Monday, June 15, 2009

It Could Happen To You

One thing anesthesia training is supposed to do is teach people always to be prepared for the worst - to "wear suspenders AND a belt," as one CRNA I know often says. It may strike some people as a pessimistic mentality to be constantly looking for lurking trouble or signs of impending disaster, but it's a huge component of our job, and without that kind of intense vigilance we can't protect people from the many potential dangers that anesthesia and surgery can present. So we make a habit of forming a plan A, plan B, and plan C at the very least, with equipment and drugs to carry out those plans ready for action.

Sometimes we are haunted not only by scary moments and near-misses from our own experiences but also by the stories carried by others. Everyone knows someone who has lost an airway, seen a patient wake up paralyzed or blind from spine surgery, run a code in the O.R., or had some other dreaded complication that people who practice anesthesia, even the best and most skilled, inevitably face more than once in their careers.

Someone I know experienced a horrific loss on the table of a very young patient involved in a motor vehicle accident. The surgeon felt there was no time to wait for family members to arrive at the hospital. The patient was brought to the operating room, and when the incision was made, blood came pouring out of the patient's body. The aorta had been sheared almost in two during the accident and had been held together by internal organs until those organs were dislodged by the surgeon's incision. The anesthesiologist tried hard to keep up with the blood loss but resuscitation was impossible, and from the surgeon's perspective so was repair. "Fix it," urged the anesthesiologist. "I'm not losing this kid." But it was not fixable. By the time the family arrived it was all over. The patient had exsanguinated.

This is every anesthesiologist's nightmare. So the last time my pager went off and it was because there was a young kid in the E.R. with a ruptured spleen, I immediately thought of this story. A ruptured spleen could mean a relatively stable patient with a slow ooze or a rapidly deteriorating patient in shock needing immediate resusciation. Even with patients who appear stable at first, surgical incision can be a prelude to all sorts of difficulty, or to none at all. You never know what you're going to get, and you have to go in prepared for disaster.

It's for dangerous cases like these that we go through all that training. They can still be scary, but at least you have an arsenal of options at the ready. Knowing how to set up and plan for tough situations is half the battle; executing the plans is the other half. The training helps us maintain a calm demeanor and keep our hands moving, taking action. When that call came in, I worked as quickly as I could to prepare for the case: large bore IV's ready, bags of fluid attached to multiple stopcocks, fluid warmers, blood tranfusion sets, invasive monitors, suction, airway equipment, multiple drugs already in their syringes.

Then I went out to meet the patient, who was deathly pale, and the family, who were worried sick. My colleague's voice echoed in my mind: I'm not losing this kid.

My own mental voice tried to nag me: Did you remember to set up everything? What if something totally unexpected happens? What will you do if you can't protect this patient? What will you do if you try, but fail?

I shushed it. I'm ready for this. Done it before. I know what to do.

Hours later I was in the family waiting room telling this family their young loved one had done well and was dozing comfortably in the recovery room. Thanks to a competent surgeon and a supportive, physically and mentally available nurse and tech, I was able to do my own job effectively and make sure this kid got through the operation. But such successes are never enough to take the edge off the tension of similar cases that follow. Knowing how you want to approach such situations makes them more manageable, and can make the work proceed more efficiently, but I don't think it makes them less scary.

I think that's as it should be. The worst thing we can do in this job is lose that edge, that watchful anticipation that things may not go as planned. It may be a somber approach, this perpetual state of "red alert," but it keeps our patients safe.


ShrinkingDoc said...

I'm glad there are folks like your and your CRNAs to take care of us when we need you! Thanks!

Margaret Polaneczky, MD (aka TBTAM) said...

God bless you for the work you do!

rlbates said...

Very nice, T!

Lisa Johnson said...

This post reminds me of a news segment where the pilot "Sully Sullenberger" who landed the plane on the Hudson talked about all his training and staying alert no matter how routine things seemed. I think that was why he was able to save his crew and passengers and the regional airplane crew, who were very inexperienced were not.

T. said...

Sully Sullenberger is my HERO! I aspire to be that kind of compliment me way more than I deserve by bringing him up! But again, thank you.

Despite the best efforts to prepare and do the right thing, sometimes bad things happen anyway. It's THOSE cases that haunt us even before they occur...and certainly after.

Transor Z said...

Wonderful post. It reminds me of the wonderful (awful) Andre Dubus short story, "The Doctor."