Archive for February, 2006


Graduation Plans

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Dear All,

Your graduation is approaching rapidly. If you have not done so already, get together as a class soon and get some ideas going for a graduation celebration. Each of you will need to pitch in and assign yourself to a committee.

If you need to do a fundraiser, I highly recommend the USC Anesthesia sweatshirt, t-shirt, and hat sales from last year’s class. Thanks to the 2005 grads, you have a nest egg to start up a project such as this. Besides, there a number of people asking for these items, both local and international!!!

Let me know what you think.


May you always do for others and let others do for you.

Bob Dylan

Categories : Anesthesia
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Eric Has a Lesson To Tell

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A couple of weeks ago I heard that Eric had a “heart attack”. Really, I said at the Monrovia bicycle shop as we prepared to go on a regular Sunday morning ride with the group that gathers there. Eric I know was this fit 40 something guy that rode hard and looked to be in good shape. Hearing that he had suffered a heart attack was certainly suprising. I am so glad to hear that he is doing well and returning to us. Here is his communication recounting his trial and hope for the future. Be well Eric and I will look for you at the bicycle ride in a month or so.

Dear Friends,

So by now I am sure you have heard the news. I had a heart attack! I just got home from the hospital and it’s been a long four days of tasteless food, needles, no sleep and enough poking and prodding to make a proctologist shutter. Let me start from the beginning.

So there I was, relaxing in Hawaii with my good friends Garnett and Fred from Vancouver. They invited me to join them for a few days of relaxation with their families. Apparently they thought I was stressed out and could use a few days on a warm, sunny beach. (As it turns out, I’m the only person in the world who can go to Hawaii to relax and instead have a heart attack!) So on Monday night, after a relaxing day by the pool we all went out for a nice dinner. After dinner we went back to our hotel and went to sleep. I woke up at 4:00 am and headed straight for the bathroom. As good as dinner was, it was not sitting well. After a few hours of praying to the porcelain god I mustered up enough energy to crawl back to bed and go back to sleep, all the while thinking I had food poisoning. Oh how wrong I was.

I spent the next day, Tuesday, in bed. I was tired, short of breath and I had a tight feeling in my chest. I assumed the tight feeling was a result of the massive amounts of throwing up I had done earlier. (I know what you are all saying, duh Eric, tightness in your chest, that should have been a red flag! Well Mr. and Mrs. Know-it-all’s, hindsight is always 20/20, isn’t it?) So I enjoyed my remaining 2 days in beautiful Hawaii curled up in the fetal position, hating life. My friends begged me to stay and see a doctor in Hawaii instead of flying home to LA especially because there was now pain in my right arm. They tried to tell me that if something happened to me while I was flying home over the Pacific Ocean that I was pretty much out of luck unless there was a doctor on board. So I got on the plane and braved the six hour flight home. When I got back to Los Angeles I was completely exhausted. I couldn’t even walk up the one flight of stairs that leads to my house without having to sit down and take a break. I was starting to wonder if I really had food poisoning or maybe it was something else.

The next morning I took a shower, had breakfast and went to work. I called one of my best friends, Tommy Dyo (an EMT) and told him how I felt, he told me that if I didn’t go to the emergency room that he would physically drag me there. My employees then took the initiative and forced me to go. All the while, I was on the phone with the nurses at Kaiser Hospital who were telling me to come to the emergency room immediately, chest pain was no laughing matter. Then at about 12:30 pm, Christine, my girlfriend, took me to the emergency room where I was immediately admitted, apparently chest pain was no laughing matter.

Upon my admission to Kaiser at Baldwin Park, I was immediately put on an IV, given an aspirin and a nitroglycerine patch. This is standard procedure for anyone who comes into the emergency room complaining of chest pain. The nurses hooked me up to an EKG machine and took blood. The EKG came back normal but the blood test showed otherwise. The nurses told me that one of the things they tested my blood for was the enzyme troponin. Troponin is an enzyme that is only present in the blood when there is damage done to the heart tissue. In a normal person there is a troponin level of .05, my troponin level was 11.34. In short, I had a heart attack. I was in shock and in disbelief. There was no way I had a heart attack. How could I? I was healthy, I ate well and I exercised regularly. I was not a candidate for a heart attack.

I was then introduced to my emergency room doctor, Dr. Lee #1. Let me take a break from explaining the time line of events during my hospital stay to point out the ethnic makeup of hospital workers everywhere. During my 4 day stay in two different hospitals, I noticed a strange trend, all of my doctors were Chinese, all of my doctors were named Dr. Lee and they all had Chinese New Year plans. As it turns out, it is the year of the dog and I was their little bitch! There was a similar phenomenon (or conspiracy??) with the nursing staff. Every single one of my nurses was Filipino. You know that section on a job application that asks for your ethnicity? For a nursing application there should only be two choices, Filipino or other. In four days I did not see one white, black or Hispanic nurse, only Filipino. Coincidence? Anyway, Dr. Lee #1 and I became very close, very fast. Before he would administer blood thinners he had to stick his finger up my butt, truth be told, it did not feel so bad! But did he really have to do it three more times? I think he owes me dinner and drinks.

After Dr. Lee #1 became thoroughly familiar with my insides, I was transferred from the emergency room to my permanent room on the fourth floor. Here I was introduced to my nurse (yes, she was Filipino) and my 4th floor doctor, Dr. Lee #2. My nurse showed me how to use the TV, which didn’t have cable, how to call her if I needed her and gave me my thermos. I looked at the thermos and told her I was not thirsty. She politely informed me that I was not supposed to drink out of it, I was supposed to pee in it. Confused, I told her that I would have no problem using the bathroom that was only 3 feet from my bed. Again she told me that I had to use the thermos because she collects the urine. Sarcastically I replied, “That’s cool, I collected stamps.” She didn’t understand my joke, maybe it’s because she’s Filipino.

Following the Angioplasty I was taken back to the Angio preparation area where I was asked to sign numerous forms by more Filipino nurses. After I had signed my life and the hospital’s liability away, I was taken to my room where I would spend the night under the watchful eye of more Filipino nurses. I was taken to the floor of the hospital where they kept the people who were older than dirt. My roommate told me he and Moses went to grade school together. I was by far the youngest patient on the floor. To keep the blood flowing the nurses encouraged us to walk around every once in a while. Imagine 20 or more 80+ year olds shuffling their feet through the hallway hanging from IV poles with their naked butts sticking out of their hospital gowns. It reminded me of a scene from “Dawn of the Dead.”

Later that night one of my Filipino nurses came in to check on the incision near my groin where the Angioplasty was done. It became obvious to the nurse that the medication was wearing off because I had a huge erection under the sheets. She lifted up sheets and said, “Someone must be feeling better!” She returned 30 seconds later because she realized she forgot to check my incision. We both laughed and I went to sleep.

The next morning I woke up with the face of Steve Van Doren staring back at me. I was very glad to see him, truth be told, I was just glad I wasn’t staring into the face of St. Peter! Steve made me laugh all morning until Christine came to rescue me from the hell that was the “Kaiser on Sunset Older Than Dirt Ward.” They were more than willing to release me, but not until I spent my life savings on a three month supply of medication. At this point in time I would like to make a public service announcement. To all men (and possibly women) who are excessively hairy: Please realize that the sensors used for the EKG machine, the tape used for IV’s and any other adhesive material the nurses may feel the need to stick to your hairy body, are made with industrial strength glue. And I won’t lie to you; it hurts like hell when they remove them. For your sake, when the nurse asks you if you would like to be shaved in the places the stickers are going, for goodness sake, say yes! Picture this, me, the hairiest person in the world, covered with super glue strength stickers and the doctor tells me it’s time to go home. I was very excited until I realized that the stickers had to come off. It was like a scene from “The 40 Year Old Virgin.” There I was, lying in bed having these stickers torn off of me one by one as I watched all of my hair being torn off too. This was by far the worst part of my hospital stay.

After we left the hospital I had a hankering for food, nothing in particular, just anything that wasn’t apple juice in a plastic cup or powdered eggs. So Christine and I made a beeline for Wahoo’s Fish Tacos and I ate until my heart was content. There you have it folks, I, Eric Elkaim, a healthy 42-year old male with no blood pressure or cholesterol problems, had a heart attack.

At this point, I would like to thank my friends and family who showered me with love and care during my time in the hospital. The love came in the form of phone calls, letters, flowers, soup and personal visits. I especially want to thank my Mom, my Sister, Tommy and Melissa Dyo, Rick Kitamura, Marc Middleman, Mark Ferrari, Christine Medaglia, the crew at PartyWorks (Jordan, Juan, Freeze, Ob1 and Darian) and all the hospital and support staff at Kaiser.

Peace and Love,


P.S. To all the 40+ year old men and women reading this letter, please take the time to make an appointment with a cardiologist today. The appointment will only take an hour and it may possibly save your life. Trust me; your family will thank you.

Categories : Cycling, General
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Correspondence can bring many things. Recently there has been a lot of mail, much of it from friends and family with discussions of life, projects and goals. I even had a request for money recently from a needy soul that could not be turned down. What I wanted to share today was a series of communications from this last week that has occupied my mind for several days. Maybe after reading these you too will pause and consider what a gift we have been given to serve and learn from our patients. Their contribution to us is tremendous and must never be forgotten. This is a sacred trust that I am appreciating with a new understanding. Thank you Jim for that. It starts with a letter from Jo. I find her vignette interesting and instructive but what comes later is beyond instructive. Let’s see what you think.

Hey David, here is a funny story,

As student nurse anesthetists we are fortunate to have some common sense especially since we have some critical care background and have actually touched patients. Anesthesia physician residents often do not have this luxury. They get thrown into an operating room because they have graduated form medical school and are expected to perform. While SRNAs are guided on how do things should be done in the operating room for a long time.

Recently I heard a story about a M.D. resident that was interesting. The surgical case involved a patient scheduled for a total knee replacement with an epidural catheter and an Laryngeal Mask Airway (LMA). A Nurse Anesthetist enters the OR to send the physician on a break. The patient is breathing 38 breaths per minute and chewing on the endotracheal tube. The physician states, “Oh that’s new this must have just started”. Propofol is then slammed intravenously and B/P drops precipitously and then the low blood pressure is then chased with ephedrine trying to bring the blood pressure back up.

There is a lesson to be learned here. You can’t blame the physician resident because many times when they are new in their training they do not have sufficient oversight. The patient obviously needed something other than slamming propofol – possibly a dose of narcotic and not hypnosis. The epidural was infusing but did the patient get a loading dose up front? These things may all effect how the patient was tolerating the surgery. What I have seen clinically is that when epidurals catheters are working well you need far less opioids and less volatile agent as the MAC is lowered. These patients usually wake up very comfortable.

The morale of the story is to feel good about the education that we receive as nurse anesthetists and feel proud to be apart of this prestigious profession of Nurse Anesthesia. Remember that 65% of all rural anesthesia is given by Certified Registered Nurse Anesthetists (CRNA’s). Some day you might be taking care of me or my loved one and I want the best and most competent anesthetist on the job.


At first I glanced over this note from Jo and scribble a few notes to myself while reviewing the many interactions that I have had with residents. Jo is a dear friend of mine – however I find that her reasoning incomplete. At least there is more here that is bothering me that I can not mine fully. She states correctly that patients with epidural catheters require lower MAC and less opioids then proceeds to disparage the hypnotic and suggest that the patient needs additional opioids? I began thinking that the idea of giving more opioid for a light patient is the wrong choice and her criticism of the resident could take a different slant. For me the propofol is not a wrong option but the lack of vigilance by the resident deserves comment. So ran my thoughts. To confirm my suspicions I ran off a note to a friend, we’ll call him ‘John’, a long time anesthetist back East. I was dealing with the trees and not the forest. My thoughts continued at that time this way:


…I was not there in the OR and all of this is second hand information but an interesting discussion about CRNA SRNA and Resident relations mainly. We all have our prejudices I guess. For me the physicians do just fine and receive extensive training. At times in the beginning of their training there may be things that happen that are not the best practice. Who is to say that Student Nurse Anesthetists do better really? Personally I do not find it profitable to compare providers but to look for a best practice regardless of the practitioner. John, I thought you might get a kick out of this story and look forward to your comments on the scenario. Hope all is well with you and that your scheduled surgery goes well. I am wishing you all the best from Los Angeles.


The response I received back has been lingering in my mind for the past few days. When I started the web site my goal was to try to put together something with content that would be both instructive and entertaining while showing what it is like to be a nurse anesthetist student. John goes beyond my expectations.

Hi, David

I have many thoughts tumbling through my head at this stage of my career. As to the story your friend related, I find your take on it to be the more reasoned. Yes, the average SRNA is probably much more oriented to the care of the patient, by virtue of the nursing background. This stereotypical SRNA is also more clinically astute because s/he’s been on the front lines, watching actual patients get better or get worse and die, so s/he has earned to look at everything, make no assumptions, and always to keep that “sixth sense” activated whenever s/he is responsible for a patient. Those hard-earned lessons from the ICU on a 12-hour night shift do stand the SRNA in good stead.

And it’s probably true that the average MD trainee at whatever stage of her/his training is probably less experienced and clinically seasoned; more educated in basic sciences than the average RN (notice I said “more” educated which doesn’t necessarily equate to “better” educated). But a friend of mine long ago put it this way: “Good nurses know a lot about medicine while good doctors know a lot about nursing”. When I look back to the people who had the most influence on my developing anesthesia career (and it’s STILL developing) I find nurses who took it upon themselves to be very educated (and very WELL educated) and physicians who had that common sense and humanitarianism that is stereotypically viewed as the hallmark of nursing. What each had in common was a curiosity that motivated their learning, a humility that taught them that their learning would never end, and an empathy for the suffering patient who was at once her/his sacred responsibility and greatest teacher. The other thing they had in common was my enduring respect; you see, I’ve seen callous CRNAs and empathetic and truly altruistic physicians. We must be careful not to be guilty of that error which we decry in others: judging an individual by the letters behind the name and not the character attached to the person.

As to your friend’s assessment of what was needed, we all know that anesthesia is a complex specialty. From first principles, the patient should never have been allowed to come to such a state, under the care of an anesthesia provider, that the patient was chewing the tube and breathing 38 breaths per minute. The rescue of the patient from that unacceptable state can take many forms, some better than others. The bolus of propofol was a “fast” answer. Fast is important, but one must be careful not to overshoot lest one have to engage in the “dueling drugs” scenario as your friend described chasing blood pressures all over the place. You made another astute observation: “I wasn’t there…” This is a very mature approach to analyzing anecdotes about cases; you know that not everything that happens can be reduced to marks on an anesthesia record, and that even the most careful observer is biased to some extent.

I have a feeling that neither you nor your friend would have gotten yourself into the situation of needing to rescue the patient from inadequate anesthesia. In a couple of jobs I’ve had in the past, we’ve had trainees rotating through the anesthesia department. Now, I’m always careful about generalizations, and the following observation is given with the very large caveat that generalizations are poor tools to explain things. That said, I noticed that there were in general two “styles” exhibited by anesthesia trainees. One style was more “high tech” and the other more “high touch”.

One manifestation of this was the manner in which the trainee monitored the patient. Some stood with their backs to the patient and watched a bank of monitors. These tended to miss things that a more experienced onlooker would see evolving before they manifested themselves on the monitors. These were the “high tech” ones. Many were very intelligent — far more so than I — and usually more educated as well. As a generalization, these were doctors. Others gave their primary attention to the patient, and looked to monitors as a secondary information source, to validate their clinical impression of the evolving anesthetic. Most of their time was spent seated or standing in close proximity to the patient, their backs to the monitors. Sure, this has elements of a false dichotomy, but by and large, these latter were nurses. They didn’t treat numbers, they treated patients. And they usually “picked up” things before the “things” became “problems”.

Sometimes the “high touch” crowd couldn’t even characterize what it was that was about to go wrong. Usually the “high tech” ones could recite the “book learning” about what had just gone wrong. If you haven’t found this out already, in anesthesia it is frequently the case that we are too smart too late. You’ll also know the daily reality of something I once read: Most great discoveries are presaged not by the exclamation “Eureka!” but by “Gee. That’s strange….”

The only good thing that came out of Jo’s experience is that you are talking and thinking about it and learning from it. The occurrence of inadequate anesthesia in this patient — the failure of our specialty, the patient’s trust betrayed — became, if you will, a “chance experiment” in the laboratory that is your learning. No Institutional Review Board would ever have approved of the situation into which this patient had been allowed to deteriorate, even for the pragmatic good of your learning. But it happened. Remember, “stercus contingit”. You have been handed a learning opportunity, purchased at a very high price by your patient. Learn from it, get all you can out of it. And, as you progress in your career and teach others, remember the debt you owe to that patient, in whose care an error was made, allowing you to learn from the remediation — and yes, even the “cover up” — of the error.

Here is where I have a huge problem with many physicians with whom I’ve worked. There’s an attitude of entitlement. “I earned this degree. I got out of training with six figures of student debt. I am owed”. No. Wrong, wrong, wrong. They are who they are, they know what they know, and they have what they have, because of an unending string of patients who held still for their first clumsy attempts at the laying on of hands, who suffered at their mistakes as they repeated lab tests and painful procedures, who died at their imperfect hands — at all of our imperfect hands. David, I submit to you that this is a debt that can NEVER be repaid; the currency to satisfy such a debt has never been minted, nor could it be.

I recently had a physician make some comments to me in passing. I think he meant to encourage me; I’m not sure. He commented on my skill at regional anesthesia, especially in the massively obese parturient with whom we’d just dealt successfully. I described how I’d evolved in my skill to a peak several years ago, and how I’ve had to refine my skills as my senses and strengths change. I used to palpate everything, and my sense of touch was my paramount one. As I age, my tactile sensation has diminished, and I rely more on vision. And even that is failing as I approach my seventh decade of life. But I continue and I do my job well and carefully. He expressed surprise when I told him how old I am — that surprises everyone because I’m blessed with a youthful appearance. Then he told me that he doesn’t intend to work past the age of sixty, not at all while I intend to work until it would no longer be safe for my patients for me to continue to do so. I’ll know when that is, and a carefully selected group of people with whom I work will validate that judgment. Only then will I pursue a lesser career, and I will leave with reluctance and with regret for that huge unpaid debt, with gratitude for every patient who has taught me what I know. For now, CRNA doesn’t describe so much what I do as who I am.

PS: My surgery has been put off until the 22 of this month. Several things have to be in place for it to take place, one of which is some sort of fibrin glue to be used in the repair. I am blessed to have tissue that doesn’t act its age, and a “sports medicine” orthopedist who normally limits his practice to athletic injuries in genuine athletes. He’s agreed to apply his skills for an old man who fell on the ice, whose “athletic” prowess is confined to paddling canoes and kayaks to photogenic places, or slogging along on a mountain bike or cross-country skis to places that aren’t crowded, and whose major competition is against entropy — and gravity. His method includes aggressive rehabilitation. It will return me to my “playing field” sooner, and ease the overwork my absence will impose on my partner and our already thinly-stretched locums. That’s important to me.

Thanks for your kind good wishes. I’ll keep you posted. In the meantime, work is busy, and that’s great therapy.

Categories : Anesthesia
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