Thursday, October 28, 2010

The Ultimate Examination.

I like to think of myself as a pretty practical person. I also believe that there is always a better, more efficient way of doing things out there ... I just have to find it. Tedious time-consuming tasks drive me crazy. Rules and regulations exhaust me. Boundaries and limits just freak me out. But with advancing age, I slowly seem to understand the logic behind all these things... or so I think ...

In my early registrar years, "the system", drove me insane. I was so sure that it could be done better, faster, and more efficiently. In retrospect, if there was any such possibility, the prof and co, would've implemented it! Ah .... the ignorance of idealistic youth ... But still, I hated the endless waiting and inefficiency, that often ruined my days.

Cutting time was 8 o' clock. Morning meeting was 7 o'clock. In the beginning, I tried my best to miss the morning meetings. They were false and scary, and not the greatest way to ensure good karma for the rest of the day. Plus I could sleep an extra half hour!! In those days it still mattered how much sleep I got. I was young and in pretty good shape, so yes dammit ... sleep was good.

If all calculations were done correctly, I had to be in theatre at the latest 7:30. Had to queue up for my drugs, then prepare for the first case. Didn't take too long if you were the only one in the queue, but by then, the morning meeting was over, and a mad rush for drugs and equipment ensued.

So, I got smart. Instead of queuing for drugs everyday, I queued up once a week. Saved myself hours every month. By drugs I mean schedule 7 stuff like morphine, pethidine and other opioids. Stuff that susceptible individuals could get hooked on. Thank the Lord I never had any such issues. We had special drug sheets where everything we used on patients was written up and checked. The sheets looked so old and forgotten that I often wondered if anyone ever actually checked them.

Got my answer soon enough...

We also had a huge restroom, with 3 beds, an almost fully equipped kitchenette and a TV. When it was quiet we'd all sit around there socialising and drinking coffee. Initially I did a lot of calls and every chance I got I would lie down on one of the beds and try to catch up on some sleep.

A couple of months down the line, I had perfected my own personal little system. Half way through my list that particular day, I got a message. The prof wanted to see me in his office ... STAT.

STAT ... well ... that didn't bode well, but I couldn't for the life of me think of any serious screw-ups I'd made. A senior colleague watched over my case as I walked into the lion's den.

The prof ... and his very clever, and very attractive right-hand consultant. I do believe I have mentioned this guy before. Both looking at me very intently. My drug sheets were spread out on his desk, and suddenly I knew, my little system had been discovered! Phew!! Nothing serious after all, so I promptly relaxed.

Five minutes into the interrogation, and my stomach was in knots. Why, where, how, when, how much, what??????? It felt like I was on some kind of trial! They suspected me of drug abuse!!! Over and over I explained my system, how I tried to save time in the mornings and miss the rush. Nothing. That I was lazy and wanted more sleep. Nothing. Look at the sheets I urged them, I collect just enough for one weeks worth of cases, nothing more. Surely if I was using it myself I would be taking a lot more??? Still nothing. I couldn't believe these guys. I'd thought I was reasonably liked and respected in the department, little did I realise that they had been watching me for all this time. And this was their conclusion!!! Every time I lay down, they thought I was drugged!! It was ridiculous and unthinkable, they really didn't know me at all.

I knew I had nothing to worry about. My sheets were correct and I kept all my anaesthetic charts, so on paper I was clean, but that was part of the problem. Most druggies always were ok on paper, everything always added up ... They would have to do some checks prof said. Ok sure!! Blood tests, urine samples, anything, no problem!!

Well first we need to check for any puncture sites - at least you never wear long sleeves or multiple layers beneath your scrubs. So lets go please ... upper body first, then lower body, including feet.
What like a strip-search??? Here and now??? Basically. Why do both of you need to check??? The prof was old enough to be my dad, but the younger guy, well ....
Witnesses are necessary for the report. Geez, this was getting worse and worse!! Firstly I needed to get practically naked before my boss and his side-kick. Secondly at that specific point I couldn't remember what underwear I was wearing. Thirdly the allegations and reports sounded pretty serious. Fourthly, I was innocent.

I tried for humor. Come now prof, you can't be serious? I'm ok and I don't do this kind of thing, really! A detailed explanation and I knew where I stood. They were the only two in the department who were aware of this issue. They didn't believe that I was guilty, but well one never knows and I had to be checked out. Apparently they'd had two positive cases in the not too distant past. They were just doing their jobs and if I hadn't been trying to cut corners, none of this would be necessary. I had the right to involve someone else if I wanted to, but they could do the examination, clear me of all the nonsense and nobody would be any wiser. At least I was given the choice. This was not a case of the more, the merrier ...

I whipped off the scrubs, turned this way and that way till they were satisfied. My underwear matched, but luckily they didn't seem to notice. It was over pretty quickly and obviously I had passed the test, flawless, unpunctured skin. Thank you Dior. The atmosphere was much friendlier suddenly. Ok, now go lie on the bed in the tearoom, have some coffee, and collect your drugs daily like everyone else.

I learnt a valuable lesson that day, and they were fortunate to be graced with my pre-pregnancy body. Otherwise both parties might have been scarred for life.

Sunday, October 24, 2010

Two for the price of one.

It was a midnight c/section. Baby was four weeks early. Mom was HUGE and in labour.
Dad was making jokes....

C/sections have really come a long way in the last couple of years. An elective one can almost be compared with a visit to your favourite spa or salon these days. The appointment is made on a day that suits you, Dad is allowed in, they play music of your choice, it gets videoed & photographed, mom's hair is freshly highlighted, she has a french-manicure, make-up is impeccable etc etc ... and the doctors make jokes. All that's missing is the glass of chilled chardonnay ...

The ambiance of a midnight c/section depends on the collective personalities. The majority of the medical species, suffers from the cinderella syndrome, ie, we lose it after midnight. We do try to cover it up during normal working hours, but one has to bear in mind that we are not exactly normal to begin with.

On this particular night, everyone was pretty jovial and jesty. Dad was exceptionally manic. An extra-ordinarily big guy, he proudly informed us that he himself had weighed in at 5.4kg! (Sadly, his mother didn't have the luxury of a c/section). To give you an idea, I judged him well-over 1.9m and about 120kg. He was rock-solid, but not in the steroid-infused-body-builder kind of way. Obviously a sportsman of some sort. That's why poor Mom looked like a beached whale ... their offspring was genetically enhanced in size. I was grateful on her behalf for the four weeks worth of discount. I eye-balled him, and asked if he was of the fainting sort ... I have always been slightly fascinated by these incredible hulk type of guys, but the thought of this particular one falling on me, was not in the least fascinating. He was offended by my question, but I explained that I routinely asked all dads, and I told him to rather fall to his right, as falling to his left would seriously cramp my style. I didn't need that!

The procedure was going well. When it came to delivering the little mini-me-hulk, the surgeon gave it one shot then reached for the forceps. A reasonable choice considering the prior discussion regarding baby sizes. Well Dad didn't quite agree. One look at the forceps and he started swaying. Now my first priority is Mom, but suddenly I was worried about Dad. In the three seconds it took for me to get to him, he'd totally flaked out. His head hit the ground from a height of about 1.6m ( he was sitting in my chair), in just under three seconds. No serious physics needed to figure that the impact was, sort of impressive. The resounding thud was remarkable, and of course ... he fell to the left.

There were a few technical dilemmas at this stage. One, he was in my way. Two, he was a dead-weight lying at an awkward angle. Three, he was unconscious and bleeding. Four, everyone else was busy, so only I was free to attend to him. Five, I still needed to keep an eye on Mom.

I just about shattered a disc getting him into the rescue position. He was more than double my weight ( using ideal body mass of course). Quick check: he was breathing & had a pulse, but had a serious forehead laceration and his tongue was bleeding. Some suction to clean up his airway, some oxygen for good-will, a pressure dressing for his forehead, and some ice for his tongue. A few slaps on the cheek to help him catch a wake-up ... and voila!! Dad was back!!! A little worse for wear, but nevertheless stable.

He was firmly shooed out of theatre and straight to casualty where he was promptly X-rayed and sutured. At least that was the end of him I thought to myself.

But about ten minutes before the end of the procedure, Mr-not-so-incredible-anymore, was back! Patched-up, and I quote, " good as new". Well by now it was way past midnight, and all fairytales were over, and all gloves were off! The poor guy was ragged senseless, he probably wished that he'd had the sense to just wait outside! I have never seen a guy that size blush. Although it was probably embarrassing for him, to me it was a great improvement on ghastly pale ...

Eventually we took pity on him, advised him to go via admissions next time he felt like some treatment, and congratulated him on his remarkable ability to create a 4kg prem.

Sunday, October 3, 2010

My first loss ..

Ten years ago , on May 5, I was a fresh young registrar of 5 months, with a recently acquired Diploma in Anaesthesiology. My confidence was boosted by my success and I was starting to feel as though this weird and wonderful job, could, perhaps, just work for me.

Although I now adore my work, I am the first to admit that I was by no means a natural-born doper. I had no idea what I wanted to specialize in, but knew that a GP practise was out. My initial objective for joining the anaesthetic department was purely personal. For one, I had heard that the hours were not too bad, and most importantly, I needed to overcome my fear of anaesthesia. How ironic is that?? Scared, with a touch of laziness! Anyway, I figured that doing it over and over on a daily basis for a year, with a professor or two breathing down my neck, would do the trick. When I passed the Diploma exams, it just sort of went without saying that the degree would be next.

The day I signed my reg papers the prof pulled me aside, welcomed me to the task force and said, " 5 in 5 years." Needless to say, I misunderstood as per usual...
Well, I do love children, but 5 in 5 years whilst specializing was like begging to be institutionalised, or even worse, pure suicide!!
I was promptly corrected, " 5 DOTT's " .... Death on the table ...

My worst fears were confirmed, this species really was alien, and totally nuts, and I was signing up to join them!!! Was I nuts??? I was expected to kill 5 people in 5 years?? What about that wierdo Hippocrates??? What about my mental health??? What about being able to sleep at night??? What about getting out of this 5- year- stint in the same condition I got into it???

Some of my what about's must have been visible. No good to show a weakness, but hey, I never bragged about any superhuman powers. He explained. The only way to learn how to deal with the inevitable DOTT, was to actually experience it a few times. 5 Times seemed reasonable, it could be more .... but be assured, he said, it would happen.

Well, with the formalities out of the way, I pushed that conversation to the furthest recesses of my mind, and got on with my training. No point in harboring crap thoughts.

Back to 5 May....

I was blessed with the paediatric orthopaedic list. I was excited and ready for it!! All paeds lists were supervised by a consultant, so although I wasn't alone, it was still my list and I was responsible for all the preparations. The first case was a 5 month old baby for bilateral clubfoot manipulation. He weighed 5 kg. Anyone who has ever had a kid could tell you that at 5 months no baby weighed 5 kg unless it was seriously premature at birth. This one wasn't.

The theatre was prepped to perfection. From ambient temperature, to warming mattress, tiny paediatric equipment, all drugs drawn up, diluted to accommodate the child's weight, and clearly marked, warmed bubble-free infusion lines ... everything was exactly right. Even emergency drugs were drawn up and ready for use. I felt proud, and confident that the consultant would be satisfied.

With a skip in my step, I walked over to the mother and took the child from her, assuring her that the procedure wouldn't be long. I put him on the nicely warmed theatre table and he just lay there, looking around, but not moving. No premed had been given. He was soooo comfortable I thought to myself. I had definitely prepared well. Once again, anyone who's had a child knows that no 5 month old lies so utterly still without arms and legs kicking in all directions. Especially having just been taken away from their mother. I didn't have any then, so what did I know? The consultant arrived, and we started the inhalation induction. Unfortunately, in those days, sevoflurane was still scarce and expensive so we made do with halothane. Within minutes the IVI was up and running, then I intubated the little fellow with no difficulty at all. It felt good.

You are not in. No end-tidal CO2. You are definitely not in.

The gas we humans exhale is CO2, and by measuring it after an intubation, we confirm the correct placement of our endotracheal tubes. Because the entrance to the trachea and the entrance to the esophagus are in such close proximity, and even more so in little babies, it is possible for the tube to go down the wrong pipe, thus blowing air into the stomach instead of the lungs. This classifies as an anaesthetic disaster. End-tidal CO2 is also a very sensitive indicator of cardiac output. No cardiac output - no life.

I most definitely WAS in, I saw the tiny vocal cords, there was no way I wasn't in. But now was not the time to argue. I stepped aside for the consultant, a very well-respected and highly intelligent anaesthetist. Within seconds, he re-intubated the child himself. Still no end-tidal CO2. Heart rate was good, ventilation was good, but no end-tidal CO2. The consultant appeared totally calm, but a few beads of sweat had broken out on his brow, something was wrong. Horribly wrong.

Without being told I began administering the emergency drugs, closed the anaesthetic gas, gave 100% oxygen and sent the sister to get help. An intense resuscitation followed, probably the most intense one I have experienced to this day. Theatre 8 exploded with a flurry of activity. When things go wrong, the news spreads faster than the speed of light, and help appears out of nowhere. A reg was appointed to keeping time and recording everything that was being done. Another was appointed to cardiac compressions, another to the airway, another to all IV administrations and a last one was used as a runner. The professor himself, together with the consultant, was in charge. Even the orthopods helped.

One hour and forty five minutes later, the baby was declared dead..... DOTT ......

How could such a perfect day end in such a tragedy?? I was shattered, totally totally shattered. I felt a million things and absolutely nothing all at once. My life flashed before my eyes while I wondered what the hell had gone so wrong. Walking back to that mother, empty-handed, was one of my most horrible experiences. I was sent home that day ...... Sadly the post-mortem yielded no answers, and after expert investigation, the cause of death was given as halothane- induced cardiac suppression.

I still don't know why I didn't quit anaesthetics that day - God knows I wanted to - but the next day I was back at work, and the next, and the next ....
Out of the obligatory big 5 as I later began to call them, that first one was by far the most traumatic. I couldn't look at a baby for months afterwards without feeling ill. I have never used halothane again, no matter how expensive the sevoflurane. I'm particularly sensitive to paediatric cardiac patients whose stories more often than not, don't have happy endings ... and ...
I have not taken a child from it's mother pre-operatively since then.