Happy Physician Anesthesiologists Week!
There is much to celebrate, even in this uncertain and challenging time. The practice of anesthesiology is changing dramatically — just read Dr. Karen Sibert’s CSAOF piece “A Brave New World?” — but we wanted to share some positive stories where our training and experience have made a real difference in a patient’s life. These are just a few stories shared by CSA members, I’m sure you all have your own.
When Seconds Count…………
Sydney Thomson, MD
I assessed an elective patient scheduled for a STSG for a traumatic non-healing wound. He was in his early 40s and otherwise healthy. The first thing I noted was that he was very pale. He also admitted to feeling very tired and just had no energy. I checked his CBC to discover his HCT was in the mid 20s. This was markedly different from the HCT in the 40s reported six months prior. On further discussion, he described blackish stools for the last few months. I ordered an EKG that revealed diffuse t wave inversions that were also new. Based on this information, I spoke with the surgeon and contacted the patient's PCP. I suspected he was suffering from anemia related to a GI bleed. The EKG changes were disturbing since they could represent ischemia or a myocardial infarction. The PCP agreed the surgery should be cancelled pending a workup. Luckily, I was able to see the patient when he returned six weeks later for his procedure. The workup found a bleeding peptic ulcer that required treatment. His anemia resolved along with his EKG changes and his energy returned. The surgeon was grateful that I had delayed the case since he felt the skin graft would have a better chance of success now that the anemia was resolved and the improved oxygen carrying capacity would aide in wound healing.
Christine Doyle, MD, FASA
I had a late starting room, so I went to see the patient in the Ambulatory Surgery Unit (ASU) rather than waiting until they got to the holding area. The nurse pointed out that the EKG auto-reading was abnormal. I examined the patient and she was breathing ok and looked fine. She said that she felt like she was having an asthma attack. I ordered a breathing treatment and did pre and post peak flow measurements, and there was no real change. I got a copy of her earlier EKG from the clinic, and this was a new (but not acute) change from 3 months earlier. She mentioned that she had just returned from the Philippines. I called her cardiologist and he had me send her directly to his office. Turned out that she had had a pulmonary embolism, likely related to her long trans-Pacific flight. Had we done the planned orthopedic procedure, the surgeon (and hospital) would have been blamed for that PE. Although he was annoyed at the time, he thanked me once he heard the news, and the patient came back electively about a month later and had an uneventful surgery.
As a resident, a patient asked for a labor epidural. My attending and I went to the room and planned to do a CSE as she seemed to be in a lot of pain and was having trouble controlling herself. I got the epidural space easily but couldn’t get the spinal. So I dosed the epidural and threaded the catheter. And then the NIBP gave me the same heart rate as the FHR — in the 140s. I put on the pulse ox, and it was exactly matched (same machine, same algorithm). The nursing staff kept repeating that the FHR was ok. Auscultation showed that her heart rate was indeed in the 140s, although her radial pulse was less and was thready. We called the OB back into the room to examine the patient — and the ultrasound showed the fetal demise. She ultimately went to the OR for a caesarean hysterectomy for hypotension and was found to have an abruption with bleeding into the uterine wall (a Couvelaire uterus). Every medical professional who had seen her before we did, missed it.
Doyle C, and Angelotti T. “Detection of an unsuspected maternal hemorrhage via a fetal heart rate tracing.” Journal of Clinical Anesthesia, September 2004, 16:465-468.
Rita Agarwal, MD, FAAP
I was out with my family for dinner a few years ago, I have twin boys and an older son. My twins were about seven and one of them was having a meltdown. He took off to the rest room, with my husband hot on his heels. I was settling the other boys and after a few minutes looked towards the back of the restaurant where the restrooms were. I noticed a man looking somewhat blue and the lady next to him yelling at him. The restaurant was pretty dark and very noisy, and it was clear no one was paying attention. I looked back, the guy was BLUE. I rushed over and immediately started trying to do a heimlich. He was a big and tall guy, I got my hubby over, he took over, while the man’s companion and I tried to stand the man up, so we could get more effective abdominal thrusts. The man was getting weaker and weaker and leaning very heavily on us. At this point a group was gathered around us. I started moving people away, while grabbing for the steak knife and eyeing the straw. Luckily, right about then, he hacked up a giant piece of steak. I truly believe that if I hadn’t seen him when I did, recognized what was happening and run over, he could very easily have died, or ended up with a restaurant floor tracheostomy.
Another story from residency. My senior resident called me to help with a newly admitted OB patient. The lady had been found at home unresponsive. She was 23 weeks pregnant, had no prenatal care, and her family had gotten concerned about her because they hadn’t heard from her in a few days. She had fetal demise and was febrile and found to have a glucose in 900s, with ketones in her urine. As she was coming up to the OB suite, she started seizing and vomiting. Her BP was 60/39, HR 127, saturation was unreadable. My senior resident and I immediately intubated her, started 2 big bore IVs. We rapidly placed an arterial line and central line, sent labs, and started insulin/glucose and dopamine. All this in about 30 minutes (those were the days when we mixed stuff and prepared IVs and arterial line bags ourselves), while the OB team was still trying to go through their differential diagnosis.
The team was very upset with us and started angrily questioning our decisions. The patient woke up about several hours later and she ultimately made a full recovery. The working diagnosis was that she had untreated diabetes which lead to fetal demise, DKA, and sepsis. The OB team and family later thanked us for saving her life, once all the dust had settled.
Andrew Kadar, MD
I was setting up for an elective vascular operation when an emergency intervened. A sixty-something year old man who had a carotid endarterectomy the previous day, was wheeled into the OR. He had a huge lump on the left side of his neck that even extended over the midline. He was unresponsive and showed retractions just above his sternum with each struggling breath. I surmised that he was obtunded from hypercarbia, possibly from a stroke as well, and needed to be intubated right away. Assisting his ventilation with a mask didn’t help much if any, due to the obstructed airway. I opened the patient’s mouth, inserted a Mac 4 blade and saw no discernable anatomy. This happened a long time ago, before the availability of fiberoptic laryngoscopes or even the Videomac.
The anxious surgeon asked, “Why don’t you just paralyze him?”
“Because I might not be able to ventilate and then he’d be dead.
Can you open the wound and let some of this hematoma out?”
The circulating nurse quickly poured betadine over the wound; the surgeon cut a few sutures and a gush of clots landed on the side of the bed. I then went to intubate again. This time, I could make out the very bottom of the cords and inserted a tube. With the airway secure, the surgeon explored the neck, stopped the oozing and we delivered a living patient to the ICU.
The ASA website has some great material to help educate colleagues, staff and patients. Some were designed for Physician Anesthesiology Week, but others (like the one below) can be used indefinitely. Please share your comments and thoughts with us.