Thursday, January 06, 2005

I hate my job

I hate my job.

What is my job really. I'm a cardiac anesthesiology fellow. Which means that I've finished training to be an anesthesiologist and that I'm doing speciality training to do predominatly anesthesia for heart surgery. I'm about half way done with my fellowship. This means I'm in the gray zone between being in charge of the case and just following directions.

Anyway, today we were doing a descending thoracic aortic aneurysm repair under hypothermic circulatory arrest. This probabaly requires some explaination. A portion of the biggest blood vessel in the body, the aorta, has enlarged to a size that risks rupture at any time. The surgeon was going to repair the portion of the aorta that comes down through the chest with artificially material. This requires putting the patient on a cardiopulmonary bypass machine (the "heart-lung" machine). The bypass machine does the work of the heart and lung while it is on. For this surgery, once on bypass, the body is cooled to 18 degrees centigrade. The head is than packed in ice to protect the brain and the bypass machine is shut off. This is the circulatory arrest portion. The surgeon then cuts out the diseased portion and repairs it quickly then returns to bypass. While the bypass machine is off, no blood is flowing through the body. The longer the bypass machine is off, the higher the risk of complications to the patient, including death or stroke.

Anesthesia for this surgery is quite complex as well as you can imagine. These patients require complex monitors to watch their status during the operation. These include a big IV, and arterial line to monitor blood pressure, an introducer in a vein in the neck to give lots of blood or fluids through, a pulmonary artery catheter to monitor their heart function during the operation, as well as a double lumen endotracheal tube to isolate each lung so that one lung can be deflated during the surgery. In addition to protect the spine during the procedure, we routinely put in a lumbar drain to take spinal fluid out from around the spinal cord. All in all... before the surgery starts, as anesthesiologists, sometimes we need 2 hours or more to put all the monitors in before the surgery even starts. That is, if all goes well. Sometimes it takes longer. Today it took longer. First of all, the patient had had a difficult intubation in the past. This meant we needed to use a fiberoptic scope to place a breathing tube in the patient. The other monitors went okay until we placed the spinal drain. Suffice it to say instead of a 20 minute procedure, we took almost three hours to place the damn thing. This ultimately included calling another anesthesiologist in, moving the patient to another bed, placing him prone and using xray flouroscopy to place the catheter.... once it was in, we had to move him back to the other bed and place him on his right side, so the operation could take place. Instead of starting the actual surgery at 10ish.(Thursday is a late start day), we started at almost 2pm. About 6 hours of preping this patient before the surgery even started. I wanted to scream.

It amazes me to think that we can do this surgery at all. I'm sure these people must have just died at home somewhere, or in the mall, or at the post office, not ever knowing there was a problem. It amazes me that we can do most of the procedures that it is possible for an anesthesiologist to do before 10 in the morning.

I love my job.

3 comments:

GasPundit said...

Heh. This is one of those great cases as a med student, when your responsibility is almost zilch yet you get to see (and participate) in very cool stuff.

Also glad to hear someone who has actually done this for a while state that he/she is still amazed we can perform this surgery. I'm just a med student, but the novelty of CPB should probably have warn off by now; it hasn't. I consider it a miracle these patients survive at all. Even more so that this is done on a "routine" basis across the country.

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