Thursday, 17 January 2008

Under Pressure...

It’s just before 5pm on an evening when I was on call. I stroll down into theatres from the day-case unit to pick up the cardiac arrest bleep and try and find Anita, the anaesthetic SHO on-call for the daytime, to get a handover.

As I’m walking down to the main operating theatres, Sharon, one of the senior theatre nurses, walks up to me and says, “Michael, are you on call this evening?”

“Yes. Why? What’s going on?”

“You’d better get to the Emergency Theatre, that patient from this morning is coming back.”

I have no idea what she’s on about, I haven’t been in main theatres all day but there are lots of people rushing around with bits of equipment so I guess something major is happening.

“What patient?” I say to Sharon’s disappearing back.

“Leaking femoral artery graft” replies Sharon over her shoulder and she vanishes round the corner.

Oh shit.

This is very bad news indeed. I go to the emergency operating theatre and find Anita who tells me that the patient had an attempted stenting of his right femoral artery in the morning but is being rushed back to theatres because the stent is leaking, that is blood is leaking from the patient to the floor. You don’t have to work in a hospital to realise that this is a BAD THING INDEED.

The Emergency Operating Theatre is a flurry of activity. There are about a dozen people inside setting up bits of kit, opening boxes and getting things ready. As I’m talking to Anita, two of the surgical registrars run past us and I’m told that the vascular consultant is on his way.

“How do you want to do this?” asks Atul, one of the Operating Department Assistants.

“Let’s not mess around in the anaesthetic room,” Anita replies. “We’re going to go straight through to theatres and we’ll anaesthetise him there whilst the surgeons are prepping.

Just then, the patient comes round the corner. He’s on a bed, being pushed by two porters. One of the staff nurses from the ward is pressing a pad onto his groin, but despite her best efforts, blood is leaking from around her hands and is collecting in his bed in a big, crimson puddle on the bed. The bedsheets are saturated red and blood is dripping onto the floor as the patient comes towards me. The patient already has a central line from the morning’s operation and a petrified-looking Year 1 surgical doctor (FY1) is squeezing a bag of blood into the patient’s central line whilst a student nurse is squeezing some more fluid in through a drip.

“Oh, shit,” I think to myself. As the enormity of the situation unfolding in front of me hits home, I notice my heart is hammering inside my chest and my mouth has gone so dry that it hurts to swallow.

It’s at this point that Anita looks at me and asks, “Do you want to do this one?”

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I’m going to pause this story for a second and explain a couple of things about being a novice anaesthetist. This situation is my worst nightmare. I need to anaesthetise the patient RIGHT NOW because without the operation RIGHT NOW, he’ll die. If I can’t anaesthetise him, the surgeons can’t operate and he’ll die. I’ve never met the patient and know nothing about him so I really have no time to plan my anaesthetic, I’m just going to have to get on with it, fly by the seat of my pants and hope that it turns out OK.

Anita is a year more experienced than I am, and I’m sure that she could handle the situation. The question she was really asking me was “Do you think you’ll be able to cope with this?”

I’ve been working in anaesthetics and intensive care for five months now. This is long enough to know what I SHOULD do in the situation, five months is long enough to be painfully aware of what will happen to the patient if I get it wrong and can’t deal with it, but I’ve not yet had to actually deal with a situation like this it myself. The old cliché goes, theory and practice are two very different animals.

In my head, I know that if I want to be an anaesthetist, it’s in exactly this sort of situation that I have to stand up and be counted. I have to show the “leadership” and “calmness under pressure” that they kept asking me about in my interviews for the job. So despite my sacredness, my self-doubt and my misgivings, I look Anita in the eye and say:
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“Yes.”

She smiles and says, “Good. OK, he’s all yours.”

As they push the patient, Mr Jones, into the anaesthetic room, I say “Go straight through to theatres, I’ll anaesthetise him in there.”

Mr Jones is actually in better shape than first impressions would suggest. He’s conscious, lucid and is actually probably the calmest person in the room. I don’t think that Mr Jones had any doubts in his mind that the good old NHS would be able to sort him out.

I help shift him onto the operating table, which was actually quite difficult to do – the staff nurse loses her grip on Mr Jones’ groin for a second and a spurt of his blood goes straight up in the air like a scarlet fountain.

Once he’s on the operating table, people start connecting ECG monitors, blood pressure cuff etc…

“Hi there Mr Jones, my name is Michael. I’m the anaesthetist and I’m going to put you sleep in a couple of minutes. How are you feeling?”

“Not too bad.”

“Do you understand what’s happening?”

He nods.

I turn on the anaesthetic machine and put the oxygen mask onto Mr Jones’ face.

“Could you hold this for a moment please, sir.” As Mr Jones takes hold of the oxygen mask, I dash back into the anaesthetic room and get my drugs.

I quickly find the Thiopentone and the Suxamethonium and walk back into the room.

“What’s his blood pressure?” I ask.

“168/73,” comes the reply. Good, he’s got a decent blood pressure, which means I have a few minutes to play with. I decide to get a little more information as I’m mixing the drugs.

“Have you had any problems with anaesthetics in the past, Mr Jones?” I enquire as I squirt the saline solution into the vial of Thiopentone.

“No, not really.”

“Do you have any allergies” I give the vial a shake to dissolve the drug

“Not that I know of”

“How much do you weigh?”

“Ooh, about eleven and a half stones”

Right. Here comes the maths part.

I have 500mg of Thiopentone drawn up into a 20ml syringe. One of the facts I’ve remembered during my evenings is that the dose of Thiopentone needed to send someone to sleep is 5-7mg per kilo, though this is often less in elderly people like Mr Jones. This man weighs 11½ stones. I’ve remembered that this is about 75kg. How many ml of Thiopentone shall I give him? Too little and I won’t anaesthetise him properly, this means I won’t be able to intubate him which will mean we can’t start surgery and he’ll bleed to death. Too much and I’ll overdose him, I’ll obliterate his blood pressure and I’ll never be able to get it up again - he’ll have a cardiac arrest and die.

I spent many an afternoon in watching Countdown in my early teens and I was thankful to those afternoons for honing my mental arithmetic skills. I work out how much Thiopentone and Suxamethonium I’m going to give Mr Jones and put the syringes on the anaesthetic machine.

It’s time to start the rapid sequence induction

“OK, Mr Jones, we’re ready to go. I’m going to hold this mask on tightly onto your face now and I’m going to hold it for three minutes. Then I’m going to send you off to sleep. Just as you’re drifting off, Atul here is going to press on your neck, just here. Don’t be worried or think that we’re trying to strangle you; it’s just that this is the safest way to send people to sleep in a situation like this. Is there anything you want to ask me?”

“No,”

I press the oxygen mask onto his face.

I never appreciated how long three minutes can sometimes seem. I look around. The surgical registrars have scrubbed up and have got the drapes onto Mr Jones’ leg. I see the vascular consultant rush into the room with one of the theatres staff behind him, trying to do up his gown as he rushes towards the patient. He looks at me.

“I’m just about to send him under,” I tell him and he nods while his registrars prep the surgical site.

One minute has passed.

Slowly everyone in the room slows down what they are doing and more and more eyes turn to me. They can’t start until I put Mr Jones to sleep. I have to do this now or Mr Jones will die and I’ll forever have his coffin resting on my conscience. I’m properly bricking it, but I’m trying my best to appear calm and stop myself from physically shaking.

I briefly remember an episode of Scrubs where JD is having trouble dealing with emergency situations. He asks Elliot how she manages to cope and she replies, “Just breathe… deeply… and slowly… and you’ll find that you do have more time than you realise.”

I take her advice and take three, deep, slow breaths.

Two minutes have passed.

I ask someone raise the bed for me. I ask someone to turn on the Yankauer sucker and put in near my right hand. I ask Atul to show me the light on the laryngoscope blade. I look at the clock and three minutes are up.

“OK, here we go, I say. I’ll see you when you wake up, Mr Jones.” He nods at me.

“Cricoid pressure on please, Atul.” I inject 14ml of my Thiopentone solution into Mr Jones’ central line and follow this with 1.5ml of Suxamethonium.

Mr Jones’ muscles ripple and contract as the Sux kicks in.

“Fasciculations,” I say, though I’m not sure who I’m talking to. It’s probably to reassure myself as much as anyone else.

“Scope, please.” Atul hands me the laryngoscope and a slide it into Mr Jones’ mouth. I’m vaguely aware that the room has gone quiet, but I’m acutely aware that I can’t see what I’m looking for. I use my right hand to pull on Mr Jones’ top teeth to open his mouth more and tip his head back. I push the scope further into his mouth. “Breathe…” I say to myself. The epiglottis comes into view and I push the tip of the blade into Mr Jones’ vallecula and lift his tongue up with the scope. “Breathe…” His vocal cords come into view, more or less… and I decide my view will have to do.

“Tube, please” Atul passes me the endotracheal tube and, thankfully, I’m able to push it through Mr Jones’ vocal cords and into his trachea.

“OK, I’m in.” I can now use my anaesthetic machine to breathe for Mr Jones and keep him asleep for the operation. I pull the scope out of Mr Jones’ mouth while Atul inflates the cuff. I double and triple check the position of the tube, start the ventilator and tell the vascular consultant.

“You can start now”

The hard work was done.

Over the next hour or so of the operation, I organised transfusions and infusions, put in an arterial line and made sure we gave Mr Jones the best possible chance of surviving.

Mr Jones went to the Intensive Care Unit after the operation and I went home feeling very, very pleased with myself indeed.

- Michael.

5 comments:

the little medic said...

You write so well, I could barely press the down key fast enough I was so interested to see what happened.

I think a big well done is deserved.

so... WELL DONE!

Jo said...

Wow! What a post :-) Thank you for sharing it with us.

steph said...

Well-played!

I think Scrubs should take a bow too :)

Faith Walker said...

Wow- i was on the edge of my seat through that! Just discovered your blog- I like.

Faith

Devil's Kitchen said...

Excellent post, Michael. And so rare to find an anaesthetist too...

DK