ECT – the conflict within

DISCLAIMER 1 – EXTRA-LONG POST. You have been warned.
DISCLAIMER 2 – More importantly – this is in no way supposed to be a ‘for’ or ‘against’ type of post regarding any particular therapy/treatment – it is just my opinion and my own feelings about this experience which was very new to me. Bear with me, before rushing to judgement or conclusion – and if you already have formed an opinion without prior knowledge/experience then please stop reading further!)

For those of you who do not know, I have recently started my 6 month rotation in Anesthesia as part of my emergency medicine training, and it has introduced me to a whole new weird and wonderful world that is equal parts unexpected and fun and slightly scary but mostly awesome. But more about that later. Today (and for the past few days) I have been wrestling with some inner demons (wow, that’s not melodramatic at all!) about a recent experience and the ensuing internal conflict broiling inside me. I will try to explain things in my usual way, which is to take you on that journey with me.

So the day usually starts at 7:30 AM, and the rota tells you it’s a different theater every morning – I checked the night before and all it said was that I was assigned to a particular consultant to shadow (read badger/annoy for the rest of the day!) and that we were supposed to be in the “ECT” area (theater?) in a completely different building from the one I had been going to for operations/procedures requiring anaesthetics in the past week. My first thought was ECT? It can’t be electroconvulsive therapy? That’s not still being done in this day and age? But I texted one of my friends in the same rotation as I am, and he said this area was in the building that houses the maternity block, and I thought it was probably some sort of gynaecological/obstetric procedure requiring anaesthesia which is why I am being assigned to this and I am sure I thought of ECV – external cephalic version! I reassured myself and went to bed, woke up the next day bright and early and headed to whatever this amazing day heralded. It was not amazing. Atleast, not initially.

ECT, as it turned out, did mean electroconvulsive therapy – a treatment for drug-resistant psychiatric conditions (please excuse the rough/non-medical language) – and I found out that what I was assigned to today was in fact the ECT suite, a separate entity from the rest of the hospital- where I was shown around while I was waiting for the consultant. There was a procedure room, with anaesthetic stuff and an OT table, and a separate recovery area. There were 4 nurses, a head nurse, 2 health care assistants and 1 psychiatrist/consultant – aside from my anaesthetics consultant and absolute-novice-baby me! The whole area was very peaceful and calm, and the staff were very friendly and spoke in calm, reassuring voices even when they asked me if I would like a cup of tea. I felt myself calm down a bit (I was nervous because A- I had no idea what to expect and B- I HAD NO IDEA WHAT TO EXPECT!)

There were 4 patients on the list for today. 3 of them (the first 2 and the last one) were regulars, here for their 7th, 3rd and 11th treatments, so they did not need pre-assessments doing from an anaesthetics point of view – just a confirmation of their consent for the current procedure (consent did not mean a blanket consent for all treatments, you could consent to the first treatment and revoke consent at any later treatment session, if you were deemed to have capacity. All 4 patients today had capacity) The 4th one had completed 12 sessions of the ECT previously and that usually meant their treatment was over. But their doctor had assessed them and had thought that despite the improvement the patient could benefit from further sessions, and so they had to give another detailed informed consent – because initially they had consented to the 12 sessions, and this was adding on to what they had initially consented for. But I digress – there was just so much to take in and learn that I do not want to miss out on any of the details/finer points that I came across.

So anyway – while we waited for the first patient to turn up, my consultant took pity on the incredulous expression that I had on my face (this was without me realising it) and explained a few things to me, and looked up a very good paper for me to read about ECT. He broke down what we needed to do here, which basically entailed: introducing ourselves; confirming patient details; confirming no changes to medical/pre-assessment history had taken place in the last week since last treatment; putting a cannula in; hooking them up to some monitoring (continuous ECG trace, pulse oximeter, blood pressure, an initial temperature reading) and also hooking them to an EEG machine which is basically just like an ECG of the brain – mapping the electrical activity of the brain; administering the induction agent (usually propofol) and/or a sedative, and supporting the patients breathing before, during and after the procedure till the anaesthetic wears off.  ECT is basically electric current that is run via two ports/electrodes placed at both temples while the patient is unconscious. The current causes your neutrons to fire in a way to cause a generalised toniclonic seizure, and your brain activity is mapped continuously to make sure it has worked, and that the seizure lasts a certain length of time (usually greater than 10 seconds but on average about 30seconds in duration). It is essentially equivalent to being ‘under’ for a surgical procedure, just like you don’t feel the surgeons scalpel or drill, you do not feel the actual shock. Your heart rate and oxygen levels and blood pressure and all that jazz is continuously monitored and in the event of any fluctuations, it is handled by the team of extremely qualified individuals in attendance, as it would be in any surgical procedure. But the actual procedure was what caused me to be so incredulous. Why, you may ask? I will explain, but first let me take you through the first patient’s treatment.

This was a 50-something female, with a history of depression, and she had become so depressed that she had stopped eating and drinking, and none of the medication or combinations of medications had seemed to work on her. I had all this information from her history sheet, and chatting with the consultant psychiatrist made it clear that this was sort of a last resort. She had become anorexic to the point that she didn’t really have the strength to lift up her head from where she lay in bed, to take a sip of water. She was initially medically rehabilitated, her caloric intake monitored and her strength returned, and while she had become medically fit, her depression was still strong. She began this prescribed treatment, and today was coming in for her 7th session. She had been almost a complete mute prior to the first treatment, and was markedly different today. She walked in to the room unsupported (I thought she would atleast be in a wheelchair). She made eye contact with all of us. She smiled at me when I said good morning, and replied shyly that it was indeed a good morning. As they hooked her up to the various monitors she looked around with that smile her face, and gave adequate responses to the questions and requests from the staff members, such as May I put these ECG stickers on you?, and can I put a cannula into the back of your hand? We walked her through the procedure, put her under and after she had drifted off to sleep and we were monitoring her airway and breathing, we put a rubber/foam type thing between her teeth so she wouldn’t end up biting her tongue or lips, and then they placed those electrodes on her temples and …I don’t know what I expected, probably that the patients arms would flail around and her legs would jerk up off the table and it would all be very violent and gruesome. It was certainly difficult to see, but nothing quite as dramatic as that. She just straightened out a bit, feet became a bit rigid and there was a generalise trembling, followed by some twitching. The continuous EEG trace showed she had had a seizure that lasted 34 seconds, and while she became tachycardiac during it, she settled down almost at once after the seizure ended. She began breathing spontaneously after a few minutes and was taken to recovery as she regained consciousness. And now for the crux of this post – the reason why I was so conflicted.

All my life, or at least the last 10 years when I have been a doctor (15 if you count medical school) I have been working with the idea that we need to minimize seizures and we work very hard to figure why someone may have had their first fit, to try and prevent it from happening again, and I have been involved in extensively counselling and reassuring family and patients and parents of toddlers etc on the subject – so the ‘inducing’ of a seizure as a treatment was a bit of a shock – no pun intended! I knew the patient came to no harm from the immediate procedure, the electric current and the anaesthesia, and they actually did not feel anything, much like any surgical procedure (with the added benefit of amnesia as a known side effect of propofol!) and much more importantly, the patients reportedly feel better and they don’t have memory of it etc etc. But having never actually witnessed it before, I had quite mixed feelings about it because it conflicted with my mindset of ‘how to manage a seizing patient’ – as opposed to this current situation – once again, no pun intended! The conflict I speak about is not of the “ohmygod I do not agree with this practise how dare they?!” type of reflection, and I apologise if it sounded that way. Rather it is more of a “everything I feel inherently about this situation is basically not true!” and I had to actively try and work towards not panicking when I saw this patient seize. And the one after that. And the one after that. It didn’t get any easier, and I didn’t get used to it and it really bothered me. I didn’t know what really was most bothersome for me. Was it the fact that I pride myself in being completely professional and see all sorts of unexpected medical scenarios and presentations as an emergency medicine trainee with the calm and focussed approach that is taught and cultivated in my specialty, but that in my almost 6 or so years of emergency medicine experience, I have never been this affected by any procedure or situation? In other words, was it the procedure that had bothered me, or my own reaction to it?

A few positive notes/observations from the day –
*Any patient who can consent because they are deemed to have capacity will be asked for their explicit consent for the treatment, and they will be given the full information regarding it. Out of the 4 patients scheduled for the day, the 3rd one who was coming in for her 13th treatment (having completed 12 previous ones and deemed to still be in requirement of a few further sessions) came in and then declined to give consent for the next one. And, even though she had consented for 12 sessions and had had them, AND she had the capacity to refuse at any time, we respected her decision and she went home. We didn’t just strap her down like a bunch of frankenstein-y mad doctors while cackling in high pitched laughter to administer jolts of voltage against her will – though I will be the first to admit this is what I thought when I first found out I was in the ECT suite, that this was my unfortunate concept of ECT, based on nothing but my (very vivid, it turns out) imagination.
*Also, it has been around since 1938 – there is tons of research on this topic and while it is all shrouded in controversy mostly due to preconceived notions and ideas, there is no denying the absolute faith people have in this treatment.
*The sons of the first patient who’s treatment I detailed earlier were sat outside in the relatives’ room and while the patient was being wheeled to recovery, I went and asked them how they felt the treatment was affecting their mum. They both agreed there was a distinct difference in Mum, that she had begun enjoying her meals – looking forward to what was on the menu for the day,  offering to go to the park with the grandchildren and making plans for one of the sons’ wedding that was supposed to be an out of country type thing. This was in stark contrast to her being in the throes of progressively worsening depression since their father had passed away a few years ago.
*They don’t just administer this treatment without trying anything else.
*It is not like touching a live wire; you don’t feel anything – you aren’t zapped like a Tom&Jerry cartoon situation. In fact, the voltage is so low that I was surprised that while the current was being administered, one of the nurses had their hands on the patient’s chin as a reinforcing/reassuring measure. They were clearly not feeling the effects of a transmitted significant voltage, unlike in a cardiac arrest situation if you administer an electrical shock, you have to be clear and not touching any part of the patient’s body lest you get a shock as well. It is all very professional and clean and protocol-oriented.
*There are a lot of good people working very hard to make the experience as comfortable and easy for the patient as possible.

At some point I will probably do some research into the subject. It has certainly piqued my interest – but I am ashamed to admit I won’t be looking forward to the next time I get assigned to this area, and I dread looking at the rota announcing when I am going to go there next. And at some point I may actually grow to appreciate the whole process. And look beyond the obvious conflict. But today is not that day. Sigh.

Anesthetics introduction – teaching day

(very rough edit of the knowledge gained from this teaching day – will edit by tonight.)

Introduction given by first speaker – (I missed out the first 10-15 minutes of it, maybe longer, was searching for parking) Gave a few pearls of wisdom, in particular, the Royal College of Anesthetics e-learning website link

2nd speaker – Difficult Airway
objective is to oxygenate – help with ventilation
can be by mask, tube through nose or through mouth, or through trachea
airway assessment — HISTORY -check for pathology – burns etc, identify previous anaesthetic history, charts etc, visualisation of laryngoscope views – grades
clear is grade 1, partial block is grade 2 (take home message was that 1+2 easier) EXAMINATION – multiple airway assessment tests – none accurate enough – 5 things most important to be done – 1)-how likely to face mask ventilate, tight seal etc, facial trauma, elderly, dentures, sunken face, high BMI, snorers/sleep apnea – /2)-mouth opening – 3 cm magic number, estimation usually, LMA/laryngoscope fit, foreign objects, tumors, masses – 3) – neck movement ‘sniffing morning air position ‘ flex neck, extend head trying to align the axes for optimum visualisation, 4)-malampatti score (4 classes – first gen reassuring. upright,mouth maximum open and tongue protrusion max, visualise tongue, posterior, uvula, tonsillar pillars
DAS difficult intubation guidelines – 4 plans need to be aware of
(5)-cricothyroidotomy explained theoretical but not practically ever used – worth knowing in case ever required – explained cartilages etc and neck surface anatomy – I noticed everyone palpated their neck involuntarily, including me!)
priority is ventilation not intubation – whichever way that may be achieved

3rd speaker – PRE-ASSESSMENT
HISTORY (what surgery, elective/emergency, major/minor, PMH, systemic review, medications, allergies, anticoagulants, any prior problems with anetshetics/personal or familial – any surgery to same site, starvation time, risk of reflux, dentition, how they have been in last few weeks, assessment of fitness (climb upstairs) , less than 4 mins exercise tolerance is not good for anaesthesia/ EXAMINATION (gpe, murmurs, chest, vascular access, airway, the back, high BMI, positioning)/INVESTIGATIONS (confirm, assess or alter risk – depends on patient)/MAKE A PLAN (think about conditions cvs -heart failure,aortic, mitral stenosis, ACS/MI within 3 months; fracture NOF)
Preassessment is your own personal way to do things, no perfect way: “there are many ways to skin a cat” (!!!)
patients risk of undergoing surgery/undergoing anaesthesia (?high risk patient, ?high risk surgery, ? high risk anaesthetic) for each problem identified, has it been optimised as much as possible, or how can the risk be reduced/optimized, and do you need to change your plan.
PLANNING
– pre-operative – optimisation any more investigations, treatments, fluids/inhalers etc, ask for help if needed.
intra-operative – technique, induction, maintenance, wakeup
post op

CONSENTING THE PATIENT – Royal college website (anesthetics rcoa pils) details consent information for any medical condition/procedure
complications – sore throat, dental damage, cuts to lips etc, pain, nausea, anaphylaxis, death, loss of airway, awareness and regional complications – low bp, particularly with obstetrics, itching, urinary retention, headache, failure of procedure, infection, bleeding, nerve damage (1/50000 spinal, 1/13000 epidural)

4th speaker(s) – scenario enacted by actual anaesthetic consultants and fellows from the department – to give an idea about how things go in theaters. walking though an actual scenario – from introduction, consent, explanation of steps to patient, end tidal co2, patient under, putting tube in under vision – grade 1 view – inflating cough, good chest rise – end tidal trace, fix tube. looking at the monitor —–smooth induction

5th speaker – anaesthetic drugs
induction agents – 1)propofol -lipophillic, stings a bit, onset 20-30 seconds, 2-3mg/kg generally 300mg given, bradycardia, propofol infusion syndrome 2)thiopental -4-5mg/kg onset 10-20 seconds, tachycardia
muscle relaxants – neuromuscuar blocking agents – depolarising (suxamethonium, succinylcholine) and non depolarising (atracurium, rocuronium, pancuronium, vecuronium)
inhalation – no2 (not very common), sevoflurane, isoflurane, desflurane
reversal – anticholinesterases (neostigmine usually, sugamamadex – newer drug)
other drugs
MAC – minimum alveolar concentration of anaesthetic agent which is required to prevent movement in 50 percent of patients.

6th speaker – anaesthetic equipment

LMA – must have absent airway reflexes, cuff deflated, muscle relaxant not required – but is not a definite airway (vomit, aspirate)
i-gel – preferable
ETT – SIZE – 8 FOR MEN, 7 FOR WOMEN, AGE/4 +4 PAEDS – definitive airway
uncuffed for smaller children; RAE tube – out of the way of head neck surgeries.
bougies – angle tipped rubber tube, aid intubation
laryngoscopes (under direct visualisation)- mac (size 3 adult, size 4 for large adults), mccoy (lever to lift epiglottis), miller (paeds)
indirect laryngoscopy -in cases where visualisation is not optimum. e.g. airtraq, mcgrath (video laryngoscope)

breathing circuits –
APL VALVE
Bain circuit – most commonly used
BMV – AMBU BAG
WATERS CIRCUIT

Anesthetic machines
PENLON NUFFIELD 200
draeger primus – main anaesthetic machine
explained the charts etc – lots f abbreviations lots of number, lost of values and waveforms and colours – confusing but will become second nature to us! reassuring? not really!

7th speaker – chat with an ODP who tells us about his experience and his duties and what is required of them and of us – they check the instruments, the machines prepare trolleys, the tubes, the drugs etc for each interaction – make sure everything is clean or new or usable, batteries etc, lights of the laryngoscopes etc, and going through the checklist, who’s checklist – (something that he asks the whole room if they know about and they all say yes, but I have never heard of. yikes.) they also offer suggestions, ideas, but the final responsibility of what is happening is the anaesthetists. they won’t draw the medication, they won’t give meds (unless emergency situation) here to help you, work with you and make sure your training opportunities are met and are fulfilling – someone asked what pisses you off – lots of laughter – nervous, me thinks?

8th speaker was just the first speaker again – qualified the previous talk with “know your ODP, they will be your best friend”

BREAK FOR LUNCH (not provided *frown*)

Coming back in from lunch to another scenario that started off as a smooth induction but then went on to become a critical incident (penicillin administered to a patient with no known allergies – while undergoing surgery) – some hilariousness ensued as the “surgeon” put her hands up when the patient became critical and watched as the “anesthetist” dealt with it all, even exclaiming “oh is that what is done?” when the anesthetist administered epinephrine as part of the anaphylaxis treatment. *titters of laughter*

9th speaker – vasopressors/pharmacology
background – vasoconstriction, inotropic effect, sympathomimetic – alpha 1 blood vessels, beta 1 in lungs, beta 2 are in lungs, blood vessels
indications – hypotension due to whatever reason – treat if >30mm hg drop from baseline systolic BP or MAP <60, or any evidence of hypo perfusion/end organ damage – always fluid resuscitate before chronotropy.
most commonly used agents – ephedrine (synthetic sympathomimetic), metaraminol (mainly alpha effect, can be given peripherally, reflex bradycardia) and noradrenaline (usually for very sick patients in profound circulatory failure, both alpha/beta actions, needs to be given via central lines)
others – adrenaline (all adrenergic receptors, asystole, anaphylaxis), dobutamine (beta 1 agonist – cardiac effect, should be given through central line), dopamine (central neurotransmitter)
Points to consider -access : peripheral vs central ? arterial line if needed, boluses, side effects, tachyphylaxis (with long term treatment, receptors become desensitised), arrhythmias

another qualification from speaker 1 who I feel might be the head of the department or atleast leading this day. “These drugs are your best friend!”

10th speaker – one of our peers from an ACCS program currently rotating in aesthetics/itu somewhere : hemodynamic monitoring
NIBP, HR, pulses, mental status, etc do the basics
Invasive – ARTERIAL LINES (continuous BP monitoring, trends etc with drug administration, ABGs, posy-major surgery) commonly put in the radial artery (always do the allens test) discussion of types of art lines followed by a discussion of how to put up and put in an art line (OFF TO PATIENT OPEN TO AIR), complications (air emboli), can stay in for a week; CENTRAL LINES (cvp measurements, medications that can’t be given in peripheral lines), goes in a big vessel, should all be usg guided, patient positioning important, aseptic non touch technique, explanation of the technique (excellent explanation and demonstration, including usg) followed by blood gas, transduction image and a car – also discussed complications, how to measure cvp (normal cvp 0-8) – web links provided – frca
session in the middle about us being able to handle the instruments and ask questions

11th speaker – introduced himself as the last speaker of the day (thankfully!) with 9 slides to his presentation and the first slide was his name and he reported the last slide is thank you and any questions.
analgesia – definition – unpleasant sensation associated with emotional connotation related to tissue damage
types/managements/etc etc This part was particularly vague for me as I was just checking the clock by this time, looking forward to the long drive home.