The world of medicine is like a bubble. A lot of people THINK they know what goes on there, but unless you're down in the trenches it's unlikely you do. So here is my semi-anonymous blog, here to tell you what really goes on in the life of a medical resident.

Wednesday, January 10, 2007

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.

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Anonymous trenchdoc said...

Thats why at TBFTHITW... we use ENDOtracheal tubes not a half assing it plastic vulvas during surgery. This is a mistake people make over and over again.

8:56 PM

Blogger AnesthesiaDoc said...

Ahhh, the negative pressure pulmonary edema. Should've used a bite block! However, patients tend to spit them out sometimes despite your best efforts.
I have learned that nothing in anesthesia is routine, things can go down the pooper with little warning. I've also learned that the very moment your staff picks to return to the OR after having gone for a break is the exact moment the patient will develop a ridiculous tachycardia and hypertension and start flailing on the table. Never fails.
Watching someone brady down and arrest from hypoxia is one of the scariest things I've's like watching a train wreck in slow motion.
I disagree with the above poster that the problem was that there was an LMA and not a tube. Same thing could've easily happened with an ETtube. Or my fingers in the patient's mouth...but that's another story.

1:20 AM

Blogger Flea said...

Gosh, I hope that enough info has been altered in this story so as to make it unrecognizeable! You can't be too careful, especially since the last two commenters suggest that a deviation from the standard of care (use of LMA) might have occurred. [That's one of the criteria for medical malpractice, for those unfamiliar with these things. The others are Doctor-Patient relationship, Bad Outcome, and Causal Relationship Between Deviation from Standard of Care and the Bad Outcome.

As for the appearance of the LMA. I agree it looks like a vagina. But guys, I don't recommend trying to f*** one.



7:40 AM

Blogger Couz said...

Don't worry, Flea. The story in question had many details changed about it to make it postable!

Now I'm paranoid, though. Maybe I'll take out some more.

10:53 AM

Blogger Couz said...

And I agree with anaesthesiadoc... I've seen the same thing happen (although the sux was given sooner, and the situation was managed more easily) with an ET tube. I don't think the 'plastic vulva' really made a difference here.

10:54 AM

Anonymous Anonymous said...

someone should post a pic of what this LMA thing looks like...curiosity is killing me and google was no help.

4:00 PM

Blogger Couz said...

Here's the first one I found...

4:07 PM

Anonymous Anonymous said...

hah. Except for the 3 holes...and the plastic perfection.

11:26 AM

Blogger Bohemian Road Nurse... said...

Well...I think they look like weird stingray things, but then I always was weird....

10:08 PM

Anonymous Anonymous said...

While taking ACLS...we called them "vaginas on a stick"...leaving the instructor thinking we were insane.

10:20 AM

Blogger honkeie2 said...

I went looking for laryngeal mask airway and found may pictures of it......and yes it does look like a cooter! lol

7:49 AM

Blogger Sarah said...

hey, i'm flattered to be linked on your page.

4:26 PM

Anonymous posicionamiento en google said...

It cannot have effect in reality, that is what I consider.

7:13 AM


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