Physical exam

Most daily progress notes include a physical exam portion to say how the patient looks, how the heart and lungs sound etc, this was the best exerpt today I found while looking through my patients

"HEEN: WNL, could use a shave"
(HEEN=Head,Ears, Eyes,Nose; WNL=Within Normal Limits)

Surgical Plan

The cardiac surgeon today announced the plan for today's cardiac case:

Out of the room by noon, without a balloon

(Referring to the Intra-Aortic Balloon Pump - a device inserted through the femoral artery into the descending thoracic aorta, used to augment cardiac output and help a person with poor heart function come off of the cardiopulmonary bypass pump)

The hard part about leaving early is avoiding the family members of patients you've just put to sleep

Paging system down

You don't realize how much we rely on the paging system until it goes down. We've turned into the hospital you see on TV, with "stat" pages overhead every 30 seconds.

heart trouble/car trouble

Sorry ma'am, the ambulance that your new heart was travelling in has broken down


(it's going to be a long day)

Monday Morning

You know a cardiac case is going badly when you walk in Monday morning and there's a case to take over in your room from last night - and that case has already been going for 15 hours!

Truth from patients

A patient said to me today - "There are two places you can't lie about your weight - when you're having anesthesia and when you're bungee jumping"

weekend call

Saturday cardiac call... doing an abdominal case for the cardiac service and an abdominal case for the thoracic service... weird.

Gall bladder

I was doing non-cardiac cases the other day... thought I might have a straight forward day for the first time in a while. Things seemed in order looking at the patient's history for a cholecystectomy (Gall bladder removal). I said hi to the patient asked a few questions and then moved along to see my other patient that morning.

The resident came up to me a few minutes later and told me there was an "issue". The history has looked unremarkable and was wondering what I had missed.

Apparently the patient wanted to take her gallbladder home with her as was getting visibly upset when the surgery resident told her that wasn't the usual procedure.

Now I'm wondering why someone would want to take a nasty old gallbladder home...yuk.

I think the gallbladder usually gets sent to pathology after these surgeries. I can only guess what they're looking for but 1)they're checking that you actually took out a gallbladder and not something else 2)possibly looking for cancer in the gallbladder... i'm not sure but that seems reasonable to me.

"I think she's gonna walk" said the surgery resident after 10 minutes of talking to the patient "I need to talk to the attending surgeon"

Apparently the patient wanted to bury the gallbladder in the backyard as some sort of spiritual closure from having it removed from her body... not too unreasonable if that's what you believe in.

The attending surgeon came down and sorted it all out.... She was not going home with her gallbladder... and she wasn't walking out.

Busy morning

It's a busy morning for me... I've got two cases to start... one of them is a Left Ventricular Assist Device (LVAD) in a really sick patient with bad heart failure.

She's in the intensive care unit and will be a transport to the OR. I'm there a few minutes early (as I try to do, but don't always succeed) I meet my resident in the ICU and he tells me the case is on hold.

"Why?" I ask.

Apparently there are two LVADs scheduled for that day, which is pretty rare. They do have two sets of surgical instruments, but there's a particular wrench which they use to tighten certain components of the device. They only have one of those wrenches. They don't want to start the case unless they make sure they have everything they need for the surgery. Of course the OTHER room has already started.

I'm more than a little annoyed... both cases have the potential for lasting most of the day... so a delayed start is less than optimal. Both cases had been scheduled since the day before, so you think that it would have occurred to someone to deal with the problem before it was an issue.

The charge nurse was in the process of contacting the representative from the device manufacturer to see if he could bring the extra wrench.

A few minutes later, they said we could go ahead. The two surgeons agreed that whomever was to the stage that needed the wrench first would get to use it first. Then they would quickly clean and resterilize it so the other could use it.

Not the best solution, but workable I guess.

In the meantime, the representative from the company was able to get there in time with extra tools so that there was actually no issue. Still much unnecessary stress for me though.

are you busy?

I'm standing the preop area in the morning talking to some of the residents before cases get started for the day. One of the preop nurses comes over...

"Are you busy?" Fateful last words "Are you covering the recovery room?"

No cases have come out into recovery room yet, "I'm not covering, but you need help with something?"

"Can you come over and look at one of our perioperative techs? She's having some chest pain? We're going to hook her up to the monitors... could you look at her EKG?"

They bring her over to a recovery slot, hook her up to monitors, everything looks okay, vital signs stable.... I take one of the residents over with me... we start getting some history.

Family history of vascular disease... pain started this morning while she was moving things around in the OR... yes I've had his before... not as bad as this time... it's always gone away.... just a little short of breath... just a little sweaty....

She looks fine to me, but the story is a little suspicious for having heart disease... soon my resident and I are wheeling her over to the ER... just to be sure.

Of course she qualifies for chest pain protocol.... they want to "rule her out" (2 sets of EKGs and blood tests 8 hours apart to see if there's heart damage) and probably watch her overnight maybe a stress test in the morning...

Never a dull moment.

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."