consent

All surgical procedures must have a consent form signed by the patient before we go back to the OR. Most of the time this is done in clinic before surgery. The doctors describe the risks of the procedure, and weigh them against the benefits. (Sometimes glossing over the risks, in my opinion, but that's a different discussion) With some surgical services this is done the morning of the procedure before they go to the OR. (Usually with the more straight-forward procedures).

To assure that we don't miss this there are brightly colored signs at the patient bedside that scream "NO CONSENT"

I walk up to the patient and there are these NO CONSENT signs everywhere, so I start flipping through the paperwork after I introduce myself. I see a signed consent form..,

I'm surprised a bit, because the surgeons are still in the OR as far as I know someone else from the team would have had to come out to take care of the it.

The Preop nurse is starting an IV, "I see someone came down and consented the patient"

"No, she filled it out herself."

???

Apparently the patient is a recovery room nurse at another medical facility, saw the paperwork and just started filling it out herself.

Not necessarily great in a medicolegal sense, but mildly amusing to me.

platelet shortage

Interesting email this week:

This is a reminder that Thanksgiving is next week. We anticipate severe platelet shortages for the first week of December. Platelet availability will be VERY tight December 1-4. Monday and Tuesday will be the worst days since there will be virtually no blood donations Thursday-Sunday. If you have elective surgeries with high anticipated platelet needs, I would recommend rescheduling for the following week.

I guess I never thought of that, but it makes sense.

Platelet availability is dependent on recent (last 4-5 day) platelet donations. The week immediately after Thanksgiving and the Christmas-New Year holidays are always characterized by platelet shortages due to low whole blood donations in the preceding week.

morning surprise

You think you're going to have a relatively quiet day...

2 thoracic rooms, only 2 cases

one room is a late start, so no having to try to start two rooms at the same time.

Come in... pull up the computer to double check the patient's histories...

Hmmm... double lung transplant.

*sigh* it's a living

Dirty Car

Image from Wikimedia Commons Original Batmobile copyright ABC-TV and DC comics

One of the cardiac surgeons always has the dirtiest car in the lot (He must live on a dirt road or something. We were there on the weekend and he mentioned that he's going to have to find out who wrote something in the dirty back window with their finger.

What did they write on the window of the surgeon who does the most tranpslants/VADs(ventricular assist devices) at our hospital?

VADMOBILE

Hilarious... (to me anyway)

Web logs

Occasionally I go through my counter logs to see how people get to my blog.
I try to add links to blogs that link to mine, etc.
I use the free version so it doesn't tell me much.

But there's some interesting stuff.

• Links from several other medical blogs
  
• Many google searches for things:
  
  
  
  • Some medically related stuff, especially related to anesthesia
    "abdominal surgery" "cooling down on pressors medication" "scar tissue sternum" "difficult airway box"
    
    
  • "what does it mean when a doctor says a pt is a very poor historian"
    see 7/16/2007 Poor historian
    
    
  • People who are sleepy
    "i'm sleepy" "I'm sleepy the entire day" "How not to be so sleepy" "at work so sleepy" "I'm at work and so sleepy" "Why am I so sleepy" "I'm sleepy what to do" "why am i so sleepy all of the time" "im so sleepy all the time why is this" "so so sleepy"
    
    So some of these people may be looking for my blog (I don't know why they would) but I'm guessing there are lots of people out there who don't sleep well. There are many medical reasons for this. You should look on the web (which you are trying to do I know...)
    
    Here's a short list from my limited experience in the field (I'm not a sleep expert. This is not a medical diagnosis. Go see your doctor.):
    
    
    
    • Not enough sleep (at least 8 hours a day)
      
    • Poor sleep environment (Not dark enough, too loud, pets, children etc...)
      
    • Sleep apnea (A medical condition where you stop breathing when you sleep. The body wakes itself so you will breathe. Can be treated. Makes a huge difference. I know!)
      
    • Excessive caffeine and stimulant ingestion (including nicotine. I know someone who if they drink caffeine after 2-3pm can't sleep at all)
      
    • Thyroid hormone deficiency
      
    • Other medical conditions
      
    • Medication side effects
      
    
    
    
  • Always some links to some of my random images that I've "borrowed" from the rest of the net.
    "necktie.jpg" "ferret.jpg" "gastroscope.jpg" "heartvessels.gif"
    
    
  • "book called shock of your life"
    I have no idea, but here you go... Shock of your life by Adrian Holloway Go for it, it's only 11 bucks.
    
  
  

Gah!

Don't want to talk about the exact incident.

When I supervise residents or CRNAs I am responsible for their actions...

...regardless of whether or not I am aware of them.

The case was managed correctly.

I didn't know about significant blood loss until I was informed by another anesthesia provider.

Wouldn't have done anything different, would have liked to know about it.

Helpless

On Saturday I was at a popular nationwide-chain arcade/restaurant/bar and playing around trying to win enough tickets to get a stupid little trinket.

I heard a bit of a commotion. Apparently a young girl fell to the ground off a seat and her mom and little brother were screaming and crying (respectively). I rushed over because it didn't look like anyone was really helping (though there was a small crowd gathered). The girl seemed unresponsive.... I felt for a pulse and put my ear to her back to see if she was breathing... she was. I asked the mother what happened... she said it looked like she had a seizure, though she was a healthy kid and never been sick in her life. I made sure someone had called 911 and really didn't know what to do next. I'm pretty used to dealing with rough situations in the operating rooms, but in a restaurant I have no equipment, no IV, no drugs, not even any monitors other than my own senses....

The bartender came over and said he was also an EMT (Emergency Medical Technician) I let him take over, some other doctor came over, but I didn't catch what kind of doctor she was. I let him step in because I figured he was used to those situations, and besides she was breathing and had a pulse so I really didn't think i would do anything different otherwise.

I hovered a bit until the ambulance arrived and she seemed to be waking up a bit.

The rest of the evening was uneventful, but I couldn't help but wonder if she was okay, and also knowing my own weaknesses outside my usual work environment.

Time Out Day

Image taken without permission from Benches.com

Apparently it's National Time Out Day...

No we don't have a bunch of rowdy 6-year-olds in the hospital (though it seems that way sometimes)

It's a partnership of the Council on Surgical and Perioperative Saftey and the Joint Commision, and other organizations such as the American Society of Anesthesiologists and the Association of periOperative Registered Nurses, among other groups to improve safety in the operating rooms and prevent wrong site and wrong side surgery. (There have been several tragic cases of the wrong limb being amputated... etc. gah!)


For some reason National Time Out Day was June 25th in 2004, June 22 in 2005, June 21 in 2006 and June 20 in 2007. Really it's National Time Out Day-somewhere-in-middle-to-end-of-June. Guess you couldn't really have it fall on the weekend, the effect would be lost.

Anyway the chocolate bars with a timeout card and whistle were an odd touch... but who doesn't like chocolate.

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