Wednesday, 23 July 2014

Premonition

Before I start this, no I can't see into the future, and yes I'm a damned pessimist.  But then you probably knew that anyway.  If I could see the future I would have sunk every penny I had into Apple stock in 1982 and I'd be retired by now.  Despite this severe shortcoming, I do get premonitions now and then.  You know, that overwhelming feeling that something really bad is about to happen.

You guessed it - my Inner Pessimist reared his ugly, stupid head again recently. 

"I have a bad feeling about this," I said to my assistant just prior to my patient being wheeled back into the operating theatre.  Those are 7 words you never want your surgeon to think, let alone say aloud.  Esther (not her real name) was 50ish and not terribly healthy coming into her ordeal, having had a stroke and heart attack in the past several years.  And now she was actively dying in front of my eyes.  By the time the emergency physician called me, she was floridly septic - her heart was racing, her blood pressure was dangerously low, her kidneys were failing, and she was delirious, barely able to keep her eyes open.  When I got there her entire family had gathered around her bedside, looking more like a funeral procession than anything else.  They could tell by the look on my face that the situation was grave.

Why was Esther dying?  Well, if you ever needed proof that perforated appendicitis is a different disease than regular appendicitis, Esther is your proof.

As I waited for the staff to ready the operating theatre, I thought back to the last patient I had who developed sepsis from perforated appendicitis.  He was half dead by the time he got to the hospital, and over the next two days he completed the process.  Now the seconds ticked by interminably, and with each passing minute I had a stronger and stronger feeling this case would be a tough one.  Little did I know how right I would be . . . sort of.  Well, not really.  Kind of.  Ok, the case itself wasn't hard, it was just that, well . . .

Hang on, let me back up a moment. 

We finally got Esther into the room and placed her on the operating table right at midnight (since appendicitis always happens in the middle of the night, apparently).  After putting on the appropriate monitoring equipment, the anaesthesiologist was supposed to quickly put the patient to sleep, put a breathing tube in, and let me get to work.  But that's not precisely what happened.  Ok, that's putting it mildly - it's not even remotely what happened.  Instead, this is exactly what I heard, word-for-word, as Dr. C (not her real name) tried putting the tube in:

Nurse: "Do you see something?"
Dr. C: "Yes, but I don't know what it is."

Wait, what the hell is going on up there?

She tried to put the breathing tube in five times, and five times she managed to get it into the oesophagus rather than the trachea.  WRONG, WRONG, WRONG.  After nearly an hour of trying, she called a second anaesthesiologist, who had to drive in from home, to assist.  While she was waiting, she tried putting in an radial arterial line so she could monitor her blood pressure directly.  True to form, she couldn't get that in either.

At this point my blood pressure was rising even more than Esther's was falling. 

The second anaesthesiologist arrived as Dr. C tried again.  Finally after an hour and 26 minutes, a temporary tube finally was in the trachea.  Her oxygen saturation, which had been hovering around 88%, increased to 97%, and I started prepping.  And then, trying to exchange her temporary tube for the permanent tube, she pulled the tube out.

GOD.  DAMN.  IT.  Back to square one. 

As I fumed in the corner of the room, trying to regain my sanity and keep my blood from boiling, she tried again.  A minute later I heard her yell "The tube is in something!" (her exact words).  Wait, something?  SOMETHING??  There are only two tubes there!  Which something is it in?!

It was the wrong something.  Again.

I wanted to scream "JUST STICK IT IN THE GOD DAMNED HOLE ALREADY!" but as the only man in the room, I didn't think that would go over too well.  So, taking a note from almost two decades of marriage, I wisely kept my mouth shut. 

Finally, FINALLY, after trying for 1 hour and 51 minutes (yes, I timed it), the endotracheal tube was in (the right something this time), and I could finally start the actual procedure.  The surgery itself, which consisted of removing the necrotic (ie dead) appendix and draining her pelvic abscess, only took 35 minutes.

We kept her on the ventilator overnight as a precaution and removed the breathing tube the next day.  Esther's vital signs, bloodwork, and kidney function all improved rapidly once the infection was controlled, and a week later she walked out of the hospital and went home.  Not surprisingly, her biggest complaint as she left wasn't abdominal pain; it was a sore throat. 

I can't for the life of me imagine why.

27 comments:

  1. Maybe that anesthesiologist should of had a ham and cheese sandwich for that day. Ihear your local Fiction store has a great deal on spam.

    ReplyDelete
    Replies
    1. Bill, I'm not sure what you're trying to say here, but it almost sounds as if you're accusing me of fabricating this story.

      Delete
    2. Bill
      Whatever fits the bill. Heard that trolls live under a bridge.

      To Doc,
      Glad to hear that this lady recovered. Thanks for sharing your truthful stories.
      Obviously Billyboy isn't familiar with the many things that can, and indeed do go wrong, pertaining to medical facilities.
      Of course irritating, time consuming, frustrating "not able to do" tasks, procedures, etc...happens in lots of situations.
      Unfortunately, I have a low tolerance for set-backs, delays, and such.

      ~ A fan

      Delete
  2. I'm not understanding the comment above, but thank God she walked out. Sounds like a night of hell for you.

    ReplyDelete
  3. Is there any excuse for what happened there? Is there any real reason other than incompetence why she couldn't put the tube in?

    ReplyDelete
  4. Some people are extremely difficult to intubate. Not knowing the anesthesia provider, I cannot comment on her competence, but wonder did she try any other adjuncts besides the usual laryngoscopes blades: glidescope, intubations LMA, fiberoptic bronchoscope?

    In 30 years of doing anesthesia, I have run into three patients that neither I nor any other of my anesthesia colleagues could intubate by any means. Two were on elective cases and we woke up the patients--I don't know what became of them after they left recovery with regard to any further attempts at the elective surgery--the third case was no elective and the patient was trached.

    ReplyDelete
    Replies
    1. My iPad is sabotaging me: that should say intubating LMA and non-elective. Also 20years of anesthesia. Apologies for the typos.

      Delete
    2. There were several maneuvers she tried including various blades, a fiberoptic scope, and an intubating LMA. None of them was successful.

      Delete
  5. One of the many things that make me thankful that I am strictly on the heavy lifting side of the medical field is that I will never have to intubate a patient. I have seen it go right, and I have seen it go badly. glad to hear the final outcome was successful.

    ReplyDelete
  6. Spoken like a true surgeon ;-)

    "By the time the emergency physician called me..."

    And a rant about a difficult airway.

    I'm pleased I don't work with you.

    You have a God complex.

    ReplyDelete
    Replies
    1. A God complex? Why, because I told a story about a 2 hour intubation, or because the woman was septic when she got to the hospital?

      Please. You'll have to try a lot harder than that to troll me.

      Delete
    2. I swear Doc if you weren't already married.... I'd ask you to marry me.

      Delete
    3. I am not sure what Skippy, the stupid poster above, is taking issue with, Doc. Are surgeons arrogant?? Hell yeah, and ortho boys are the worst. Surgeons fix problems, trauma surgeons save lives. I dont care how arrogant a trauma surgeon is: I am there because I need help, not looking to have cocktails.

      Delete
    4. PS. A good friend is an anesthesiologst and has been unable to intube a patient twice. Its his worst nightmare, and worse than an ER resident yelling, "call Anesthesia, I cant intube this guy."

      Delete
    5. It is a terrible feeling for the anesthesia provider, aggravating for the surgeon even on an ordinary case, but especially so when the patient is an emergency.

      I feel bad for all three in that situation, but, fortunately, the patient was ok in the end.

      If the anesthesia provider frequently has difficulty, especially if others have no difficulty if called to assist on the same patient, that will need addressed at some point with her department head.

      Delete
  7. This made me wonder, have you ever operated on a patient that refused anesthetic? If so, what's that like? Any abnormal challenges? Are they coherent? Do you talk to them?

    ReplyDelete
    Replies
    1. When I say refused anesthetic, I mean that they were awake during surgery, having also refused sedatives.

      Delete
    2. Without meaning to sound like an ass, do you realize that there is no surgeon who would operate on someone fully concious? Let alone speak to them during surgery. There's a reason we're put under while doctors are digging around inside us.

      Delete
    3. Yes. I've done a few procedures under strict local anaesthesia. The patient is awake and talking. It can be tricky, but possible for certain things.

      Delete
  8. Wow, Doc, the trolls are strong with you, this time around. Full moon?

    ReplyDelete
    Replies
    1. No kidding, this was barely an outrageous story...and Esther not her real name lived. It wasn't even tragic.

      Delete

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