Sunday, May 30, 2010

Decisions decisions...

Huge, round, imploringly innocent, brown eyes turn to mine... Please, please... they beg me silently. Oh man ... the desperation is almost tangible.

A thrombosed haemorrhoid, a warm breezy saturday afternoon, a busy busy stomach happily digesting away at one hour ago's lunch ... a discomforted over weight patient, and a desperate surgeon.

All eyes on me.

As far as I am aware, surgeons encounter the term ASA at some point during their training. Ok, they may not be aware of the full implication of those three letters, but they hopefully get the general idea.

ASA is the American Society of Anaesthesiologists. A bunch of people who spend years and millions doing research, developing protocols and safety guidelines regarding the administration of anaesthesia. Then they are kind enough to print and bind all that excess knowledge, and distribute it world wide. Of course, whether we choose to use the info or not, is totally our prerogative.

The cool thing is, that although the safety of the patient is put above all else, the safety of the anaesthetist somehow gets all tangled up in there too. So ... if the patient is safe - it's almost a given that the doper is safe. If the patient is in trouble, all eyes fall on the anaesthetist first.

Perhaps you can see why we adhere by the ASA guidelines as much as possible. It's in the best interest of everyone involved. Even the surgeons, although they don't always see it that way.

Latest guidelines regarding pre-operative fasting stipulate NPO x 6 hrs for solids, NPO x 2 hours for clear fluids. As always there are stipulations for specific cases, eg certain patients benefit from getting carbohydrates pre-op etc etc. But in general the 6 hrs / 2hrs rule applies.

Also, we are not unreasonable. The problem of theatre time and long lists is fully understood, time is money after all. More often than not, a case is individualized. We even try to find out exactly what was eaten. A clear broth or bowl of jelly for example, may, according to the severity of the case be categorized under the 2 hrs group. In an absolute emergency where time is life, we have our ways and means of doing what we must, without waiting. But it's not ideal.

Allow me to explain the reason for all this paranoia. Chemical pneumonitis is a type of pneumonia one gets when foreign chemical matter (ie food) finds its way into the lungs.
The treatment for this includes a stay in ICU, on a ventilator with a tube down one's throat, amongst other things. It doesn't happen often, but when it does, it can be rather scary.
With induction of anaesthesia, all smooth muscle tone is relaxed, and the patient can easily vomit especially if there is a full stomach on board. Remeber that the patient is asleep and can't spit out his puke. So if we don't suction it out fast enough, it simply flows into the lungs. Yuk!!!!!!!!!!!!!

Back to the saturday afternoon dilemma. A chubby patient, with an extremely sore bum, satisfied himself to his hearts content, then got up from the lunch table and drove himself to hospital. ( Must have been one hell of an uncomfortable ride!)
The surgeon, desperate to get it over with, making bambi-eyes at me and promising the procedure to be 5 minutes only. Just a bit of propofol please???

All eyes on me.

Do we go ahead or don't we??

Let's see ... sore bum plus 5 hour wait, with all our asses covered vs fixed bum plus aspiration and a 5 star ICU retreat.

I know what I chose. What would you choose???

Tuesday, May 25, 2010

The weakest link.

I have mentioned this woman before ... but this was the last straw.
It's eight months down the line, and well to be honest, I'm feeling more despondent than ever. The more exposure I get to them, the more wary I am of my new colleagues. Often I wonder if they feel the same way...
Making new acquiantances is like a walk in the park for me, making true friends on the other hand takes me years and years. It's how I am, and although it makes a quick settle quite difficult, it's a trait I don't think I could change even if I tried.
So although I walk solo, I still try to do my job to the best of my ability. I often feel as though I'm being "checked out", which makes me even more determined to be the best. I don't lower my standards, or settle for second best, or allow anyone to cloud my judgement. And I can be quite painful about perfection when the need arises.
Yesterday was a public holiday. I was on call. At 9am I got a call for an emergency c/section. By 9:30 I was scrubbed and in the process of doing the spinal, when my mobile rang ... twice in succession I might add.
It's a common occurence in the medical profession to "have your hands full" or your "mind full" for that matter. Thus being unable to answer calls.
I was just pulling off my gloves after settling the patient, probably about 5 minutes after the missed calls, when my phone rang again.
This time, I could answer. An extremely distraught and irrate colleague wanted to know where the hell I was. He had been called by an even more distraught receptionist claiming that the anaesthetist on call had gone AWOL. The best is that she'd even called the "head" anaesthetist, (who had taken a much needed weekend away with her family, and thus been rudely awakened), as well as my home ... only to be told that I was at work. Still no warning bells went off in her empty mind.
Anyone who knows me, knows that I'm never late for work, especially not for emergencies. The fact that there was even the need for me to explain myself out this ludicrous misunderstanding, really pissed me off. When he finally got the message, and realised that I wasn't lazing around, and "frolicking on some beach", but actually at work all along, he calmed down.
But for me, the damage had been done. Everyone had doubted me ... everyone had taken the word of the thickest, most incompetent, receptionist to ever walk the face of the earth. Perhaps for the first time since joining their workforce, I know where I stand.
I'm good enough to work through the night - no complaints. I'm good enough to do all those patients nobody else wants to touch. I'm good enough to dope for all those surgeons that nobody else wants to work with. I'm good enough to help out when others are tired.
I'm also good enough to be judged first, and questioned later.
It's true what they say about the strength of a chain ... one weak link and you're screwed.
Seems it really is each man for himself, after all.