Friday, March 26, 2010

Another day in the OR

Every day is a new challenge. Some days it involves a new anesthetic machine, or combination of several: one machine to deliver anesthetic agents, with a non-functioning ventilator, a separate ventilator-only (much older), a console with EKG and pulse oximetry, except there is no cable for the pulse ox and that is a separate machine altogether. Many of the drugs we use here are completely foreign to me: many are no longer available in Canada, or haven't been in common usage since the 1980s. The onset of action is often very slow, or takes forever for recovery of anesthesia.
We also have daily challenges with the residents. Today's challenge was to get them to pay attention to the monitors, in particular the alarms. Alarms exist for a reason: if they are ringing off, usually in an annoying, high-pitched way so that you pay attention to them, at least have a look as to why. I cannot comprehend how it is possible to ignore a sound that irritating. Plus, it is a clue that you need to respond to what is going on in the case: another important learning point. When the heart rate goes up precipitously, or the saturation goes down, you can hear the change in speed or pitch, and act accordingly. The resident I was working with today did not appear to be responding to anything, at least with any degree of haste (or in a timely manner). I had to point to the monitors to direct their attention to abnormalities. The supply-demand ST depression the patient was developing from an increasingly rapid heart rate was interpreted by the resident as "peaked t-waves". There is work to be done.
Spinal anesthetics appear to be much safer. Both residents and anesthesia technicians are quite proficient at them, patients are extremely stoic and tolerate being awake for even repairs of femur fractures, and they provide consistent and predictable operating conditions. These are not fool-proof, however, as the resident Patty was supervising had a patient with a systolic blood pressure in the 50s, and it was a struggle to get him to correct it immediately with some ephedrine. In a 72 year old, who was actively bleeding.
We keep reminding ourselves that we have seen major improvements since Patty was last here 18 months ago.

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