Monday, January 11, 2010

That little voice

The funny thing about anaesthesia is that there are so many ways to do the same thing. I like to think that this indicates that we, as a speciality, are an enlightened bunch, unburdened by the restrictive "do it my way because we've been doing it like that for 40 years" mentality which is prevalent amongst our surgical colleagues. Of course, it may also mean that we don't have the faintest clue what we are doing. (Un-bloody-likely!)

However, when that nagging little voice in the back of my head tells me to do something a certain way, I know better than to ignore it, and I submit to it, like a junior medical officer submits to the whim of the consultant. I had the misfortune to be reminded of this over the weekend. The 13th case on my Friday private list (yes, 13th case for those of you in full-time state practice - it IS possible to do more than 3 cases per day) was booked as a partial gastrectomy for a chronic, non-healing ulcer.

Since the patient had been out of the ward on a smoke break when I was doing my pre-op visits (go figure) I had to see her quickly on the red-line (the reception area of theatre). Now this already puts me on the back foot. I don't know what problems await me when I see the patient. Fortunately she is a 60yr old female, fairly well preserved despite a smoking history which is verging on biblical.

My plan for her would have been to give her an epidural, and put her to sleep. But, after looking at her, the little voice started up. For some reason, I was worried about the epidural. For those who don't know, an epidural is a small catheter placed in the area around the spinal cord where local anaesthetic can be administered for pain relief. Although it usually works brilliantly for pain control, there are some risks involved, and the one that scares us as anaesthetists the most, is haematoma formation in the area where the catheter is placed. This is a disaster, with the worst case scenario being permanent paralysis. I still can't explain why I didn't do an epidural for this lady, my only defense being that I had a bad feeling about it.

So I put her off to sleep, bang in the central line and Dr Ego starts his operation. Almost immediately I sense an increase in surgical anxiety. I pop my head up over the drapes and I see blood. Everywhere. She is oozing and bleeding actively from all over the place. This continues throughout the surgery, total blood loss is about 1200ml. Which is a lot, especially for this particular surgeon. However, he seems happy, we close her up and install her in ICU.

However, the niggling voice continues overnight and I try to sound surprised when Dr Ego phones me at 07h30 to say that the patient has bled 2litres overnight and he wants to go back and have a look for a source of bleeding. So I race off to the hospital, where the patient has already been put onto the table. She does not look good at all.... Now I have a surgeon pacing, nay, champing at the bit to get going, but my gut tels me to increase the level of monitoring first. If I hurry her off to sleep, she is going to die, she is so far behind on fluids and blood. So I tell him to go have a coffee, and put up an additional big IV, an arterial pressure monitoring line and then gradually put her to sleep.

Despite all this added care, she still drops her pressure and makes a fairly credible attempt at dying. Fortunately I have my real time arterial pressure monitor, and I pick it up immediately (as opposed to the noninvasive BP which only reads every 3minutes and is unreliable when the pressure is low). A few big hits of adrenaline, 3 units of blood and a whole load of sweating later, she is looking better. If I didn't listen to my gut and allowed myself to be pressurised by the surgeon, the outcome would have been worse. We never did find a source of bleeding, and put it down to some kind of coagulopathy. (Probably related to the 8units of blood she was given..)

I can't say how often that gut instinct has saved my bacon. It is something that seems to come with experience although I have come across experienced guys that don't have it. But it reinforces to me the importance of good training at an institution where the majority of the patients are really sick.  Then, everything else seems easy....


Bongi said...

my ego was recently chomping at the bit with a bleeding peptic ulcer. the gas monkey also took time to place a large bore line and rush in some blood. when the fan was being hit shortly afterwards that line proved life saving. a good gaskunsternaar is worth his weight in gold.

just out of interest, when you talk of good training, the institution you refer to, wits or tuks?

Doc-ZZZ said...

Hi Bongi, I was trained at the one south of the Jukskei! But I have no doubt that the training is just as good in the Jacaranda city....

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