Epidural testing

I put in a thoracic epidural with a resident yesterday.

Epidurals are small catheters that go into the space right outside the spinal cord. We give local anesthetic solution through them and it numbs up portions of the body. They are useful for controlling surgical and labor pain. We test them to make sure they are working well. One way is to use a piece of ice and see if the patient can feel the coolness. The other is to use a "sophisticated testing device" called a toothpick to see if they can feel pain sensation.

We finished putting in the epidural and I asked the resident to test the patient. She was testing areas and the patient was amazed that she could not feel the toothpick at all...

"Give me that..." she grabbed the toothpick and started jabbing herself in the side. "Wow" Somehow she believed that we weren't actually poking her with the toothpick.

It's the first time I had a patient test themselves.

The epidural was working.

The patient decided to take the toothpick home. She gave it to her husband. "Don't throw that away... and don't use it."

Helicopter

I hear helicopters in the background. Not so long ago, as a child, I often looked up in excitement at the incredible speed, power and agility of such magnificent machines. Now more often than not (even when I'm not at work) I hear that engine noise and I think... work

soaked to the skin III

Now to help the patient you have to relieve the pressure around the heart.
Usually this is (relatively) easy. You use a sternal saw and cut through the sternum. (middle of the chest where the ribs come together).

In this case it was more difficult. He's had cardiac surgery before. Which means they've already sawn (sawed?) through his sternum in the past. This is problematic because there's sometimes lots of scar tissue there now, so if you try to get in through the sternum quickly, you make have to go through scar tissue. And in that scar the patient's aorta, which is the biggest artery in the body, may be scarred together. The other option is to go in through the side of the rib cage. Since he hadn't had any surgery on his chest from the side, there's less chance of scar tissue and bleeding.

Now, the next scene is as close as you may see to a medical drama on TV. Usually as a medical professional you say "Naw that never happens!" and you criticize the accuracy of things on TV. But, now they tilt him to the side, the surgeon throws on sterile gloves, no gown, and starts cutting though the side of the chest to get to the sac around the heart. He's got blood all over his arms, he's calling to have someone page one of his partners to help him out. In the meantime, I'm giving him lots of medication to keep his heart pumping(pressors), because now it's squeezed down from the blood on the outside of it.

His partner shows up. also throws on sterile gloves, no gown. The nurses are checking blood and giving it. All of a sudden, the blood pressure shoots up to 3 times normal.... They've relieved the pressure around the heart by opening up the pericardium. Now the heart has no more pressure around it and all the medication that we're giving to help the heart squeeze is working too....

But now there's bleeding all around the heart... they need to look for the hole that caused the blood to escape the heart and fill up the pericardial sac in the first place. It's dark in the EP lab, because most of the procedures are done looking at video monitors. Even with all the lights on it's dark in there. At this point they've fillup a whole suction container with blood (1.5 liters) we're giving blood. they're a good way towards filling a second. He asks for a certain kind of stitch... of course they don't have it in EP lab. Why would they need a cardiac surgery stitch. he puts his finger over what he thinks is the hole and yells to have them call up to the OR and get the stitches he needs. I yell to have them call up also and have them get a cardiac OR ready. I assume we'll need to go up there eventually, if we make it.

He finally gets the stitch he needs... puts in a couple more.... still bleeding from around the heart, now there's some bleeding from there entry into the chest too. "I don't know how we're gonna get this guy upstairs" he says. A couple of more stitches, some more blood given, more pressors given. he finally decides that he's got some marginal control of the bleeding and to pack some pads around the heart, to hopefully place pressure on the hole and give us a chance to get up to the OR where the proper equipment and help can be used. The pads go in, 2 stitches to hold the rib cage closed, and a big sheet of sticky plastic (think medical grade iodine impregnated contact paper) to keep the area, marginally clean. I'm a bit surprised we've managed to keep him alive this far.

We roll the patient over to get him over to a stretcher. This is what starts the soaking of my clothes. we get him moved over. we rush to the elevator and up to the OR. It takes several minutes to get up there, we're giving blood and pressors like crazy. we need to position the patient on the side more properly so he has better access to the side of the chest than he did downstairs.

I help roll the patient again, i'm leaning over the wound and it's starting to well up around the plastic sheet. now it's leaking over me, warm. I can't stop, because I know this guy's going to die, and I can't let it be my fault. We finally get organized and they're prepping the patient to go back into the chest.

we're sort of stable now on lots of pressors, but giving a little less blood... until they open up the plastic.... blood starts gushing out again. we scramble a bit. One of the other cardiac anesthesiologists shows up, asks if I need a hand. I ask him if he can help the residents out so I can change.

I scurry down the hall, my belly and crotch covered mostly in blood. I must be a sight. I go to my office, take my scrubs off, my underwear is bloody too. yuk. Luckily I have a clean pair if my office (for call nights) I go wash my hands and I'm back in the OR.

Twenty minutes later, the surgeons can't find the hole, and they're bleeding from all around the heart and incision and multiple transfusions and medications later the man's 80+ year old heart gives up.

I ask the resident if she's okay to tidy on her own and we all walk out of the operating room defeated.

Unfortunately we can't win them all.

soaked to the skin II

anyway, sorry for the delay.. where was I...

So they're doing CPR on the patient. I went up to the anesthesiologist and asked what was going on. Apparently they were doing an ablation in the ventricle and they had starting getting low blood pressure during the case, then a cardiac arrest.

Now you see some people have irregular rhythms in their hearts. Usually these are cause for little areas of abnormal tissue in the heart, they can burn these areas and usually the irregular rhythms will go away. This is called an ablation. Sometimes they burn through too much and they can get into trouble. It's known to happen, but usually rare.

The problem they have here is now they have a hole in the heart and it starts to bleed. That in and of itself isn't great, but the main problem is that the heart sits in a little sac of tissue called the pericardium (literally "around the heart"). Once it's full of blood, if you have continued bleeding it starts to compress the heart and the compressed heart can no longer fill and pump blood. This causes low blood pressure and eventally cardiac arrest. This is called cardiac tamponade. The way to fix this is to open up the pericardial sac and let the blood from around the heart out, then it can again fill and pump blood. The problem with this is that you still have bleeding and now it's not just limited to the pericardium, but can continue to bleed.


More later...

soaked the skin

As an anesthesiologist you shouldn't need to go to your office and change your scrubs in the middle of a case.

No I didn't soil myself because the case scared the heck out of me because it did, but I was covered in blood from moving the patient on to the bed.

I'm on call today and I was headed down to the Electropysiology (EP) lab to relieve the anesthesiologist down there so he could go home. I'm poking around looking to find out which room he's in. I pop my head in one room, I see a CRNA... have you seen Dr. X? Oh he was just here but he's probably next door... they're having trouble.

Hmm... that's not a good sign. I go into the room and usually the room is dark and quiet, the patient is on the bed under light sedation... they're usually pretty sick, but generally unexciting. Anyway... I go into the room, there's a ton on noise and they're doing chest compressions (CPR) A cardiac surgeon is standing near the bedside and they're pulling out surgical equipment.

(More later)

Stat!

"Staff Stat to OR Z"

Hmm.... not good. usually.

This is an alarm system we have so if there's anesthesia emergency and the staff is not in the room, the resident or a nurse can call overhead on the speakers and everyone available can come to the room to help whomever is in there.

Sometimes it's only a false alarm, the patient's oxygen level is reading a little low and the resident gets a little worried.

Sometimes it's much worse.

"Staff stat to OR Z"

I shuffle quickly over there.

I walk in, they are doing chest compressions. Apparently the patient "crashed" about 10 minutes after the start of the case.... low blood pressure of uncertain origin, didn't improve with treatment at all so they started CPR (Cardio Pulmonary Rescusitation). Emergency drugs were given.... epinephrine, atropine, all the good stuff.

After about 15 more minutes after I arrived, they called it, meaning they pronounced the patient dead, all attempts unsuccessful to resuscitate failed. The anesthesia staff in charge of the case don't know what the issue was... the patient was "relatively" healthy. Definitely will need an autopsy to see if anything obvious shows up.

Anyway, we all shuffle out, mostly feeling defeated a little.

Ten minutes later,

"Staff stat to OR 10"

Weren't we just in there?

I head back over there. They're doing chest compressions again.... apparently they were cleaning up the room and filling out the death packet and they saw some rhythm on the monitor so they felt they should give it another shot. Although in the meantime, they hadn't been ventilating the patient or watching the patient since she were pronounced dead. (why would they?)

We persisted a few minutes and then we all decided that it was probably futile... some sort of agonal near death heart reflex (which often happens).

We all left the room again... though not before I disconnected the monitor.

Sadly we can't win them all.

Computers down!

Went to a doctors appointment today. I usually go at 8am. The doctors tend to run behind and if I'm the 1st patient of the day they can't be behind. Anyway, the doors are usually unlocked at 7:45 or so. I pull up and there are three or four people milling around the door. At about 8 they open the door. I walk in and try to check in. Apparently the computers and phones were down. They couldn't check me in, they couldn't put me in a room. Fifteen minutes later, they put me in a room and found some forms to manually check me in. The doctor comes in a few minutes later, he's obviously flustered.

How are you doing? Did they check your sugar today? No of course not, the computer would have told them to do that. Sorry we have no chart, we're all paperless now. What was your last Hgb A1C? your memory is better than mine... an altogether unsettling visit. He's a really good doctor and actually remembered a lot off the top of his head.

Funny how relient we are on computers in the medical field these days. I know I couldn't do my job very well without a computer

Oh, Happy New Year