VIVA TIVA Saturday, August 27, 2011 A simple lesson. The simplest things can also be the most humbling. In my very first clinical rotation in 4 th year, surgery rotation no less, it quickly became obvious how things worked. On the first day, we were heartily chucked into the deep-end and the registrars watched with relish ... who would sink - and who would swim. I swear they took so much joy in watching us suffer. It helped form my subsequent opinion of most surgeons ...One of my patients was day 1 postop . A young man with stomach outlet obstruction. The prof had operated on him personally. This was mentioned a few times, so I guessed it had to mean something. Sort of like ... no stuff-ups allowed on this patient. Not that stuff-ups were tolerated at all, but we were only human. It was around midday and we were having lunch in the cafeteria. Yes ... even surgeons must eat. A huge amount of work had been dumped on our clueless heads and we were trying to figure it all out. Suddenly my beeper went off. Nothing serious, but hell of a scary seeing as it was the first time. My patient's drip had tissued , it was my job to issue him with a new one. Ok , I said looking around at my mates. Which of you know how to put up drips? Four very blank faces looked back at me. Fantastic! First day, prof's pet patient, and already the shit was heading towards the fan. As I made my way back to the ward, I thought ... how difficult could it be? Find vein, put cannula in , attach fluid. Simple. Alternatively, find someone who knows how to do it, watch and learn. Simple. Back in the ward, there was no possible help in sight. Senior students had vanished into thin air, and as for the registrars, God only knew where they were. Not sure I'd have asked them for help anyway. I refused to get phased about a drip, and secretly I was relieved to be alone. Witnesses were the last thing I needed during Operation Figure It Out. It took me a while to collect everything I thought I'd need. Then I grabbed a chair and sat down next to the patient. He was either heavily drugged, or in a very deep sleep. He just lay there, sweating profusely, totally oblivious to everything around him. At that point it didn't matter why he was not responding to the environment. It was a blessing in disguise cause I was gonna hurt him, a lot , and he was not going to feel it. What a bargain. Gently I applied the tourniquet and looked for a vein. Honestly, it was my very very first attempt at an IV cannula and I was going to do it blindly. I felt bad about that. How could I touch a patient and not know what I was doing? ( Subsequently I got very well acquainted with that particular emotion). Can't tell you how grateful I was for his semi-comatous state. An experienced person would've put up hundreds of drips in the time I sat there holding the bloke's left arm. In retrospect, I may have been waiting for divine intervention or something. Finally, I just had to take the plunge. I poked and poked and poked, praying that he wouldn't wake up. Sweating more than he was, I hardened my heart and blocked out everything around me. It helped that he was so out of it. A vein would be found even if it killed me. And even if it took me all afternoon. As with all procedures, there is of course, a certain way to go about it, ensuring a good success rate. Well ... that left arm resembled an old pin cushion by the time I finally had it figured out. I was exhausted. My neck and shoulders were stiff and sore. My hands were cold and clammy and there was blood on my shoes. But the blessed Ringers was pouring into the blessed vein. Simple was simply not always simple. In those agonizing moments I learnt to have a healthy respect for my job. Even today when drips are our bread and butter and we put them up in mere seconds, you get the odd patient where simple is simply not simple...... You sometimes struggle, and quite simply, it keeps you humble. Posted by VIVA TIVA at 10:08 AM No comments: Monday, July 4, 2011 The bougie. What is a bougie ? Well, I don't actually know how to describe it, but it's the most insignificant- looking thing ever. It looks useless, but catching it in action reveals its true value. Like most important things in life, it is firm, and slightly pliable. A long tool, of differing widths, made out of some sort of plastic I think. Some are hollow inside (those are the coolest cause you can actually ventilate through them!) and others are not. On the whole, absolutely nothing to write home about at first glance ... but let me tell you, once you experience a bougie , there's absolutely no turning back. A bougie is a life-saver. It saves yours figuratively, and that of the patient literally. I can personally vouch for that. It can reach those places that few other tools can. I have my own bougie (a top of the range hollow one), in a funky blue colour. I just wish I knew where it was. It was always in my bag, but somewhere between my multiple moves, it got misplaced. Misplaced ... and forgotten .... So a bougie is used for difficult intubations . The idea is to get it into the trachea, then railroad the endotracheal tube over it. Thus securing a difficult airway. The one thing that consoles me is that everyone has an epiglottis, and everyone's epiglottis lies over their vocal cords. So even if you can't see them - they're there. And somehow, the bougie almost always finds that spot. The patient had a BMI of 47,9, plus co- morbidities . The procedure was a shoulder replacement. The position was "the beach chair". Intubation was inevitable. I could almost feel the problems around me. On the table I tried to position the patient as best I could. Position is extremely important for a satisfactory intubation especially in huge people. Anyway the painful shoulder kept getting in the way of the perfect position. So we were basically screwed before we even started. The IV was nothing but a stroke of luck. The arterial line proved much more of a challenge, but the cherry on the cake was the intubation . It will most certainly stay with me. On induction, I could ventilate, but had to use both hands to hold the mask. Not exactly fun, but anyway. I decided to check the airway before relaxing the patient. The mouth opening was really small, with a 2cm overbite, (not good), but I could see the vocal cords. So far so good. Previous neck surgery made me a little wary of fiddling with the neck too much, but hey I could ventilate which (at the expense of my arms) was a huge bonus. Muscles were relaxed with esmeron , and as I injected it, I wished that I'd had the sense to bring some Bridion ( suggamadex ) back with me. Bridion reverses esmeron almost instantly. It's really quite awesome. So we relaxed and ventilated. First attempt at intubation confirmed all my lingering doubts. I could see the cords but the mouth opening was so small and the ET tube just wouldn't go where I wanted it to. The introducer was too pliable and just kept bending the wrong way. The teeth were in my way and the neck was stiff. What joy... In between, I spent long agonizing moments ventilating. I cursed the patient for being so fat. I cursed the surgeon even more for operating without putting the patient on a diet first. And I cursed my short arms and small hands. After two more tries I asked for the difficult airway trolley and was considering a fast-track LMA , when I spied a bougie !!! Yay a bougie !!!! Well, what could've been quite a disaster, became a very smooth and sophisticated procedure. The bougie - just pliable enough to bend into the shape I wanted, and firm enough to hold the shape - found its mark with the first try. The tube slid elegantly over it ... and we were in business! I said a mental prayer of thanks for the genius that invented the bougie . Would most willingly have kissed his feet at that moment. My arms shook for about half an hour after all that, and ached for about three days. There was a damn good reason why I used to carry my own bougie around. How could I have forgotten? Posted by VIVA TIVA at 9:08 AM No comments: Sunday, July 3, 2011 Bad lad ... There was a surgeon ... let's call him Bad-lad. He was short, balding, and weird , with huge blue eyes magnified by Harry Potter glasses. I tried to believe that his heart was in the right place, but he constantly gave me reason to wonder. He could be quite nasty, and definitely wasn't a team player. Nobody liked him. Everyone complained about him. When Bad-lad was on-call, his surgical colleagues cringed and anaesthetists freaked (to put it mildly). He was the type to spend 15 minutes running around looking for a blanket to cover a P1 patient with, before doing the most necessary stuff like tubing, CVP etc. (Or something along those lines). I often felt a teeny-bit sorry for him, until this particular incident....I was allocated to anaesthetise for him on this particular day. Did I mention that he was also the slowest, most time-consuming surgeon in the department? In that teaching hospital, the last elective case was put on the table at 3 pm. If you were slow, and didn't finish your list by that time, the case was postponed to the next available list. Unfortunate, yes. Not the best management technique, for sure. But no sister would scrub for an elective case after 3. And well, a scrub sister is an imperative part of any surgical case. So .... Bad-lad was scratching away at some piles. He'd been at it for ages. The blood loss was almost that of a huge laparotomy . It was 3:15. We still had a hernia on the list. And I was frustrated. Seriously frustrated and extremely irritated. The sister informed her floor-nurses and runners that it was to be the last case of the day. Everyone was aware of how things worked there. Except for Bad-lad of course. He ordered me, (yes - ordered), to call for the next patient. He had to be joking. I mean a guy who spent two and a half hours on piles for crying out loud, would probably need five hours for a freaking hernia!! I gave a nervous little giggle and before I could help myself, I uttered the three little words that severed our already fragile relationship for ever. "Are you crazy????"He stopped operating. Threw down his tools. Fixed that magnified icy blue stare on me ... and silence reigned for exactly 5 seconds. Then all hell broke loose. He started screaming, and shaking like a leaf. I was accused of calling him crazy and he was hurling verbal abuse at the top of his voice. I tried to explain that I hadn't called him crazy as such - I'd simply asked a question. A simple "no" would've been enough of an answer. When the performance showed no signs of abating, my hysterical laughter bubbled to the fore. I laughed uncontrollably till my eyes teared, probably because my nerves were so frayed, and it just infuriated him even more. Fortunately the spinal had long worn off and I'd been forced to convert to a general anaesthetic, so the patient was none the wiser. Poor guy. I felt like the straw that broke the camel's back. It was not my proudest moment. And although it was never my intention to freak him out, I'd be a liar if I said that some small part of me hadn't thoroughly enjoyed the whole fiasco. That was Bad-lad and me ... finished for good. Posted by VIVA TIVA at 10:54 AM No comments: Wednesday, March 16, 2011 Fem pop ..... Fem-pop, fem-flop, fem-chop. The anaesthetists version of the vascular anthem. Those gangrenous shrivelled up arterially challenged limbs (and their nicotine -drenched owners), present, and the sing-song starts. First the angiograms , then the never-ending fem-pop-bypass. When I say never-ending, I literally mean it. A couple of days, and the nicely demarcated limb is neatly chopped off. All done, fem-pop, fem-flop, fem-chop. I'm sure it irritates the vascular surgeons, considering the heroically back-breaking efforts they make to save these limbs, but I suspect that deep down they sing the same little tune. All except the unique vascular specimen I've become a slave to in the last 2 years. This guy just doesn't give up! Ever. He is difficult (no surprise there) , and he can be painfully stubborn, but yes, I like him. Early on in our synergy, he asked about the fem-pops I'd been exposed to back home. I nonchalantly sang him the anthem fem-pop, fem-flop, fem-chop, and giggled - just a little bit mind you. It soon became apparent that he didn't share my humour. The daggers in his eyes could've stabbed me in the chest across the blood-brain-barrier and all! Needless to say, the next topic was amputations. When I explained that the local threshold for amputations in the teaching hospitals was quite low, the horrified look on his face was, well, hor