Just When You Thought It Was Safe to Go Back in the Water...

Okay, surgery isn't Jaws II. But what I mean to say is that it's often shocking how complacent you can get around things when everything goes well for a while.

It's been a long time since I've been away from the academic centre... or to borrow a phrase from The Flea, TBFTHITW.* Things in the community are... well, nice. Patients come into hospital with usual things, like urosepsis and COPD exacerbations. Some are palliative, and pass away quietly with adequate pain control. Surgery happens, people recuperate and rehab. Births happen, very rarely by c-section, and require nothing more in the way of intervention than a few absorbable sutures for mom and some blow-by oxygen for the baby. It's easy to fall into the complacency trap.

Last weekend I was on call for my preceptor's call group. Now that his call group no longer accepts the care of orphaned patients, rounding on the group's patients in the hospital rarely takes longer than 3-4 hours. Mercifully short, and I can often salvage at least enough of the weekend to go for a long run while there is still daylight left.

On Saturday, one patient on our list stood out like a sore thumb among the usual band of CVAs, ACSs and 'gastro+dehyrations'-- a kid in the ICU. Hmm. Don't see that everyday, particularly not in our sleepy community hospital.

So the story is this-- healthy kid sustains a fracture. Not a serious fracture, but it is slightly displaced and may not heal correctly without intervention. Enter surgeon who arranged for an ORIF of said relatively minor fracture (Open Reduction and Internal Fixation-- basically, we cut you open and put your bones back together, then make sure they stay that way).

It should be routine. Instead, as the kid was emerging from anaesthetic he bit down on the tube. The details are sketchy-- I wasn't there, just read the notes from anaesthesia in the chart. The patient was intubated with an LMA (as an aside, does anyone else think that those things resemble female genitalia?) and when he bit down, it obstructed the flow of oxygen through the tube. When someone is in this state-- emergence-- you can yell in their ear to stop biting down all you want and it won't make a difference. They have little to no control over their actions, but are no longer under the effects of the muscle paralytic. So as this guy's oxygen went down-- and it went WAY down, to about 50% O2 sat as evidenced by the OR record-- he continued to bite down reflexively. And then, likely secondary to hypoxia... his heart stopped.

Holy crap. At this point I was sitting at the ICU nursing station, reading the kids chart like a bestselling novel. A full 10 seconds of asystole. Basically, the kid was dead. Compressions were started, and eventually the anesthesiologist got another dose of sux into him which re-paralyzed him. The situation improved from here.

The result of all this was non-cardiogenic pulmonary edema-- basically, a heckuvalotta fluid in the lungs. Not so good for the breathing. And more fluid third-spacing... going to places it shouldn't. The poor kid looked like the Stay-Puft marshmellow man on a CPAP. After 18 hours or so on CPAP, the intensivist managed to wean him down to O2 by nasal prongs, but attempts to wean him beyond that resulting in rapid desats.

The poor kid and his parents were stunned. Thankfully, the story had a happy ending... he hung out in the ICU for a couple of days until he was able to be successfully weaned from supplemental O2 and went home, none the worse for wear.

Still... scary story. Serves me right for starting to think of surgery on healthy people as 'routine'.


* The Best Fucking Teaching Hospital In The World, a phrase intended to illustrate the view of the staff/clinicians/trainees at said hospital that everything done there must be the right way to do things, because we're TBFTHITW.