The PACU Pager

In the world of anesthesiology, the pager generally functions in non-patient management roles. I might return pages to hear people say things like, "Hi Jonathan, this is Nina in the Education Department. We just need you to sign your contract for next year," or "Jonathan, this is your team captain for tonight. Do you have any dinner preferences?" Typically I receive one or two pages per day.

Not so carrying the Post-Anesthesia Care Unit (PACU) pager, as this week has shown. The mornings typically start a bit more slowly--as is evidenced by my writing this post. (I've already worked on the crossword.) By ten o'clock, however, the pages really pick up, and it's possible to go non-stop until the evening team captain takes over at four o'clock, or five o'clock on Thursdays.

This week seems especially busy, as several surgical floors and ICUs have censuses nearly at capacity. Then, the PACU becomes more of a step-down unit. Yesterday's special experiences included

• The angry, paranoid Dominican women with a deep venous thrombosis (DVT) and pulmonary embolus (PE), who's already had a fasciotomy for compartment syndrome in her leg and an IVC filter placed to try to prevent future PEs. She's been camped out in the PACU for days. The day before her breathing rate and work of breathing had increased, though she maintained her oxygenation. Her fluid intake was two liters greater than her output for the day, her lungs sounded "wet", her CVP was elevated, and her chest x-ray was consistent with fluid overload. Even though she didn't have a history of congestive heart failure, I gave her a small dose of Lasix, which prompted increased urine output and eased her breathing. I clearly documented all this, yet I still got the impression that the surgery resident thought I was nuts for giving Lasix and not more fluid. (?) Fluid management in the PACU seems to always be a point of contention between surgeons and anesthesiologists.
• The same angry, paranoid Domincan woman once again, yesterday, began her difficult breathing. In discussing it with my attending, we considered she was having repeat PEs even though she was anticoagulated. In addition, perhaps her paranoia could be related to her withdrawal from her ordinary 5 daily beers. I talked to the ICU fellow and requested that she be transferred there. The ICU is a much more appropriate place for her than the PACU, especially since I can potentially be covering 40 patients at once. Of course, the ICU resisted accepting this patient until her troponin level became elevated, evidence of heart strain and damage (perhaps secondary to her pulmonary emboli).
• Another Spanish-speaking woman with atypical post-op chest pain (after a shoulder arthroscopy). Being a nurse, she insisted that the EKG I got wasn't a good once since they forgot to put a lead on. (My paper copy showed all the leads. Still trying to figure that one out.)
• A woman with a history of post-op hypotension with chest pain. Given that it was nearly five o'clock, we got an EKG, labs, and called the primary team to admit
• A woman with a history of chronic pain killer use who demanded intravenous Demerol (a medicine better at producing heroin-like euphoria than actually helping with pain).
• An Asian man with asymptomatic bradycardia down to 30. Once again, get an EKG, contact the primary team and recommend admission and cardiology consultation.
• A young woman with a history of Wolff-Parkinson White ablation with tachycardia, flushing, and chest pain after a slow infusion of Vancomycin (an antibiotic which, if given too quickly, causes "Red Man Syndrome" of hypotension, tachycardia, and flushing). Fortunately everything resolved, but we still got a cardiology consult in the PACU. It came out later that she'd had this same reaction before with Vancomycin. It might have been helpful to tell us that before!
• A middle-aged British woman with persistent hypotension on a phenylephrine infusion despite what appeared to be adequate fluid resucitation.
• Doing various blood draws and starting IVs when the nurses can't do it. Sometimes I get the sense they don't try very hard.

Part of what makes the experience memorable is not just the patients, but the way the nurses contact us. There are three main PACU areas on two different floors. I will try to sweep through and ask if anyone needs sign-outs as long as I'm in the area, but without fail, several times a day I'm paged back to an area I just left for a sign-out. I feel better that other residents have this same experience.

For some curious reason, the pager is programmed to give me two pages for every one page sent. When the arrests/stat-intubation resident handed off his pager to me (which I carried from 1600--1700), I got four pages for every one page sent. (Both pagers receive PACU calls as well as stat-intubation calls). At one point during the hour two nurses must have paged me at once from the ambulatory PACU, meaning my pagers rang 8 times within a minute.

All that to say, it's been a different perspective on anesthesia care. I like the mornings. The afternoons go fast, and they aren't so bad as long as I'm doing PACU things rather than ICU management or nursing tasks. But it will be nice getting back to my ordinary relationship with my pager in another week or so. "Sure Nina, I'll be by to sign the paperwork," and "How about Indian food tonight?"