of the best pediatric surgeons in the country to see her immediately in the city. Surgery was quick and went well. Her appendix was nearly ruptured and I considered myself lucky to live in an area with so much choice and talent available.

It is truly amazing that such a little vestigial tube of flesh can cause so much trouble, but it most certainly does. Dana remembers her appendectomy as the time that our two elder boys, then age two and four were given free rein in the kitchen and on the computer. As she lay in bed suffering while her doctor husband was taking care of his own patients instead of his ailing wife, they went to town on the snack drawer. Then primed with sugar, they printed hundreds of pictures of Pajama Sam, Sly Fox, and Putt Putt the talking car, heroes of their favorite “Humongous Entertainment” games.

Kate remembers enjoying Harry Potter a lot despite the pain in her stomach, her quick trip to the hospital where daddy worked, and the popsicles after surgery. I remember being humbled and thankful that we live in a time and place where we have immediate access to such wondrous medical technology, and an appendectomy is considered minor surgery. Though perhaps I should reconsider that final thought, as minor surgery is always something that happens to someone else.

Jeffrey Swisher, M.D.

San Francisco, CA

Dr. Jeff Swisher is an anesthesiologist who practices in San Francisco. He graduated from Stanford University with degrees in International Relations and Medicine, and lives in Marin County with his wife Dana, three teenagers, two large dogs, and a merciless take-no-prisoners black Bombay cat named Gin. He also plays in a middle-aged-guy rock band named “Blatant Malpractice.”

Behind Closed Doors: You May Get Groceries and Other Adventures in Childbirth

Ask any doctor you meet to describe the most amazing thing that they
 have ever experienced in their career, and I would lay strong odds that 
most would say childbirth. Of course everyone in all of history has been present for at
 least one birth, and mothers for at least two. But I have always felt
 it has been a great privilege to be present for so many. I have witnessed thousands, and have even had to help deliver a few babies myself when things moved faster than the obstetrician or midwife expected, and I along with the nurse were the only ones present. It may be trite to call it a miracle, but for lack of a better word, it really is. The first breath and cry of a baby as the lungs expand with life-sustaining 
air, is like a brilliant white sail snapping full on a crisp ocean 
breeze. Even after the thousands I have seen, I still have a catch in
 my breath, and a skip of my heart with every new birth.

As the Chief of Obstetric Anesthesia at my hospital, I feel doubly professionally privileged. Not only do I get to participate in the clinical care of obstetric patients, but also help administratively, working with a wide array of health professionals, from obstetricians, to OB nurse, to pediatricians, to midwives, and even doulas. We are all focused on the health, and comfort of our patients with the common goal of ensuring a safe delivery and a healthy baby. We also strive to provide an individual experience for every one of our patients that respects their wishes and expectations for the birth and beyond.

Sometimes these goals are in conflict. There are few
 areas in medicine that garner so much public attention and generate
 such heated discussion as birthing options. Should one try for a home
 birth? A water birth? Should we be like Tom Cruise and remain totally
silent during delivery so the baby remains free of negative engrams? Hospital versus birthing center? 
Natural versus epidural? Vaginal versus C-section? There is a lot to
consider. One thing is for certain, childbirth is now safer than it ever 
was in all of recorded history. Take a walk in any 18th or 19th century cemetery and read the gravestones. They are a cold and stoney reminder of the high price of pregnancy and childbirth in the past. It was not unusual for a man to out live three or four wives, or for a mother to bury several of her babies. Fortunately, in our lifetime, this is no longer the case.

With choice however, comes controversy. Despite the theoretical
 ability to perform well-controlled birthing studies, in practice it’s not so easy; thus many issues we would like definitively resolved just
 aren’t. Even 90% probability leaves 10% uncertainty. Why do we have so many C-sections, approaching nearly 30% nationally? Does choice of pain relief matter? Does increased fetal monitoring lead to more frequent and unnecessary interventions? Do 
fertility treatments that allow older mothers to bear children, with
 an increased chance of twins, triplets, and beyond increase risk? Should anybody be allowed to have fertility treatments? Octomom anyone? I, for one, have mellowed with both age and experience in thinking there is one right answer. I believe in choice and intuition, but I also believe in science, and data-driven answers. My personal journey in the birth of our first child outlined below is illustrative of some of these dilemmas. Let’s just say, I was young, I was a new anesthesiologist, and I was faced
 with a challenging situation…of course hilarity ensued.

When Dana and I found out we were expecting our first child in the 
final months of my anesthesia residency, we simultaneously became inundated with good wishes and overwhelmed with advice on how to prepare for the big day. As a new anesthesiologist, I truly believed that we were the good guys and helped make the process of birth a lot more comfortable and safe. But not everyone is always on board with our efforts, even today. Miranda Kerr, the Victoria’s Secret supermodel and wife of erst while “Lord of the Rings” elf Orlando Bloom, has opined in the current issue of Harper’s Bazaar, U.K.

The Aussie who is on the cover of the August issue, told the magazine
 that she decided to have a natural birth without any pain medicine 
after watching baby-bonding videos. Kerr saw that babies without an
 epidural come out and go straight for the breast.

“Then they showed the ones (babies) right after the epidural, and that 
didn’t happen,” Kerr said. “The baby was a little drugged up, and I
 was like, ‘Well I don’t want that.’ I wanted to give him the best 
start in life I could.”



There is little doubt, if I were fortunate enough to be in that genetically
 privileged baby’s booties, I would leap like Legolas, straight for 
Miranda Kerr’s perfect breasts, drugged up or not. And for the record, here is Victoria’s real secret. The fertile Queen became a huge fan of pain medicine for labor. One of the world’s first
 anesthesiologists, John Snow was celebrated for his ability to safely 
gas Her Highness senseless with chloroform during the births of her 
last two children. For this skill, and perhaps his success in
identifying and halting the source of a horrific cholera epidemic in
1854, he was named by a 2003 poll of British doctors as “the greatest
 physician of all time.” Is it a coincidence that we have the word 
“snowed” to describe the state of blissful lack of awareness?

Faced with our impending delivery, one of our first tasks
 was to register for a childbirth education class. I must admit, as an
anesthesia chief-resident with a fair amount of experience on the 
obstetric floor, perhaps a little arrogantly harbored doubts about 
the value of this undertaking. I had seen numerous complicated birth-plans crafted in these classes burst into flame at the
 unyielding onslaught of the dragon’s breath of labor pain. I looked at 
the glossy brochure brought back from Dana’s first OB appointment. The misty cover picture was a mother gazing down at her 
preternaturally chubby baby nestled against her breasts; its inner 
copy was filled with words like “holistic” and “toxin-free.” I began to 
cynically snicker… and was immediately shot
down with “the look.”

Here is some hard earned marital advice. Do not laugh at your pregnant
 wife. Even if in the past she has been a willing co-conspirator with
 you against the excesses of modern baby marketing, just 
don’t do it. To this day, one of the biggest arguments in the history 
of our twenty-two year marriage was about the exorbitant cost, and
“real need” of designer crib linens and bumpers. Give up. Just buy
 them.

On the very threshold of the first day of birthing class, empathy 
pillow in hand, Dana paused and made me solemnly swear that I would 
not let the teacher or anyone else in the class know that I was a 
doctor, and even worse, an anesthesia resident. She made me promise 
that I would listen attentively, wouldn’t snort derisively, roll my eyes, or sigh heavily… no… matter… what. In order to cement this 
deal, she gave me “the look” once again, and I knew I had no choice. I 
even agreed to carry the empathy pillow and go “hee-hee-hee, 
hoo-hoo-hoo” when prompted. I introduced myself to the doula-educator who seemed a touch too sweet, and 
had an edge I immediately recognized as pure passive-aggressiveness. Kind of like Dolores Umbridge for all the Harry Potter fans out there. I
surveyed the room and the ten or so other couples scattered about. Some were bewildered and dazed newbies, and a few were clearly repeat
 parents, bored and all been-there-done-that.

The first few classes were actually fine, nothing too controversial. Most of the topics were blandly informational, about such 
things as the early changes of pregnancy, lactation, mood swings, and and 
must-have baby equipment. The routine was to present paired related 
topics, like nutrition and exercise, stretch marks and skin-care: so 
far, so good. I was dutiful. I was attentive. I was respectful. I
 took pains never to wear my scrubs to class, or discuss my day in the 
operating room. When asked, I said I was a student, which was sort of 
true. It would be an exaggeration to say that I enjoyed the class, but 
all in all it wasn’t horrible. So we continued to attend. And then one
 week, late in the curriculum, things took a decided turn for the
 worse.

On that fateful evening, we arrived a little tardy to find the teacher at the whiteboard busily scribbling away. Everyone seemed 
unusually hushed and serious. Her ample rear-end wiggled, and the
 dry-erase marker squeaked as she wrote. The two topics of the night
were already delineated on either side of the board – doubly 
underlined in her flowery script:

“Unexpected Fetal Demise” and… “Risks of Epidural Anesthesia”

Dana shot me a warning glance as she could tell I was starting to get
 riled up. She painfully squeezed my hand after we sat down on the
 floor - no chairs allowed here - the empathy pillow accusingly thrust
 between us.

Under “Risks of Epidural Anesthesia” she had drawn an elaborate
 diagram. In the middle was a big circle with the word “Epidural” in 
it. Several spokes extended from the center like a wagon wheel. At the
 end of each spoke were other circles, some big, some small. And then
 she started to write in each of them… In the first big circle she 
wrote, “Nerve damage, Possible Paralysis!” in the next, “Chronic Back
Pain!” and the next, “ Use of Caine Drugs and Narcotics = Toxic, May 
Cause Future Addiction in Baby!” and the next, “Interferes with 
Breast-Feeding and Attachment!” then, “C-Section nearly Guaranteed!”
And then starkly, “Death!!” Undoubtedly she felt the ultimate
 catastrophe gleefully deserved two exclamation points. Finally, in the 
tiniest, loneliest, most distant circle attached to the growing wheel 
of anxiety she glumly wrote in small letters, “…you may get pain 
relief.” And that was it 
for me. I lost it.

I imagined myself a superhero, like Clark Kent ripping off my striped oxford
 button-down to reveal my scrubs with the crimson “S” beneath. Only in
 my case it was an “A” for Anesthesiology! I leapt to the board, grabbed the marker from the startled woman, and drew my own 
wagon wheel. In the big central circle I wrote, “Trip to Grocery 
Store” and then the spokes: “Horrific Flaming Car Crash!” and, 
“Kidnapped by Aliens and Anally probed!” and, “Poisoned by Botulism!”
 and so on. Finally in a small circle I wrote, “… you may get
 groceries.”

Needless to say, we were invited not to come back to class after that.

I could tell Dana felt sort of relieved, even co-conspiratorial. She smiled at me, and I was reminded once again that I had married the right person. Later, in the 
hall, several of the dads clapped me on the back, and made me feel
 a little better. A few of the experienced moms mouthed, “Thank you!” Of course
I knew that some of them had epidurals with their first pregnancy, and as far 
as I could tell, they were alive, they all walked just fine, and not
one of them had cocaine-addled junkie toddlers in tow.

Jeff Swisher, M.D.

San Francisco, CA

Dr. Jeff Swisher is an anesthesiologist who practices in San Francisco. He graduated from Stanford University with degrees in International Relations and Medicine, and lives in Marin County with his wife Dana, three teenagers, two large dogs, and a merciless take-no-prisoners black Bombay cat named Gin. He also plays in a middle-aged-guy rock band named “Blatant Malpractice”.

Behind Closed Doors: Our Heroes, Something Given and Something Gained

An empty operating room in the witching hours of the night is as spooky as any haunted house. Most of the rooms I work in do not have outside windows. Like a casino, or an underground bunker, “daytime” is relative. Even so, I often get goose bumps whenever I walk alone into an operating room to set up for an emergency nighttime case. I am the first to arrive. The noises, bright lights, and bustle of the many concurrent routine operations of the day are replaced by the low hum of the air ducts and the soft fluorescent glow of monitors and machines. The room is cold and mostly dark as I enter, and it is easy to imagine the lingering spirits of all the people who have undergone operations in here. Shadows play in the far corners of the room, and distant footsteps from outer halls echo off the linoleum floors, stainless steel tables, and pallid green walls.

I’m still a bit groggy from my few hours of sleep before the after-midnight summons to the hospital. The call is followed by a foggy and wind whipped drive south over the Golden Gate Bridge. Sporadic northbound headlights of oncoming traffic pierce the gloom, and still startle me despite the hundreds of such nighttime trips. The bridge has no median barrier, and the center lane markers are flimsy moveable rubber pylons. Like invisible hands, sudden ocean gusts shove my car into the oncoming lane. I repeatedly correct my course and drive cautiously, with the window open to stay awake and alert, bracing myself with the cold night air.

Night cases are often transplants of one sort or another. The frequency of organ transplantation has greatly increased over the past four decades due to better tissue preservation, immune suppressing drugs, surgical techniques, and technology such as operating microscopes and Jedi sabre-like argon beam coagulators that cauterize the thick, bleeding edge of a transected liver. Kidney transplants are now routine, as are heart, lung, liver, pancreas, cornea, and recently even face transplants.

In 1968 the famed Dr. Norman Shumway performed the first heart transplant in the United States at Stanford. Ten years later, one of my college friends, Sam Poole, had heart transplant #120 by Dr. Shumway. These transplants were still so new that Sam’s mother, Victoria, wrote an inspiring book about him called “Thursday’s Child” subsequently made into a Hallmark movie starring Rob Lowe in one of his first screen appearances. What I remember most about Sam was his incredibly infectious enthusiasm and lust for life. His body ultimately rejected the transplanted heart despite the steroids and cyclosporine immune suppression therapy that made his skin thin, his bones brittle, and ruined his kidneys. We have come a long way since, and those who undergo transplants can live long and healthy lives.

The case I am here for is a kidney transplant. Like soldiers, firefighters, and police officers, doctors and nurses often engage in dark and decidedly inappropriate humor as a way to deal with the illness and death to which we are exposed. We joke about “donor-cycles”, and Darwin Awards. However, there is no levity when one considers the source of transplanted organs. Specifically, this case is an en-bloc kidney transplant: not one, but two kidneys. The paired donor organs come from a child.

I am a father of three healthy teenagers. I can’t even begin to imagine what it would feel like to make the decision to donate your child’s organs following an unthinkable, and tragic death. It is simply beyond my capacity. So now, in the middle of the night, in a dark and silent operating room I am setting up to transplant this dead child’s kidneys into a man suffering from end-stage renal failure. I look at my wristwatch at the time: 2:12 A.M.

The wristwatch is a 1960 vintage Swiss made Pierfa quartz, as old as I am, with a bright gold Speidel Twistoflex band. I have just had it repaired after the many years it sat unused in my dresser drawer. It belonged to my father, Lieutenant Commander L. Bush Swisher, Jr., who was a young and perpetually smiling Navy anesthesiologist from Morgantown, West Virginia. The watch is one of the few possessions I own from my dad, who suddenly, and with only the briefest warning of a severe headache, suffered a bleeding intracranial aneurysm on a sunny but bitterly cold morning in late January of 1968. He died two weeks later, just before twilight in a small hospital intensive care unit in Glen Cove, New York at the age of 34. I never had a chance to say goodbye. Had this happened today, we may well have saved him. Novel calcium channel blocking drugs, high resolution CT scans using catheter angiography, and the ability to thread small metal coils into the ballooning aneurism, greatly diminish the risk of arterial rupture, bleeding, and death. But not in 1968… and my life, and the lives of my mom, brother and sister were forever changed.

Now, as I stand at the head of the bed after successfully inducing anesthesia on the middle aged man comfortably asleep before me, I intently watch the surgeon as he carefully places the tiniest of circumferential sutures connecting the vessels of the donor kidneys to the recipient. And then I feel the presence of someone right behind me… It is 3:23 A.M. The room is hushed as everyone concentrates on the task at hand. The hissing rhythmic sound of the ventilator is hypnotic as it delivers each breath; pauses then sighs as the anesthesia machine scavenges the expired gas. It is a child- a very sad and frightened child. I don’t know why, but I envision a six-year-old girl, and I do not turn around. I can’t… because I am in turn scared and overwhelmingly sad. At that moment, the surgeon releases the arterial clamps. The mottled gray-blue donor kidneys begin to pink with new blood and life, and I feel a gentle touch on my shoulder… and I know… I absolutely know without any doubt, that my dad is standing behind me as well. A calm, warm, reassuring feeling suffuses me, and just as suddenly as I was stricken with grief, I become unable to contain an emotion I can only describe as pure joy. I close my eyes and see a boyish, broadly grinning young man in Navy dress whites extend his hand to a little six-year-old girl. Holding hands, they recede from me… away from the bright overhead lights whose beams are focused on the living pulsatile kidneys that are a precious gift and a new beginning for the sleeping man before me.

I look at my watch and it has inexplicably stopped… It is now 3:25 A.M., and I see no point in ever having it fixed.

For my Dad.

Jeffrey L. Swisher, M.D.

San Francisco, CA

Dr. Jeff Swisher is an anesthesiologist who practices in San Francisco. He graduated from Stanford University with degrees in International Relations and Medicine, and lives in Marin County with his wife Dana, three teenagers, two large dogs, and a merciless take-no-prisoners black Bombay cat named Gin. He also plays in a middle-aged-guy rock band named “Blatant Malpractice”.

Behind Closed Doors: When do the Training Wheels Come Off?

With apologies to T.S. Eliot, and the American taxpayer, April is not the “cruelest month.” That dubious distinction most certainly belongs to July, the month that newly minted interns and residents are loosed upon the populace. In the world of medical education July is the beginning of the fiscal year. Fresh out of medical school, or far less fresh out of internship, the first year of postgraduate medical training, new doctors begin the arduous process that will refine them into specialists in their given field.

Many patients I have taken care of over the years have asked me questions about this transition. Several have expressed fears about having operations in July, certain that they will be guinea pigs for some new anesthesiologist or surgeon. TV doctor shows like House, or Gray’s Anatomy do not assuage these fears. Quite the opposite, my family and friends can attest to the one sided shouting matches with the television I have had when some particularly obnoxious and stupid storyline has an intern shouting at a cowering patient, or even more unforgivably at a cringing nurse. (Note to prospective interns: if you shout at a patient, you will be fired. If you shout at a nurse, you will die. Or even worse, you will wish you were dead, as nurses can make an intern’s life unbelievably miserable. Imagine 3:00 AM calls every night to tell you that your patient needs to talk to you about their bowel movement.).

Interns and new residents in TV doctor shows are portrayed as having way too much power and knowledge for their level of training. Visualize a sexy Athena springing fully formed from the head of Zeus with a stethoscope draped casually around her neck. Now imagine a dumbed down Doogie Howser….naked. Yes, that’s more like it.

It takes a long time, and a lot of observing, reading, and being pimped, before a new doctor gets any significant responsibility. Sure there are apocryphal stories about the third-year medical student with his own medicine ward service at the V.A. hospital, or the new surgical intern with a textbook in one hand and a scalpel in the other, draining pus from a black tar shooter’s swollen arm at the county hospital. But for the most part, learning in medicine is an orderly process of graded responsibility. So to my patient, who nervously asks me if a doctor-in-training will be in charge of them, the answer is no. There may be a medical student scrubbed in and watching the surgery, or a first year surgery resident learning how to guide and focus the camera in a laparoscopic gall bladder removal and learning to suture the port incisions closed at the end of an operation, or a senior surgery resident operating under the watchful eye of the attending. There is no other way to learn than by doing; but this takes a long time, under the supervision of many highly experienced eyes and guiding hands.

As an anesthesiologist, I have always taken great exception to the portrayal of my chosen profession in the media. Next time you see a comic strip portraying the operating room,

Whoa! Watch where this thing lands…we’ll probably need it.

look for the anesthesiologist. Not there, eh? Nine times out of ten we are simply an IV and a machine with squiggly lines, or tanks with a mask attached.  Anesthesiologists are typically portrayed in movies as helpless bystanders in surgery “He’s flatlining…I’m losing him!!” as they look pleadingly at the surgeon to “do something, anything!” Believe me, unless the patient is bleeding to death on the table, the first thing the surgeon does in an unstable patient is fold their hands across their chest to remain sterile, and step away from the patient while the anesthesiologist scrambles to treat the arrhythmia, hypotension, or other metabolic crisis. Even when a patient is bleeding a lot and the surgeon works like hell to stanch it, it’s the anesthesiologist who transfuses blood cells, or plasma, or platelets, or a combination of all three to help stabilize the situation.

Despite these heroic efforts, the anesthesiologist is often portrayed as the bad guy in movies. Remember Richard Widmark in Coma? He was the evil doctor who masterminded the scheme to give healthy patients lethal doses of carbon monoxide during surgery to kill them and sell their organs on the black market. I saw this movie as a teenager, and aside from lusting after Genevieve Bujold who starred in it,  I wondered who in their right mind would want to be an anesthesiologist?  Well… as it turns out…me. My dad was an anesthesiologist who was decidedly not evil, so out of curiosity and a desire to see what his life was like, I took my first elective rotation in medical school in anesthesia, and I was hooked.

It’s a mystery as to what makes a person choose what to be, to make such eventful decisions at such a young age. For me, I like to think it was more my Dad and Genevieve than Richard Widmark.

Jeffrey L. Swisher, M.D.

San Francisco, CA

Dr. Jeff Swisher is an anesthesiologist who practices in San Francisco. He graduated from Stanford University with degrees in International Relations and Medicine, and lives in Marin County with his wife Dana, three teenagers, two large dogs, and a merciless take-no-prisoners black Bombay cat named Gin. He also plays in a middle-aged-guy rock band named “Blatant Malpractice”.

Behind Closed Doors: Inside the Operating Room with Dr. Jeffrey Swisher

Welcome to my first post for PokitDok! Despite having a sister who is of one of the most prolific tech journalists on the net, I am a first time blogger. But bear with me, perhaps this is genetic, so I will give it my best shot. When Lisa Maki, my old college and Stanford Sierra Camp pal tracked me down after many years to invite me to be part of her new health/medical information venture “PokitDok”, I was intrigued. I also couldn’t get the image out of my mind of those little pastel colored sugar candy dots glued to the roll of three-inch wide ticker tape. I think they were called Candy Buttons, but I called them “Pocket Dots”. They were the perfect “pills” for playing doctor, and undoubtedly launched me on my career as a physician.

Lisa and I talked over the course of a long hike in the canyons of Mt. Tamalpais near my home in Marin. Our discussion ranged widely, and as is typical for Lisa, was engaging and insightful. We caught up on our respective lives and careers, our health issues that invariably ensue as you hit middle age, and our mutual fascination and frustration with the complexity, politics, and economics of health care delivery in our society.

I am an anesthesiologist who works in a large tertiary care hospital in San Francisco. My group of 53 physicians provides comprehensive anesthesia care for a wide variety of medical procedures and surgeries. From epidurals for relief of labor pain, to surgeries on tiny premature babies, to liver and heart transplants, and the whole range of surgeries and procedures in between, my practice is interwoven with the complex tapestry that is modern medical care. And believe me, “complex” is an understatement.

It is said that one should befriend a sharp accountant, a trustworthy mechanic, a relentless attorney, and a good butcher. I would add a well-trained anesthesiologist to that list. There are few doctors who are as present and responsible and as little known about as
anesthesiologists. Prior to your operation, we review your health history and current medical issues, as well as your medications and their various interactions. We perform a rapid and comprehensive physical exam, explain the myriad risks and benefits of the anesthetic procedure tailored specifically for you, then put you to sleep using powerful sedatives such as propofol, the “Michael Jackson” drug.

Or we can render parts of your body numb with local anesthetic drugs injected through precisely placed needles in your back, or arm, or leg. And then we stay right next to you for the entire duration of your procedure, watching you. We carefully monitor your vital signs, and oxygen, carbon dioxide, and anesthetic gas concentrations using complex machinery, tweaking here, and adjusting them as needed. We tally and replace fluids and blood loss. The latter surprises a lot of people. “You give blood during surgery?!” As opposed to whom, the blood fairy perhaps? We keep you stable, and alive, in a state of suspended animation while the surgeons do their job. Then we bring you back. Putting you to sleep is only a small part of what we do. It’s keeping you there and then getting you back—awake, safe sound and comfortable—that’s tricky.

What’s unique about anesthesiologists aside from our particular expertise, and good looks, is that we are always in the middle of things. We meet a lot of people, we listen a lot, and we have a lot of time to ponder. Operations are often long affairs involving a wide variety of folks: surgeons, nurses, scrub-techs, physician assistants, equipment reps, etc., all confined to the small space of the operating room. Conversations are lively, often about politics, economics, and the modern realities of medical care. We talk about Obamacare, death panels, HMO’s, PPO’s, mandated insurance, rising costs, decreased reimbursements, drug shortages, the list of new topics continues to grow.

So, exclusively on PokitDok, I will share with you medicine from the inside of this small room - conversations and stories accumulated over the years from encounters with my patients and my colleagues. Stories that highlight many of the issues we are all facing today with our new world of decisions and choices we must make about our health and our medical care.

Jeffrey L. Swisher, M.D.

San Francisco, CA

Dr. Jeff Swisher is an anesthesiologist who practices in San Francisco. He graduated from Stanford University with degrees in International Relations and Medicine, and lives in Marin County with his wife Dana, three teenagers, two large dogs, and a merciless take-no-prisoners black Bombay cat named Gin. He also plays in a middle-aged-guy rock band named “Blatant Malpractice”.