Saturday, 2 August 2008

In which I find myself totally out of my depth

Anaesthesia is often described as a “hurry up and wait” specialty in that there are often long, boring periods where nothing in particular happens and then there are the moments where things get very critical, very serious, very fast. I think my on-call shift today summed this up perfectly.

There were a few operations to do in the morning, but by 2pm, we had finished in theatres and there was nothing else booked. The Intensive Care Unit was quiet too, so I had a chance to read some of my novel and do a little revision as well.

At around 7pm, I get a call on the “crash bleep” asking for my immediate assistance in A&E Resus. I peg it down there and as I round the corner I am confronted with a clutch of people surrounding a small child who is obviously having a seizure.

One of the consultants once told me that when dealing with children in an emergency, the very first thing you should do is pause for thought. (In fact, if I remember right, one of the rules in “The House of God” is something like: “At an arrest, take your own pulse first”) I take her advice on-board, take a second to compose myself, take a few deep breaths then step into the Resus bay and assess the situation.

A quick glance tells me lots of important things:

- The child is alive.
- The child is breathing.
- The child is pink.
- The child is fitting.

The child’s father is doing a brilliant job at maintaining the boy’s airway with a jaw-thrust. I introduce myself to everyone and find out that the boy is called Declan, he’s 6 and has had several admissions to hospital and to intensive care with his epilepsy and this time, he’s been fitting for about 30 minutes so far. The people in the bay are: Declan’s Mum & Dad, 2 A&E nurses and the paediatric SHO and SpR.

I grab the resuscitation mask and take over from Declan’s Dad. At this point, the paediatric SpR manages to get a cannula into one of Declan’s thready little veins. I look over my shoulder at the monitor which is displaying

Pulse rate: 160
BP: 124/77
SpO2: 100%

Things are not exactly stable but they are under control – at the moment. If my year of anaesthetics has taught me only one thing it’s that things can go tits-up very, very quickly – especially in unwell people, especially in children, especially in unfamiliar environments with unfamiliar staff and unfamiliar equipment. Basically, things could go very bad at any moment and I realise that if they do, I’m going to need some help.

I call out to Julie, one of the A&E nurses, “Could you call the SpR on-call for Intensive Care and ask him to come down here immediately, please” and she hurries away to the telephone.

Declan’s parents are obviously very worried, but at the same time are remarkably calm and helpful. They’d already given him diazepam and paraldehyde, but those drugs had had no effect.

The paediatric SHO pipes up “I’m giving lorazepam now” I say “O.K.” and she injects the drug into Declan’s veins. Declan’s movements become less but his seizure continues. However, his breathing quickly becomes shallower and then stops altogether.


I gently squeeze the ambu-bag and pump air into Declan’s lungs. Mercifully, I see the young lad’s chest expanding as I do so. I can “bag and mask ventilate” him, which means that I should be able to keep him alive – at least for a little while longer.

“What’s happening?” Declan’s Dad says. Now he’s not calm at all, in fact, he’s looking visibly petrified. “It looks like he’s suffocating? Is he breathing? Is he O.K?!?”

Declan is making a little respiratory effort, but not a great deal. Typically, the sats probe has slipped off his toe and I can’t see a reading when I look at the monitor.

I try to keep my voice calm and tell his Dad, “he’s breathing a little, but I’m helping him as well.”

The paediatric SHO - Amy I think her name is - has a listen to Declan’s chest and confirms that she can hear breath sounds from both lungs. Thank God.

At this point the ITU SpR, Shane, arrives and I give him a brief lowdown on what’s happened so far. He asks me if I’m OK doing what I’m doing for the moment and then goes off to call the ITU consultant on call.

Declan is breathing a bit deeper now and his sats are still 100% but, despite the drugs he’s had, the seizure continues. Shane comes back to the bay, says that we should avoid intubating Declan if possible but starts drawing up some intubation drugs - just in case.

The lorazepam has not stopped the fits, so the paediatric duo say that they want to start a phenytoin infusion.

It takes them aaaaaaaaggggeeeeeeeesssss.

I can appreciate that calculating the dose and rate for a phenytoin infusion is difficult (see page 251, assume he’s 20kg and try and the dose, dilution volume and infusion rate for yourselves). I remember the last time I had to do it in an emergency situation, it took me a while – but it didn’t take me a full 15 MINUTES to work it all out. I think it took longer because there were two of them and they kept interrupting each other’s thought processes but eventually Shane had to step in and tell them to hurry the fuck up because Declan was still fitting.

At this point I got paged from theatres. I asked Shane to take over Declan’s breathing so I could answer my pager. (The real reason was because my hands were starting to cramp up from holding the resuscitation mask onto Declan’s face for so long). It’s the surgical registrar on call. There’s a man on the surgical ward who’s bleeding post-op and needs an operation RIGHT NOW to stop it. It never rains, it pours. I explain what I’m up to and that I can’t leave at the moment and ask him to phone the consultant on call for anaesthetics about his patient.

I go back to the bay. They phenytoin infusion is up and running at last, but I get the laryngoscopes, endotracheal tubes, atropine and suction ready for Shane – just in case.

However, this time the drug works and Declan’s fitting slowly desists. He drifts into the sleepy (post-ictal) state that follows a seizure and, much to all our relief, he becomes more stable and able to breathe properly for himself.

With perfect timing, the consultant paediatrician (who obviously knows Declan and the family well) shows up and she starts to have a chat with Declan’s Mum. I look down at Declan who, though still unconscious is peaceful and medically stable. I ask Shane if he’s happy for me to go down to theatres and he says “Sure mate” and I thank everyone and leave.

Declan’s parents, Shane, the paediatricians and the A&E nurses all thank me as I walk away and I smile to myself as I reflect on a job (reasonably) well done.

The contentedness doesn’t last very long, however, because just as I reach the doors to the operating theatres the crash bleep goes off.

**Cardiac Arrest – Medical Assessment Unit… **Cardiac Arrest – Medical Assessment Unit… **Cardiac Arrest – Medical Assessment Unit…

Like I say – it never rains; it pours.


madsadgirl said...

And some people reckon that anaesthetists have it easy. So many people think that it is the surgeons who are the superheroes who save lives; you have shown that it is a team effort and anaesthesia should in no way be treated as a 'Cinderella' speciality. My hat goes off to you, and anaesthetists everywhere.

AdamF said...

Well done.
First rule: DON'T PANIC.
Second rule: BREATHE.
A, B, C

Anonymous said...

Its nice to be needed, though, eh? You can read your book anytime...

Anonymous said...

That does sound like a good day!

More of that; and less tedious Lap. Appendix and Lap. Chole (or worse; vitreoretinal surgery!) would make my life far more interesting!