Newspaper

I was explaining the risks of anesthesia to a patient before cardiac surgery... the patient said "no problem, I'm not going any where". I said I just wanted to make sure we were on the same page. The patient said "As long as I'm not on the front page, nor on the back page (obituaries), we're in good shape"

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

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.

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 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.

Sick

It's that time of year again. Time for flu, colds, etc.

I was in charge of making sure rooms in our building were assigned to residents and faculty the other day. This includes assigning where add on cases go and making sure people get breaks and lunches and relieved at the end of the day.

One of the residents came up to me and told me he might need extra breaks because he's been having some "GI (gastrointestinal) problems" and been running to the bathroom. He said he was probably going to the emergency room after work because it had been going on for five days or so.

Yikes! A few minutes later his faculty came up to me and said his resident looked terrible and diaphoretic (sweaty) and should be sent home. I agreed and called over to the main building to see if there was someone extra to send over.

I went to his OR and told him we were sending someone over to relieve him. He protested and wanted to stay. "This is an interesting case, and I need my vascular cases"

I said, "If you need to go to the ER after work, you need to go to the ER now. You can't get your vascular cases if you fall over. You can always come back if you're okay"

He finally agreed and he was sent home. I think he didn't need to be admitted to the hospital, but earned himself a CT scan and lots of blood tests.

A couple days later, a (different) resident popped into my office.

"You in charge?"

"No, why"

"I just threw up I think i need to go home"

"Fair enough Dr. X is in charge... he just walked past here"

I went out to the break area a few minutes later.

I overheard, "X looked terrible"

"I heard she threw up"

"She must be pregnant"

Laughter from the guys. "No think she's actually sick, she looks terrible"

She walked back by, looking annoyed "I'm NOT pregnant"

Shock of your life

Image used without permission from freepatentsonline.com

I'm staffing a case down in the Electophysiology (EP) lab. Here is where the cardiologists look at the heart from the inside and do various procedures to help fix conduction abnormalities in the heart. They implant defibrillators and pacemakers in the EP labs.

There was a young man on the table, we were getting ready to sedate him for a procedure for an irregular heartbeat. Our anesthesia monitors were being put on and I was looking at the chart. All of a sudden I saw the patient jump up... I thought he was trying to crawl off the bed. Then someone started apologizing....

Apparently she was testing the external defibrillator. This is the device used to put a shock through a patient's chest to put it his/her heart back into a regular rhythm if it goes into a dangerous rhythm. You see this all the time on ER and Grays Anatomy and such. Anyway during this procedures where we are trying to cure these rhythms there is a high likely hood of putting a patient into one of these dangerous rhythms. So as a precaution they always have the external defibrillator in the room and two electrode patches on the patient. In this case during the test of the device someone had already hooked it up to the patient. So this patient got quite a nasty shock. He shook his head like he was stunned and said he was alright three or four times... all the staff were really apologetic.

This would have been a little amusing to me except for the fact that when a person is in a "normal" heart rhythm, shocking them may put them into a dangerous one that is life threatening.

Glad it wasn't me though

Neck mobility

I was in preop anesthesia clinic yesterday. I saw a patient that had been in a car accident and had his neck fused c2-c5 (I believe) and he had very little neck movement at all.

In anesthesia there are markers to predict or at least suggest it may be difficult to place a breathing tube in someone. These include mouth opening, dentition, mallampatti score, which assesses the favorablity of the anatomy of the oral cavity (i.e. mouth), hyoid to mentum distance (essentially chin size), neck thickness/anatomy, neck extension and flexion. No one predictor predicts a difficult intubation, but together they form a picture of how easy or difficult you think it might be.

Someone with very limited neck movement would be very difficult to visualize the vocal cords generally, so I was worried a bit in this case. Apparently he had had two surgeries in the past six months with no problems and the anesthesiologists had not told him anything about his airway. So just to be sure I requested the anesthesia record from the other hospital.

It was your standard anesthesia record, with lots of checkboxes for standard things that you do in the operating room.

Easy mask ventilation - checkmark -- reassuring because that means you can still mask ventilate if you happen to have trouble intubating.

Iv induction - checkmark.

Easy intubation - checkmark

Mac 3 - checkmark

2nd attempt - checkmark

Blind intubation - checkmark
whoa.... wait a minute. it was an easy intubation, but he/she wasn't able to visualize the vocal cords?

So now I flip through the rest of the records... no note about the airway at all, or being difficult or anything. I have to now doubt the accuracy of this whole chart now.... How can I trust that he was a easy mask ventition if she/he was willing to describe the blind intubation is easy.

Enough to drive you crazy.

Perioperative Guidelines

Got sent the new ACC/AHA revised perioperative cardiovascular guidelines for non-cardiac surgery. It was a PDF attached to my email, and I figured I should know what's in them since I work in the preop anesthesia clinic, so I printed them out...what could it be... ten pages maybe...

nope.

I went to the printer and it was still printing and it was neverending.

82 pages!

Yikes... I know it's a complex topic, and I need to know them.

6 pages down... 76 more to read... i think some of them are references though... maybe only 70 pages...