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The American Society of Anesthesiologists is an educational, research and scientific association of physicians organized to raise and maintain the standards of the medical practice of anesthesiology and improve the care of the patient.

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October 1, 2013 Volume 77, Number 10
Professional Transitions: Leading An Academic Department During A Critical Illness David L. Brown, M.D., Chair


Our specialty is linked to a number of occupational hazards. My story began almost 35 years ago; it was in the era when we did not wear gloves and needle sticks were frequent. This was the time of non-A, non-B hepatitis, which often ended up actually being hepatitis C (HCV). My health was really not impaired in the early years of Type 1 HCV. I still worked out daily and was viewed as being fit. My physicians and I used watchful waiting and intermittent liver biopsies to decide upon best next steps for me. Type 1 HCV has always been difficult to cure; it was my hope that my lifespan would not be altered by my HCV and I could avoid treatment. During the summer of 2011, a new three-drug regimen for HCV was approved by the FDA, and my hepatologist and I elected to treat my disease due to the increased cure rates with the new regimen. My hepatologist gave me great advice about treatment for HCV: “take the hit when you are healthy enough to take the hit.” That was lifesaving advice.

 

Interferon, ribavirin and boceprevir are together a rigorous chemotherapy regimen, and the effects were progressively debilitating. My usual 10-12 hour days as a department chair were reduced to four hours per day over a five-month period. My travel and obligations external to the clinic were curtailed. About one month into the treatment, I withdrew myself from clinical work since I was a bit unsteady at the bedside. Lack of appetite and the chemotherapy combined to produce lightheadedness, and my “good hands” for teaching regional anesthesia were no longer present. I continued to lead our institute and sought out articles about what to do as a leader when illness intervenes. I did not find anything helpful. My secretary was an important monitor of my activities during this interval, as she protected me from all but the most important issues. My sense is she and my wife had many conversations during this interval. Their conspiracy was invaluable.

 

HCV chemotherapy was not invisible. My unsteadiness and lack of vigor made our team worry about me. My hemoglobin was reduced to below 8 gm percent, and my white count was also depressed. In spite of this, I made a special effort to make walking rounds in our clinical areas just to let the team know I was still available. I recall during this interval having many conversations with our teammates when my parting comments were often, “Thank you for all you are doing for our patients.” It seemed important to me to let others know how valuable their work was and how appreciative I was for their clinical expertise. I was developing a patient’s mind! Our executive team was restructured during this time to allow our Anesthesiology Institute to keep moving forward with all the challenges facing academic anesthesiology. I was becoming increasingly fatigued; two of my “right hands” took over many important details for me.

 

Five-and-a-half months into my HCV chemotherapy, I developed Epstein Barr virus sepsis; then things became more interesting. Nearly a month in the SICU – unconscious most of the time with ARDS, SIRS and multi-organ failure – extended into seven weeks in the hospital. An irony is the SICU is part of our institute and my physicians were our anesthesiologists. After leaving the ICU, I spent time dialyzing and regaining strength. Intermittent institute-wide emails were sent to our team letting them know I was making progress; this also seemed important to me.

 

During my illness, I lost 50 pounds, most of which came out of my core trunk muscles, making balance and standing difficult. Upon returning home, I worked out intensely twice per day and received formal physical therapy as well. The blood draws to monitor my recovery became less frequent and my strength returned. My wife and family ministered to me in helping me regain weight and strength. They were with me in the hospital and there when we held a reception to “welcome” me back to the institute a month after discharge. What a wonderful time that was to greet so many. We were able to say thank you to the team that participated in my care – this was important recognition for the team.

 

I began regularly working at the office again six weeks after hospital discharge at a reduced schedule. Again, I had a sense it was even more important to walk around to rebuild relationships with our talented team after my nearly three-month absence. About six weeks after returning for four hours per day we upped my time to eight hours per day, and in another six weeks to 10 hours per day. Colleagues at the clinic were gracious to me at every turn. Our multispecialty academic group practice is structured to provide outstanding benefits, and at no time did I worry about finances. At one point during my critical illness when death for me seemed the likely outcome, my wife was reassured by the clinic leadership team that she would be fine financially – no matter what happened.

 

One of the best pieces of advice given to me during my recovery was that I should take my time in returning and make sure I was “well” before taking on too much; that was from our CEO. It was an important reassurance to me after only recently being extubated and stopping dialysis. In spite of that, I could not wait to get back to work. A near-death experience builds energy and an eagerness that is difficult to describe to those who have not had “the opportunity” for more life. Another observation is that family members of the critically ill need as much attention as the patient during recovery. Reports are increasingly published about post-traumatic stress disorder (PTSD) in ICU survivors, and yet my wife’s and my shared experience suggests family members have as much need to process the ICU experience as the survivor. We often laugh that I was unconscious and delusional during the ICU experience and that she was awake – she remembers all of it!



David L. Brown, M.D. is Professor and Chair, Institute of Anesthesiology, Cleveland Clinic, Cleveland, Ohio.


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