Score 1, Anesthesia!

While I could write about another glorious post-call day, instead I must make record of the amazing victory achieved overnight.

I'd worked nearly continuously from 0700 Wednesday morning until 0200 Thursday morning, with a 30-minute lunch break and a 45 minute dinner break late in the evening. My last case was a laparoscopic appendectomy which began at midnight. The same surgical team was planning to follow that case with another "lap appy", but it would be done by the other first-year anesthesia resident on call with me. I could potentially sleep from 0230 until 0800. (Our call day ends an hour later on Thursdays to allow the new call team to attend grand rounds.)

To my dismay, just as the junior surgeon was putting on bandages, I heard the surgery attending say to the senior on service, "Why don't we just go ahead and do that incarcerated hernia tonight, if we're all here? Just get it done, instead of leaving it for someone else to do." This meant two things to me: 1) It didn't seem like a true emergency if the patient could potentially have gone to the floor rather than straight from the E.D. to the O.R. The surgery team seemed to be adding it out of some bizarre sense of convenience. And 2) Unless the anesthesia team captain called the second-year anesthesia resident to do the hernia, I would get a mere 2-hours of sleep. There was also the off chance that my attending or team captain could try to block the case.

I suppose any sleep on call should be appreciated, so sleep I did. At 0415 my pager went off, summoning me to the pre-op holding area. Bother.

The patient was 77, but overall seemed realtively healthy and was not in any distress. I groggily interviewed him in Spanish, and when I examined his airway, I noted he was "Mallampati Class 4", which meant it might be difficult to place an endotracheal tube.

Turning to my anesthesia team captain (a third-year), I asked if they could do this case under sedation with local anesthesia. She hadn't thought of that, so we asked the surgery junior. "Oh, maybe so!" she said, further explaining, "We didn't even see bowel entrapped on the CT scan, so it's just going to be a little superficial operation...probably just a little omentum that we have to push back in."

This angered me. This was not a strangulated hernia; not even a real incarcerated hernia. It was a little bit of fat poking through the abdominal wall, and we were about to start this surgery at 0430. The anger had at least two facets. First of all, if the patient were my grandfather (with a difficult airway), I wouldn't want him operated on at that hour. Converting from local anesthesia to general could be dangerous, especially without support personnel around as they are during the day. The surgery team was essentially suggesting putting this man's life in danger because it was convenient for them to do the case then and leaving the case for the next day's on call team could be seen as "weak." And secondly (on a more personal level), I was losing sleep over the whole ordeal, and neither my attending nor my team captain had raised the questions that should have been asked originally. Time to take matters into into my own hands. The surgeon had given me all the ammunition I needed...

"If this is a 'little superficial operation' as you say, and there's no bowel entrapped," I asked the surgery resident, "then is this really an emergency? I feel like we could be putting this man's life in danger by attempting a difficult airway in the middle of the night." She had nothing to say. She called her attending, and 5 minutes later, the case was cancelled and instead posted on Thursday's "add-on" list.

As my head sank onto my flimsy, thin pillow at 0500 that morning, I didn't care about the sub-optimal call-room furnishings, and I didn't even mind the long, busy day. This was sleep I'd fought for and earned, and in the end we did the best thing for the patient. The sleep came sweetly.