A couple days of misfortune

After days like Thursday and Friday, it would be easy to come home discouraged. I think I generally try to think optimistically, but these days were stretching. A quick summary:

Thursday, patient 1: The I.V. I started in the patient's arm infiltrated* at some point. She was nearly completely covered by warmers and drapes, so I didn't realize until I took down the drapes at the end of the case. The entire arm, up to the shoulder, was swollen! I (and she) were fortunate in that she still had a good pulse (in other words, the pressure in the arm did not exceed the arterial pressure, so blood and oxygen was still delivered to that limb), and I had given no "vasopressors" in that I.V. which could have potentially compromised her blood flow.

Thursday, patient 2: During the second case, which was a laparoscopic case done in lithotomy and steep trendelenberg*, I noticed the patient had regained her twitches, which was a sign to re-paralyze her. (It's important to keep patients paralyzed during laparoscopic cases so that the movement of their diaphragm doesn't interfere with the surgery.) I gave an appropriate dose of medicine and waited a few minutes. She still had twitches! Around this time, the circulating nurse noticed a large puddle of fluid on the floor! Given the trouble with the last case's I.V., I immediately became concerned that my I.V. had slipped out and produced the puddle. This would explain why the patient wasn't paralyzed! I called my attending who came to assist. We pulled out the patient's arm (with difficulty, given the position) and realized the I.V. was fine. Meanwhile the surgeon is getting frustrated because the patient is breathing on her own and we're having trouble re-paralyzing her. It got to the point where my attending and the gynecologist were nearly yelling at each other! Turns out that for some reason or another, this patient needs whopping doses of paralytic agents. And then after my attending left, the gynecologist continued to be snippy to me. Between cases, I think she felt bad, and so she tried to joke with me that from now on I would be called "Mr Paralysis." Not funny.

Thursday, patient 3: With the same gynecologist. Case is going smoothly, except again in steep trendelenberg, I notice the patient's CO2 levels increasing. (Laparoscopic cases are done by insufflating the abdomen with CO2 since it's quickly absorbed, and trendelenberg makes it difficult to effectively ventilate patients.) I increased the patient's breathing rate a little, and switched the ventilator over to pressure control in order to keep her peak airway pressures down. Not a problem. CO2 is 40, everything's fine. Well, a colleague came to relieve me around 8:45, and I "checked out" to him by telling him the patient's medical history, where I have I.V. access, and how the case was going. Quietly I told him that the CO2 had been creeping up and that I'd switched to pressure control.

The gynecologist heard me, and said, "What's creeping up?" I told her the CO2 had increased, but that I'd compensated for it by increasing the patient's ventilation. Still frustrated, I think, from the last case, she began lecturing me that I have to let her know when this happens so that she can take the patient out of trendelenberg, blah, blah, blah. It wasn't so much what she said as the tone with which she said it! I didn't really say anything in reply, but in retrospect, even though I would be talking to my superior, I should have said something along the lines of, "As I already said, I've compensated by increasing the patient's ventilation. If I were to run into difficulty and couldn't control the CO2, I would certainly let you know."

Friday, patient 1: Older lady with multiple medical problems (hypertension, atrial fibrillation, coronary artery disease, congestive heart failure, asthma, stage IV lung cancer) getting a simple procedure--venous port under her collar bone for chemotherapy. Everything was fine, except I just felt on edge the whole time given her fragile physiology. (If you're not a doctor or nurse, just skip to the next paragraph now.) That, and when the surgeon placed an intravenous wire, I realized it's really hard to differentiate atrial fibrillation with LBBB from PVC's! I had fun authoritatively telling the surgeon to please pull back the wire.

Friday, patient 2: A very high strung patient undergoing a large procedure involving a urology, general surgery, and gynecology tag-team approach. She nearly refused the procedure last minute when the surgery resident briefly went over benefits and risks of the procedure in order to get the consent form signed! The difficulty from our end was that her two front teeth were actually caps held on with temporary cement. We warned her that in the process of intubation, the caps might be knocked off.

I intubated, and my attending was hawkishly watching the teeth the entire time. After I placed the tube, she congratulated me, "Good job." I turned to get tape to secure the tube, and when I looked back, a front tooth was missing! I saw it on the tongue! I tapped my attending on the shoulder, and her blood pressure immediately skyrocketed when she realized what had happened! (She was not upset at me, just suddenly under a lot of stress to get the tooth.) As she manipulated long forceps trying to retrieve the tooth which kept slipping farther down the throat, she bumped the other front tooth which also fell out!

All ended well. She retrieved both teeth, and we called an intra-op dental consult. The patient knew this was a risk of the procedure. And I felt better knowing that a simple tap by the forceps was enough to dislodge a tooth. Everything was going to be okay. When stress levels were back to normal, I started to mention to my attending that these mitigating factors certainly helped. We did what we could, but it still happened. Part of a day's work. Before I could say much, though, she patted me on the shoulder and said, "It's going to be okay. I mean, you will think about this every night for the next two weeks, but you'll get through it. It could have happened to anybody. Don't beat yourself up. It'll be hard, but things will be alright." Yikes. I simply nodded and told her I appreciated her encouragement!

Friday, patient 1 from Thursday: I went to write a post-op note on yesterday's patient. I explained (again) to her that the swelling in her arm would go down over the next couple of days. I was thankful that she had no pain in that arm. She did complain of significant pain in her abdomen, where the incision was. She also asked me what all the I.V. fluids were hanging above her bed. I leaned to my left to look at the fluids, and wouldn't you know it, my stethescope slipped off my shoulder and right onto my patient's belly. She cried out and cringed in pain for what seemed like 5 minutes. All I could do was apologize profusely. Maybe that's why surgeons always carry their stethescopes in their white-coat pocket.

* Infiltration is when the catheter slips out of the vein, so that any fluids or medicines given simply collect in the surrounding soft tissue rather than going to the circulation.

* Lithotomy position--think women's exam. Trendelenberg is a fancy word for head of the table down.