Showing posts with label on call. Show all posts
Showing posts with label on call. Show all posts
Saturday, June 13, 2009
weekend call
Saturday cardiac call... doing an abdominal case for the cardiac service and an abdominal case for the thoracic service... weird.
Saturday, March 01, 2008
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.
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.
Monday, February 18, 2008
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...
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...
Thursday, February 07, 2008
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)
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)
Friday, September 28, 2007
Locked out
I was on call yesterday and there was a fire drill going on so the fire alarms were going off... i was headed to the ORs to wake up a patient with one of the residents and I swiped my ID at the OR doors... Nothing... no click, just blinking lights on the pad. I swiped my ID again. Same. So I pulled on the door. still locked no way to open it. Luckily someone was exiting the locker room and I got in there and cut into the ORs. This happened on one other occasion with a different door soon after the opening of our new addition, which I chalked up to being in a new building. I don't know if this is the case with any other doors, but I'm guessing it is.
This is a serious problem. Luckily I was going to a routine wake-up with a good resident and I wasn't really needed. But we need to get into the ORs, or really anywhere in the hospital where we are needed regardless of whether a fire drill is happening or not, or a real fire, or if the building is falling down. This goes the same for the residents who may be running to a code or emergent airway.
Excuse me while I spend the next half hour composing a coherent email to the higher-ups
Tuesday, June 06, 2006
Can't sleep
Ugh. I'm on overnight call in the hospital. As staff it's only about once an month or so... which I can't complain about. What I can complain about is how it screws up my sleep schedule. All the cases finished about an hour ago (Ugh... so much neuro) and now I have the oppurtunity to sleep and of course I am taking advantage of this by being -- completely awake! By the time I'm sleepy, I'll either be paged to start some non-emergent "emergency" case, or it'll be time to go home where I have to sleep on my own time. Yuk. Whatever... my sleep hygiene is horrible anyway.
Wednesday, May 31, 2006
Memorial day weekend
Of course I was on call memorial day weekend. Luckily because it was a long weekend and they split up the call between two people so I had to endure a mere 48 hours on call.
For the first part of it, I worked a full day on Friday... an old lady with three valves that needed to be replaced. Uncharacteristically I got to leave at a reasonable hour... There had been rumors abound about a case to go Saturday morning... in fact I had first heard about "the emergent case for Saturday" on Thursday... so i waited all day on Friday for the surgeons to book it so I could plan my day better for Saturday. All day long... no case booked... everyone from the surgeon's secretary to the surgical PA to the perfusionist had heard that the case was going Saturday "for sure" Still it hadn't been booked by the time I left. I guessed they would page me when it was booked so I could set my alarm etc... imagine my surprise when I woke up Sat morning to no pages. Yipee...
I got about halfway through the day and then decided I would go grocery shopping and buy some food to grill out... steaks, pasta salad, corn, the works... no sooner than I get home from the store. [beepity beep beep] I call the OR front desk. "Type A dissection to arrive at the hosiptal in 30 minutes, Dr. *namedeleted* wanted everyone in" Fine. A Type A dissection is a tear in the first part of the aorta after it leaves the heart. This is an emergency because in that portion of the aorta is the blood vessels that supply the heart itself, and the beginnings of the blood vessels to the head. If this rips further then the heart or brain (respectively) will have no blood supply. Steaks in the fridge... hop in the car. I get the the hospital... perfusion is there, the cardiac nurses are getting there. "Where's the patient?" asks the perfusionist, "Lets get the show on the road" I don't know I think they're being flown in. Okay. Quick call. "They say they're not flying anyone in, but I could be another helicopter service". I find out that the ER doesnt know about the patient, the cardiothoracic resident if fact is at home on the couch because he hadn't heard, and no one knows about the patient. Yikes...
So we're sitting around for 45 minutes waiting for the word, when the surgeon calls in to the room. "She's in the ER, we need to go now". I grab the resident and we head downstairs, I find a woman in her late 20s, slightly tearful. I go through my history with her quickly and explain what's going to happen, she's no longer slightly tearful, but very tearful now. I reassure her and we start wheeling her back.
*time warp*
12 hours later it's 6am and we've just finished her operation. Lots of bleeding, but she's doing fine, I'm exhausted from being up all night. Luckily I get to go home, the resident needs to start an "emergency LVAD that we heard about 2 days ago" Hopefully his staff will let him out for a nap.
I know I need one
For the first part of it, I worked a full day on Friday... an old lady with three valves that needed to be replaced. Uncharacteristically I got to leave at a reasonable hour... There had been rumors abound about a case to go Saturday morning... in fact I had first heard about "the emergent case for Saturday" on Thursday... so i waited all day on Friday for the surgeons to book it so I could plan my day better for Saturday. All day long... no case booked... everyone from the surgeon's secretary to the surgical PA to the perfusionist had heard that the case was going Saturday "for sure" Still it hadn't been booked by the time I left. I guessed they would page me when it was booked so I could set my alarm etc... imagine my surprise when I woke up Sat morning to no pages. Yipee...
I got about halfway through the day and then decided I would go grocery shopping and buy some food to grill out... steaks, pasta salad, corn, the works... no sooner than I get home from the store. [beepity beep beep] I call the OR front desk. "Type A dissection to arrive at the hosiptal in 30 minutes, Dr. *namedeleted* wanted everyone in" Fine. A Type A dissection is a tear in the first part of the aorta after it leaves the heart. This is an emergency because in that portion of the aorta is the blood vessels that supply the heart itself, and the beginnings of the blood vessels to the head. If this rips further then the heart or brain (respectively) will have no blood supply. Steaks in the fridge... hop in the car. I get the the hospital... perfusion is there, the cardiac nurses are getting there. "Where's the patient?" asks the perfusionist, "Lets get the show on the road" I don't know I think they're being flown in. Okay. Quick call. "They say they're not flying anyone in, but I could be another helicopter service". I find out that the ER doesnt know about the patient, the cardiothoracic resident if fact is at home on the couch because he hadn't heard, and no one knows about the patient. Yikes...
So we're sitting around for 45 minutes waiting for the word, when the surgeon calls in to the room. "She's in the ER, we need to go now". I grab the resident and we head downstairs, I find a woman in her late 20s, slightly tearful. I go through my history with her quickly and explain what's going to happen, she's no longer slightly tearful, but very tearful now. I reassure her and we start wheeling her back.
*time warp*
12 hours later it's 6am and we've just finished her operation. Lots of bleeding, but she's doing fine, I'm exhausted from being up all night. Luckily I get to go home, the resident needs to start an "emergency LVAD that we heard about 2 days ago" Hopefully his staff will let him out for a nap.
I know I need one
Wednesday, February 01, 2006
On call
It's not quite 5 am, it's been quiet tonight. I'm on in-house call and the ORs finished really early. No pages since 9:30p or so. Thought it was turning into a great night. Of course I couldn't sleep. I usually can't sleep well at the hospital, but tonight's particularly bad, not even tired. Anyway started an exploratory laparotomy... we'll see what comes of it. I think the resident's happy to be doing the case since the resident that shares the call room snores.
Monday, December 05, 2005
Level 1Trauma
This weekend I was on cardiac call... I had to be available for any cardiac cases going on over the weekend. This can be a hit or miss call, sometimes you're in the hospital all weekend, sometimes you're at home all weekend. It had been pretty quiet til then... early out(ish) on Friday, nothing on Saturday. Then my pager went off Sunday morning at 4am. nothing good about that. Apparently some sort of penetrating trauma case that required my attention. Well usually level 1 traumas refer to emergent cases, often going straight up the OR once they arrive at the hospital. I was confused. You don't want to wait for me to drive in (newly and still falling snow) to take care of an emergency, the in-house people will take care of it.... No no... they were stable enough to be transferred from another hospital, then stable enough to go to the CT scanner, now stable enough to wait for the cardiac team to come it. Still it's an emergency. "Ok i'm on the way in"
Now I'm always kinda pissed off when I get called in... half the time I get called in for cardiac it's nothing critical (i know that sounds weird) Someone freaking out for no reason. I know it's my job to be available when they call me in, so I don't think i should be angry.... I still am. I figured if that bullet were anywhere important they'd be dead by now. I'm also mad for other people too. I think "Heaven forbid if anyone gets hurt driving in the snow coming into the hospital for this non-emergent 'emergency' "
I slip and slide my way in. I see the cardiac surgeon in the pump room. I say "hi, what's going on?" He says "I don't know... they told me she was dying and to come in, now we're waiting... i don't know what doing..." Great now the cardiac surgeon and I both don't know what's happening. Oh well easy enough to blame the Trauma service.
The patient finally shows up. Very stable. We put some invasive monitors and access into the patient. I don't see much blood in the pericardium (sac around the heart) on echo. There is some though... not much. Surgeon says it probably looked like pericardial fat because it was well-organzied clot. They take a closer look at the heart... this lady's lucky. The bullet went through the pericardium nicked the right side of the heart and kept going. A half-centimeter another direction and that nick would have gone through one of the coronary arteries and the patient would have bled to death or part of the heart would have completely stopped working. Lucky.
I feel bad now that I was angry driving in.
Now I'm always kinda pissed off when I get called in... half the time I get called in for cardiac it's nothing critical (i know that sounds weird) Someone freaking out for no reason. I know it's my job to be available when they call me in, so I don't think i should be angry.... I still am. I figured if that bullet were anywhere important they'd be dead by now. I'm also mad for other people too. I think "Heaven forbid if anyone gets hurt driving in the snow coming into the hospital for this non-emergent 'emergency' "
I slip and slide my way in. I see the cardiac surgeon in the pump room. I say "hi, what's going on?" He says "I don't know... they told me she was dying and to come in, now we're waiting... i don't know what doing..." Great now the cardiac surgeon and I both don't know what's happening. Oh well easy enough to blame the Trauma service.
The patient finally shows up. Very stable. We put some invasive monitors and access into the patient. I don't see much blood in the pericardium (sac around the heart) on echo. There is some though... not much. Surgeon says it probably looked like pericardial fat because it was well-organzied clot. They take a closer look at the heart... this lady's lucky. The bullet went through the pericardium nicked the right side of the heart and kept going. A half-centimeter another direction and that nick would have gone through one of the coronary arteries and the patient would have bled to death or part of the heart would have completely stopped working. Lucky.
I feel bad now that I was angry driving in.
Tuesday, September 06, 2005
Whoa
On call for the 1st 72 hours of labor day weekend. (Friday through Sunday) Had to work about 14 hours on Friday, otherwise dodged a bullet. No calls to come in for cardiac cases.... I imagined it would have been pretty busy. Not that I'm complaining
Monday, June 13, 2005
Tamponade
(preamble: I've been told by a good friend that sometimes my stories feel like they are over her head. I'm sorry. Most of these anectdotes are written for medical professionals rather than the lay person. But I don't want to exclude the lay person so I'll try to explain more as i go along. Sometimes though the stories need to be written in a technical way. i'll try to do better... today's story will be technical.... i'll call you later and I can clarify things)
I've been on cardiac call this weekend (as faculty). This means I sit at home waiting for my pager to go off, dreading any possible emergency cardiac cases that come in. I'm usually a wreck all weekend for two reasons. One, i know as soon as I plan to do something like meet friends for lunch or go to a movie, Murphy's law will kick in and I will get called in. Two, as a relatively new cardiac faculty, I'm probably not as confident in my skills as I should be and I have doubts about whether I can handle what comes it.
At 2:45 this morning. I get a page... "emergency bring-back bleed.... phone number blah blah blah" I call in and someone's coming straight down from the ICU. Now this isn't all that unusual. People have heart surgeries all week long, and sometimes they bleed more than they should afterwards. They ooze for a few hours, they are indecisive about coming to the OR... finally in the middle of the night they decide they've had enough and need to operate. They come down to the OR, the surgeons poke around a little and they use their electrocautery to buzz a few little blood vessels, say they can't find much, and then you go back upstairs. No big deal. The reason this is considered an emergency is that there is a possibility that there is a major bleed somewhere and it can compromise the way the heart functions. The heart can stop working because there can be blood clot all around it (rather than blood pumping through it)
So I assume it's one of those slow oozing bleeders, but you need to come in anyway and take care of the problem. I roll out of bed, do my best to fix my bed head and hop in the car. I'm at the hospital within 15 minutes, and changed in the locker room less than 10 minutes later. I walk into the OR expecting the nurses to be setting up and waiting for me to bring the patient down. Instead I see the general call residents and staff hovering around the patient. She's pale looking and her eyes look like they're half rolled back in her head. Now I'm thinking "aw, crap... this is for real" The cardiac surgery resident is throwing a few lines and we're scrambling to get this patient ready for surgery.
Now this is one of the special circumstances in anesthesia. You need to have the patient ready for surgery BEFORE they go to sleep. These compromised patients are using all their reserve to keep up their blood pressure, catecholamines rushing though their systems, peripheral vessels clamped down, all trying to compensate for this unstable state. When you put them asleep this relaxes their compensation and they can "crash" as soon as they're asleep. Also our medications to put you asleep tend to lower your blood pressure too. So to combat this, you have them prepped and drapped for surgery with the surgeon standing there ready to operate as soon as they are unconscious.
The cardiac surgeon pops his head it to see what's going on. His resident lets him know that this is the heart transplant patient from earlier in the week and that they need to get started NOW. They wash hand quickly while the nurses rush to prep the field. The drapes go up. And they let me know they're ready. I put the patient asleep and they get started immediately. My anesthesia resident puts in the breathing tube under the drapes and the surgeons open up the chest. Immediately you can see blood welling up out of the chest and a squirting bleeder. Immediately the blood pressure drops. We've lost about 2 liters of blood in about 10 seconds. We get the rapid infuser going and pump in some blood quickly and I give the patient some epinephrine(one of our stronger drugs) to get the blood pressure back up. Luckily they get the bleeder under control and about 2 hours later we get back up to the ICU.
We were pretty lucky today. I can help but think that if it had taken me 10 more minutes to drive in, or that if the team in the hospital hadn't been so proactive in getting the patient to the operating room that this lady might be dead. I'm relieved.
It's 530 am. I'm tired, i'm thinking of going home. I over hear the cardiac surgery resident, "blah blah blah accepted a lung transplant blah blah blah..." I know I'll be back later today.
I've been on cardiac call this weekend (as faculty). This means I sit at home waiting for my pager to go off, dreading any possible emergency cardiac cases that come in. I'm usually a wreck all weekend for two reasons. One, i know as soon as I plan to do something like meet friends for lunch or go to a movie, Murphy's law will kick in and I will get called in. Two, as a relatively new cardiac faculty, I'm probably not as confident in my skills as I should be and I have doubts about whether I can handle what comes it.
At 2:45 this morning. I get a page... "emergency bring-back bleed.... phone number blah blah blah" I call in and someone's coming straight down from the ICU. Now this isn't all that unusual. People have heart surgeries all week long, and sometimes they bleed more than they should afterwards. They ooze for a few hours, they are indecisive about coming to the OR... finally in the middle of the night they decide they've had enough and need to operate. They come down to the OR, the surgeons poke around a little and they use their electrocautery to buzz a few little blood vessels, say they can't find much, and then you go back upstairs. No big deal. The reason this is considered an emergency is that there is a possibility that there is a major bleed somewhere and it can compromise the way the heart functions. The heart can stop working because there can be blood clot all around it (rather than blood pumping through it)
So I assume it's one of those slow oozing bleeders, but you need to come in anyway and take care of the problem. I roll out of bed, do my best to fix my bed head and hop in the car. I'm at the hospital within 15 minutes, and changed in the locker room less than 10 minutes later. I walk into the OR expecting the nurses to be setting up and waiting for me to bring the patient down. Instead I see the general call residents and staff hovering around the patient. She's pale looking and her eyes look like they're half rolled back in her head. Now I'm thinking "aw, crap... this is for real" The cardiac surgery resident is throwing a few lines and we're scrambling to get this patient ready for surgery.
Now this is one of the special circumstances in anesthesia. You need to have the patient ready for surgery BEFORE they go to sleep. These compromised patients are using all their reserve to keep up their blood pressure, catecholamines rushing though their systems, peripheral vessels clamped down, all trying to compensate for this unstable state. When you put them asleep this relaxes their compensation and they can "crash" as soon as they're asleep. Also our medications to put you asleep tend to lower your blood pressure too. So to combat this, you have them prepped and drapped for surgery with the surgeon standing there ready to operate as soon as they are unconscious.
The cardiac surgeon pops his head it to see what's going on. His resident lets him know that this is the heart transplant patient from earlier in the week and that they need to get started NOW. They wash hand quickly while the nurses rush to prep the field. The drapes go up. And they let me know they're ready. I put the patient asleep and they get started immediately. My anesthesia resident puts in the breathing tube under the drapes and the surgeons open up the chest. Immediately you can see blood welling up out of the chest and a squirting bleeder. Immediately the blood pressure drops. We've lost about 2 liters of blood in about 10 seconds. We get the rapid infuser going and pump in some blood quickly and I give the patient some epinephrine(one of our stronger drugs) to get the blood pressure back up. Luckily they get the bleeder under control and about 2 hours later we get back up to the ICU.
We were pretty lucky today. I can help but think that if it had taken me 10 more minutes to drive in, or that if the team in the hospital hadn't been so proactive in getting the patient to the operating room that this lady might be dead. I'm relieved.
It's 530 am. I'm tired, i'm thinking of going home. I over hear the cardiac surgery resident, "blah blah blah accepted a lung transplant blah blah blah..." I know I'll be back later today.
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