A day in the life (continued, but two days old now)

7:31 - The patient's blood pressure has dropped. It is a little lower than I'm comfortable with. It appears to be related to the decrease in Systemic Vascular resistance (essentially, the inherent tone in blood vessels - anesthesia makes that go down). I give a little bit of phenylephrine and it pops back up - I also decrease the amount of inhalational agent that the patient is getting. Time to start charting. Sit down, get the chart, start recording vital signs from the computer. Write the narrative (generally pretty much the same thing - Patient seen, identified, chart reviewed, history and physical examination taken, risks, benefits, and alternatives discussed. Questions answered. Patient seems to understand the procedure, and agrees to proceed. The patient already has a peripheral IV placed by the nursing staff. Versed given at 7:22. Patient taken to room 5-COM...) Nursing staff begins scrubing patient with iodine based soap to perform a sterile prep.

7:40 - The surgeon arrives, scrubs, and we start to drape the patient. I say we, because my job is to get the top part of the drape from the surgeon and the nurse as they hand it off to me without touching them, and to, while holding the edges of the sterile drape up, clipping it on the pole. Imagine that you are at the head of a kitchen table. Two persons are on each side of the table. They place a tablecloth over the foot of the table, and then hand you the top part, only you are not allowed to put it down. Instead you have to hold it against two poles without letting it drop and clip it into place with little scissor like things that are actually clamps. I go into lots of detail about this because, when I started the anesthesia residency, one of the first things I noticed was that the very capable more advanced residents could do was to drape the bed without help from a nurse (holding one side of the drape). It is almost acrobatic in how you grasp the edge, flip your hand over and clip the drape in place. I finally knew that I'd make it in anesthesia when I could do that. It is not for the uninitiated.

The surgeon is kind of grumpy today. That is often the case (though less here in Salem than in other places. He has a bit of the stomach flu. Instead of making him slow, however, he is lightning quick. I hope I can get my charting done.

7:43 - 8:08 The surgeon is preparing to make the incision. I need to quickly verify that the Succinylcholine has worn off (a depolarizing muscle relaxant) enough so that I can give a longer acting paralytic. It is a pretty involved explanation, about why one medicine that paralyzes you has to be completely metabolised from your body before you give another type - if it isn't you can have a paralysis that lasts for several hours, which means that you have to keep the patient asleep for several hours because most people aren't too excited about being awake and unable to move or breathe. It has never happened to me, but I don't want it to start anytime soon. I check my twitch monitor - a little electric box that gives a stimulus to see if the nerves are working. AACCCKKK! My twitch monitor battery is dead! I open the back of the box to replace the battery. AAACCCKKKK! the little nine-volt battery cable is disconnected. Time to call the anesthesia tech - the surgeon is still drawing on the belly. "Chris, I need a twtich monitor in OR 5 STAT!" (I do like to be able to say "STAT" because it makes me feel like George Clooney). Chris brings one in just as the incision is made - no worries, the patient is deeply asleep, they just aren't paralyzed as I find a moment later when I test the twitches. I give 30 mg of rocuronium. The ports for the little cameras are inserted in the abdomen. The abdomen is insulfated with Carbon Dioxide (basically, filled up to the brim with gas!). Now you can drive around inside.

"Is the patient paralysed," the surgeon severely querries.

"Just gave some additional paralytic moments ago - currently the patient has only 2 post-tetanic twitches" I reply.

"Oh, the movement I saw just is going away," he concedes.

Anesthesia is all about anticipating whatever might go wrong with the patient, and fixing it before it becomes a problem. However, it is also all about whatever is going wrong with the surgeon (not necessarily the surgery) and fixing it before it becomes a problem. Alicia just wishes I would do the same at home. However, anticipating a woman's needs is still a severe mystery for me. Especially if she is pregnant. But they are orders of magnitude more fun than surgeons. (Picture #1 - See! wives are much more fun than surgeons, and super cute when they are pregnant)






8:08 - 8:24 Trying to fly through my record keeping. He is going so fast. He hit a small blood vessel and I decide that I need to work on controlling the blood pressure more tightly so it doesn't bleed so much. It takes him about 4 minutes to repair and me about 3.5 to bring the blood pressure to the low end of normal - have to draw up drugs, give them. Still monitoring patient every minute or two - Check EKG, Verify ventilation, check blood pressure, check pulse rate, check production of CO2, monitor amount of gas in belly, verify IV fluids being delivered- meanwhile my charting is not getting done. Acck! I can always tell when a surgeon is really fast because my charting gets more and more illegible. I also need to draw up drugs for the next case so they are ready.

8:24 - The gallbladder is out. Patient is still paralyzed, but upon querying the surgeon, he is having a hard time seeing, needs the patient to remain paralyzed a bit longer. This always makes my job harder, because it takes a little bit of time to reverse the paralysis. The surgeons will take all the time in the world to do their surgery, but expect you to awaken the patient as soon as they are done. Again, I elect not to awaken a paralysed patient. It wouldn't be much fun.

8:32 - The ports are coming out of the belly. I can reverse the patient. I push the full dose of the reversal. I hope I can get the patient breathing spontaneously soon. If not, no big whoop, because I can ventilate them. But I'd like to get the added safety margin of having the patient breathing on their own.

8:34 - Final sutures are going in, patient is being bandaged - Hooray! The patient begins to breathe spontaneously. Anesthesia gas is turned off. Oxygen flow is increased to wash the anesthesia gas out. The respiratory rate is about 9/minute. This reflects relatively good pain control as well. The patient begins to awaken.

"Open your eyes" I command. Patient does not respond

I repeat the order (or gentle reminder - whichever you prefer).

Finally the patient opens her eyes - NICE! No gagging or coughing. I can tell she doesn't smoke tobacco. The breathing tube is removed. Hooray!

We move to the post-anesthesia care unit (PACU). I complete my charting, give a report to the PACU nurse, and write on the chart, "Patient extubated in OR after case when breathing spontaneously, following commands. To PACU, Care transfered. " Anesthesia ends.

(more tomorrow - it turns out that to write about a day takes at least three).