Dr. Eric Freeman writes from China
Pictures from China by Dr. Eric Freeman5/2/08. Air China Flight 982 430pm
After a minute of hearing Chinese, the pilot translates the same into English. We are to depart on time to Beijing, China. This quick fourteen hour flight will be followed by another hour and a half to my final destination: Nanjing, China.
My name is Eric Freeman; I am a 3rd year anesthesiology resident at Montefiore Medical Center of Albert EInstein College of Medicine in the Bronx, New York. I will be spending one month working in the anesthesiology department of Traditional Chinese Medicine at Nanjing University Hospital.
This is the result of many months of hard work and preparation by my chairman, Dr. Saubermann and attending anesthesiologist Dr. Shay, to initiqate a formal exhange program with this hospital. I feel both honored and privilaged to have this opportunity to experience and also represent the department. There willl be an anesthesiologist from Nanjing who will be working at my hospital and staying in my apartment while I am away. I will spend the first week doing general anesthesia cases, followed by cardiac anesthesia, then regional, and finally a week being exposed to chinese acupunctural medicine.
From the reading I have done, Nanjing means "southern capital" and is situated at the south bank of the lower reaches of the Yangtze River. Nanjing was one of the six ancient capitals of China. Now it is the capital of Jiangsu province and covers an area of 860 square kilometers with a population of more than 5 million. The Qinhuai river is actually a tributary of the Yangzi river and passes through Nanjing. Various dynasties have made Nanjing their base during the Ming Dynasty between 1368 and 1644 and the establishment of the People's Republic of China in the early 20th Century. Many of the city's scenic spots date back to these periods such as Sun Yatsen's Mausoleum and the Ming Tombs are examples of the wealth of culture existing in this ancient city. Fuzi Miao or the Qinhuai River district are also well known. In 1985, the authorities decided to "renovate" and, although this may have ruined some of the authenticity of the district, it is still a very popular and pleasant area to walk, eat, drink and shop. The city is renowned for being an educational and cultural center, with a large student (foreign and native Chinese) population. Nanjing is a pretty place, with tree- lined streets, hills and lakes, making the intense heat of east China's summers more bearable. The pace of life here is slower than many other Chinese cities and Nanjing seems quite conservative in comparison to the brash modernity of neighboring Shanghai. Some consider this is one of the most charming aspects of Nanjing.
This is my second time returning to China. I love to travel at any chance I get. I have visited Beijing and Hong Kong, 2 very different cities three years ago. I know that the language barrier will make things exciting, yet challenging at times. Before I left I got a quick tutorial from Dr. Lu, Professor of Neuroanesthesia on some key Chinese phrases such how to say "open your eyes", "take deep breaths" and "squeeze my hand". I am used to long flights. This one should not be too painful. I have my Ipod, earplugs, and of course an anesthesia book to peruse for my upcoming board exam.........
5/3/08 630 pm.
Confiscated toothpaste and teeth whitener
Before I knew it, we were landed in Beijing, China smoother than a deep extubation. I had to stretch out for a few minutes as leg room was rather tight on this flight. Only one hour and a half layover for my connection so I knew I had to move. They recently opened up a new terminal in Beijing after years of construction and I have to tell you it was amazing. I was later told that it is the largest airline terminal in the world. You could feel the buzz and excitement here for the upcoming Summer Olympics in August. Realizing I had no money, I finally found an atm. The only problem now was I did not know the exchange rate. I eventually stumbled upon a money exchange counter and figured that out. Next mission: food. I made a bee-line to Burger King. Since my Chinese is so good I ordered by raising 2 fingers and pointed to the menu. I think I ate my food faster than those guys ay the annual Nathan's hot dog eating contest on Coney Island every July 4th. Another security check awaited me. After going through I was stopped to have my bag checked. The security guy held up my toothpaste and small bottle of teeth whitener. By nature, I am quite obsessive with my teeth and brush them many times a day. I tried to explain that they were in my bag since leaving New York and I had no problems going through security there. He escorted me to a counter over to another guard. Speaking slowly and using hand jestures I knew that I was getting nowhere. Frustrated, and not wanting to cause a scene, I grabbed the whitener, took my last shot of it and walked away. Note to self: buy toothpaste.
5/5/08 10pm
Neostigmine, anyone??
Well, it has been a memorable day for me here in Nanjing, China as I have completed my first day practicing anesthesia in a foreign country. Before I retire for the night I want to put it all in writing before I forget. My alarm went off at 645am. I turned on my TV and put on the one channel in English so I could stay up-to-date on current events. Quickly I threw on a pair of scrubs and T-shirt and headed to grab some breakfast downstairs in the hotel. I felt a little lighter and it seemed like I was forgetting something. Ah, yes. My nextel phone. Something near and deal to my heart for the past three years. It serves as my communication with the attendings back home in the OR. It will be collecting dusk on my desk back home for the next month. I'm starving. There is a little buffet awaiting me. No omlette guy. No bananas, muffins, cereal. Uh oh. The fried eggs look good. I grabbed a bun that had some rice inside and a piece of bread. There was a bottle of apple jelly. I opened it, and searched for a spoon to scoop some out without any luck. I ended up taking a chopstick and improvised. More importantly I needed some coffee. I drink coffee every day. I asked the woman working at the restaurant for some coffee please. She looked at me and rattled off some Chinese.
This didn't look promising. I made a drinking motion with my hands. She brings me out a glass orange juice. It was hot though and I almost burnt my tongue. I headed out for my 10 minute walk to the hospital. Maybe there will be a vendor on the street
with some coffee. I really needed some caffeine or I would be paying for it during the day. Looking to my left and right while avoiding the onslaught of bicyclists and mopeds I had no such luck. The excitement was building up for me as I entered the hospital complex. There was mass chaos in the lobby by the 5 elevators. Getting into an elevator was as challenging as finding room on the NYC subways during rush hour. Squeezing in, I made it to the operating rooms on the 5th floor.
Dr. Cui, the chairman awaited my arrival. He had a key with a locker assignment for me. I grabbed a pair of large scrubs. After struggling for a minute, this was not happening. Dr. Cui had a bunch of XL scrubs specially sent up for me. The Chinese are a petite bunch. Our chief resident and good friend of mine would probably need an XXXL to fit confortably. I had my own desk for the month in the doctor's lounge. Dr. Cui gave me a warm welcome and introduced me to everyone.
Every morning at 8am, all of the anesthesia department (attendings and residents) meet to discuss any problems that might have occurred during the evening and also if there were any issues with some patients that were to have surgery during the day. Afterwards was a short didactic session. This consisted of one of the residents reading an abstract from a major anesthesia journal in both English and Chinese. There are 6 residents in this hospital; 2 speak very good English, one is ok , and the other 2 very, very minimal. At 830 surgeries begin.
I took a look at the schedule. I saw my name highlighted next to room 7 with Dr. Xieke, one of the residents. I found him, and asked if I needed to get an ID during my visit here. He answered, "Don't worry, your face is your ID." I laughed. That certainly was true. Walking over with him we entered OR 7. I stopped and took in
a global view. The patient was already on the OR table. IV in place, monitors on. Arms extended on a board made of wood.The anesthesia machine was the Narkomed model. I certainly did not expect all the bells and whistles of a machine that I am used to or one with computerized charting, but this one took me a little by surprise. Then I remembered as long as it can deliver oxygen, and positive pressure ventilation, it is all based on the same principle. I expected to see an anesthesia cart behind me.
There was nothing. Just a little table with 2 draws. One contained boxes of medications. The other had some Endotracheal tubes.
On top was a little itty bitty sharps container and a waste basket on the side. Dr. Cui strolled in, looked at me and said, "Go ahead." Standing at the head of the patient, I nodded and gatherered myself. Glancing to my right was a MAC 3 blade and 7.5 ETT. No Miller blades, no oral airways, no tongue blade. I knew I was not in my "element" and would have to adjust the set up that I have become accustomed to during induction for the past 3 years. I asked for the suction to be connected. No head strap. I knew there was no point to look for a christmas tree. I asked Dr. Xieke to have the patient open his mouth. Mallampati 1. This patient was a 72 year old male having a lap chole done. No donut for the patient's head. Just a little elevated cushion for the head. Dr. Cui pushed some medications. Not sure what they were since there was no colored labels, just Chinese written in black marker on the side of each. The patient was off to sleep and I could ventilate without difficulty. Tube though cords, condensation in tube, and end-tidal on monitor. I needed some help figuring out how to turn on the ventilator on this machine. Sevoflurane on. Incision made.
So many questions running through my head....
Dr. Cui explained to me that they do not have any adult Miller blades in the hospital. He showed me a Miller 0 they had for peds. LMA's were non-existant; don't know how Dr. Bogdan would react to that one since they are her favorite. They are about 40 USD a pop in China. They did have a fiberoptic that was pretty much off-limits to the residents due to its high cost. Dr. Cui said I was free to use it. They have a light wand here. Never tried that back home; will definitely use it during my time here. They have a total of 3 oral airways in the OR, different sizes. They are rubber and re-usable and kept in a closet. Guess I will not be using those this month. Dr. Lagasse will be proud of me not touching an oral airway since he said they are "a sign of weakness." No fancy pink tape to secure the ETT, just some regular silk tape.I took a look at the syringes we used during induction. I recognized the one with some white stuff in it.
I told Dr. Cui that we have to label every syringe and that they are color-coded to decrease drug administration error. He left the OR and returned with 4 labels. Red was rocuronium, green was atropine,
blue was fentanyl, and grey was bupivicaine. Chinese was written on each label. He said they just write the drug name directly on the syringe. Interesting. If we did that back home I would be immediately repremanded by my attending! Sitting down with Dr. Xieke, I started asking about medications. Midazolam is commonly used. Regarding opioids, they have morphine, sufentanyl, fentanyl, and remifentanyl. Remi is apparently quite cheap in China. Ropivicaine is the local anesthetic.Rocuronium and vecuronium are the muscle relaxants of choice. Succinylcholine is very hard to come by. I had to confirm this with multiple people including Dr. Cui. Apparently it is so cheap that it is just not worthwhile in China to manufacture it. There is a very limited supply in the hospital. None of the residents have ever used it. Interesting. Propofol is the induction agent of choice. I have yet to see thiopantal or etomidate. Isoflurane and sevoflurane are used; desflurane is not available because it is too expensive. I though sevo was the most expensive, guess I was wrong. No nitrous oxide since it is bad for the environment. I was also shocked that no emergency drugs are drawn up...ie. atropine, ephedrine, neosynephrine. They have it in the draw and it is just drawn up as needed.
An hour later the surgery concluded. I looked around for the neostigmine and glycopyrolate. In the meantime the surgery team, nurse and Dr. Xieke transfer over the patient to the stretcher, intubated. I ask the resident, "whats going on here? Why are we not extubating this patient.?" Did I miss something?? Wheeling the patient to the PACU with an ambu bag, without an oxygen tank, he explains that they rarely extubate in the OR and will do so shortly in the PACU. I recalled seeing another patient outside our OR on a stretcher as we took this one out. The patient was connected to the ventilator and we left. Why bother giving report?? Nurses should be able to read....
No more than 5 minutes later I walked back to OR 7 and peeked though the door. A patient was already on the table! Talk about efficiency. I headed in, put the monitors on. There was no IV in the patient. Usually the nurses always put the IV in I was told.I volunteered to do it. The nurse grabbed everything for me. Nice vein staring at me. 18G in right hand. I threaded it in easily, yet was surprised there was no safety mechanism on the needle after the catheter is in. A smooth induction and intubation followed. The maintanence anesthesia included a propofol and vecuronium infusion and well as sevoflurane. The sevo was run at about 0.5 MAC, propofol at a sedation dose and the muscle relaxant at its standard maintanence (turned off about 1/2 hour before case over). I later questioned Dr. Cui about this combination. He feels that "less drug is better" and that it provides less side effects to the patient and allows a faster emergence. Ok. I guess. As I have learned during residency, anesthesia is an art and there are "many ways to skin a cat." This case was an open cholecystectomy and finished in about 2 hours. Another intubated patient to the PACU. The first patient was already gone. Extubated I was told and back on the floors. I asked Dr. Xieke how much reversal was given and he told me none. I did not believe him. Confirming with Dr. Cui, he was correct. NO neostigmine. No nerve stimulator monitoring. I bet the legendary Dr. Ron MIller would give a reversal agent after muscle paralysis, if not at least check for sustained tetany for 5 seconds at 100Hz or maybe extubate without reversing if it was a very long case. Well, things are definitely practiced differently here in China.....
Time for lunch. I'm going to show off how deft I am with chopsticks...
Destination: Nanjing, China
No General Tso's Chicken????
Tea Time
OR Efficiency
A Fiberoptic Intubation Show
Who needs American Idol...I'm on KTV
Spinal Anesthesia in an 11 year old.
A day with the bone docs.
Kidney transplant under combined spinal-epidural anesthesia.
Ahh eureka!….Could it be succinylcholine???
Watch one, do one, teach one
Oww…My back hurts!
White stuff in the heart room???
Weekend in Nanjing and Shanghai
Pain management and Traditional Chinese Medicine
Goodbye = 再见