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???

The weakest link.http://www.blogger.com/post-create.g?blogID=2171259283937982137

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.

Safety & Security

Something very strange happened last night.
I had to accompany an intubated & ventilated patient being transferred from our hospital, to an ICU in the capital city about 70 km away.

The ambulance was privately owned and state of the art, with all the equipement and gadgets one could ever need. I was at once impressed and relieved, as it would make the journey both interesting and safe.

On arrival, the paramedics threw open the doors, and facilitated the speediest admission I have ever witnessed ( the patient even had a sheet of printed stickers ready when we got to ICU!!). Then they proceeded to lead the way into the hospital.

But, to my utter amazement, they left the ambulance engine running ... with the doors wide open!!! Ok, it made for a very dramatic effect, with the lights glaring and all! There was also, certainly, a sense of urgency about the entire situation, but an extra 2 minutes to switch off the engine and lock the doors surely wouldn't have made that much of a difference? For goodness sakes, there was a lot of expensive stuff in there!!

Not to mention my work bag - in full view of anyone who might have the slightest inclination to look into the vehicle!!! I tend to always carry my bag with me, even for a transfer. It is an absolute work of art!! ( My bag that is). You will find anything and everything in there, from the most basic, to the most advanced, means of survival. I firmly believe that if I were ever stranded in the middle of nowhere, with my McGyver's Bag at my side, I would have nothing to fear. For the first 24 hours at least ...

It is a big hospital, so even at 10 o clock at night, the casualty department was quite busy. There were people milling about everywhere!! I tried to voice my concern to the oh-so -dedicated pair of paramedics now earnestly wheeling the patient towards the elevators, but was promptly reprimanded for worrying about such mundane matters at this crucial stage of the operation. Plenty of time for all those secondary isssues once the patient was safely handed over ....

Yeah right ....

All my life, for as long as I can remember, I have been conditioned to watch my back and lock things up. It is basically second nature to me. This blase attitude towards safety and security grates my nerves. God help them if we got stranded here, or even worse, if my precious bag got stolen ... I simply couldn't help imagining all the variations to the theme ...

Ambulance sans its wheels, (including the steering wheel). Ambulance sans its contents. Ambulance sans my bag. And well ... parking area sans the ambulance... After all, I know a place where, I kid you not, all of the above options are a part of normal, everyday life.

So imagine my surprise at finding everything exactly as we had left it! Even my bag was untouched!! And there were still loads of people all over the place!!

I guess that this is what Safety & Security really means ... even though I still struggle to comprehend it.

Theatre 10

Theatre 10 is ..... just that.

It's the 10th theatre in a complex, of, I forget how many, but lets say 15. It is situated in a corner, directly across from the catheterization lab, and if you are ever priviledged enough to get your hide through its doors, you feel it immediately.... The atmosphere is charged with a million little electrical impulses and there's permanently an excpectant air of anticipation hovering in that tiny space between the conscious and the subconscious.

It's the lions' den, the spider's web, pandora's box, call it what you like ... but the exclusive domain of the cardio-thoracic surgeons is like stepping onto another planet ... there are no rules, and it sure ain't for the faint hearted.

Now in the surgical hierarchy, it is common for the general public to equate a brain surgeon, to a rocket scientist. You know, the guys with an abundant amount of grey matter to spare. But contrary to popular belief, in the medical world, it's the heart surgeons, albeit a little less bright than the brain surgeons, who actually rule. Here, speed and balls, definitely outweigh brains and balance. This is most likely a self-appointed position, sort of like Robert Mugabe. So they blow their own trumpet, assume first place, and who ever doesn't agree ... well doesn't deserve the oxygen he breathes, and is invited to donate his heart to research.

At times, one can almost understand it ... there really is a huge weight on their shoulders. So if believing that they are Hercules makes it easier to carry, so be it. Imagine taking a sick heart into your hands, stopping it, fiddling with it for a couple of hours, putting it back, kick-starting it, and expecting it to take up right where it had left off. Perhaps I too would imagine that I could walk on water! The fact that an entire team is bubbling away beneath the surface to keep their sorry asses from submerging, is totally irrelevant of course.

Be that as it may, oozing confidence can only be a good thing. So ... you either beat them at it (which is virtually impossible), or join them. A sink or swim ... oh sorry, walk on water ... situation.

Even as an anaesthesiologist, the satisfaction gained from a succesfully sorted out stabbed heart, is hard to beat. The speedy preparations, the barely controlled urgency, the joint efforts on numerous levels, take about 5 years off your life, but the thrill ... priceless ...
The cold cases are less exciting for me, I think it's cause I get to look into the patient's eyes for just that fraction too long, and end up pondering the fragility of life for just that bit too much.

Being the adrenaline junky that I am, it pains me to say that I haven't done a heart since completing my training. In my opinion, it's not something to do occasionally. You either do it, and do it properly, or best leave it alone. But the little voice in my head ( and, no I'm not schizophrenic yet), still asks whether I miss the cases, or whether it's the uniquely captivating world of theatre 10, with all its ambivalent extras, not to mention the bunch of over-inflated water- walkers for whom I actually harbour a grudging respect,
(but can never admit it - or they might just believe they can fly next), that has me pining.

Midnight Angels

It was many years ago, but I remember it like yesterday.

I was an eager young registrar, on call for the maternity theatre. No doubt things have changed now, but back then it entailed literally 24 hours of c/sections. On any given day, about 15 howling little miracles could be delivered via the vaginal bypass route.

Most of us dreaded the maternity call ... it was endless ... and extremely painful both literally and figuratively. The gynaes were also in training and usually tended to struggle through the surgery. The patients were usually so exhausted, or so sick, that any form of communication was restricted to the bare necessities. The change over time was way too long. The maternity hospital was situated about 2 km from the main hospital so as an anaesthesiologist you were on your own. Help was at least 5-10 minutes away (and any fresh registrar with half a brain cell knew, that that was way too long ) You knew upfront that you were screwed on that day, but as is the nature of the human race ... against all odds, you still hoped, and hoped, and hoped for some divine intervention and at least an easy night. Or that all your spinals worked perfectly.

Despite all of that, I loved the maternity theatre! I enjoyed the spinals and most of all loved those little babies!! Nothing cuter than a newborn looking around , eyes alert, mere seconds after being delivered, with a know-it-all expression on its little face!! Yep the c/sections were definitely my favourite.

On this particular day it was busy as usual. It was around midnight and the endless stream of pregnant fairies seemed to ease up a little. I was tired, but the current patient was intelligent, friendly and really nice for a
change. I didn't need much convincing to have an enjoyable conversation with her.

Now in those days I used to draw up all the drugs needed for a general anaesthetic (in the event that my spinal didn't work), and have them all ready and labelled. I also had, and still sort of have, this obsessive compulsive notion of always drawing them up in the same way. So I always drew the tracrium up, diluted, in a 10ml syringe and the syntocinon in a 5 ml syringe. Tracrium is a muscle relaxant with a relatively short duration of action, which doesn't need to be reversed. Syntocinon is used to contract the uterus after delivery.

But not on that day .... No, on that day I drew up both the tracrium and the syntocinon in 5 ml syringes. Heaven knows why ... But at least I did have the syringes correctly labelled, although it didn't help me much.

So spinal was working perfectly, the patient was communicating nicely and the baby was out! Time for syntocinon. In our institution we gave 30u in the vaculiter and 10u IVI, so a total of 4ml. ( One ampoule of tracrium was exactly 5ml.)

I warned the lady that the medicine could give her a feeling of pressure on her chest, but reassured her that it would pass quite quickly. Then I took the syringe (labelled and all), wondered for the briefest of seconds why there was 5ml in it and proceeded to add 4mls to the bag of ringers and 1ml slowly IVI.


For a minute or so, all was well. Then it started ... she complained of a heavy feeling on her chest. I told her it was normal. She complained of difficulty to breathe. I started some mental checks. When she broke out in a sweat and started slurring her words, a light flash exploded in my brain! The syringes!!!!! I had mixed them up and instead of giving syntocinon, I had given tracrium!!!! I checked, and low and behold, the synto's was innocently lying on the trolley. No wonder I was perplexed by the 5ml, instead of the usual 4ml!! Faster than the speed of light I ripped off the contaminated vaculiter and replaced it with a clean one. Then I supported the patient with gentle mask ventilation, all the while talking to her softly, telling her not to worry, that all was well and that she was doing fine. Luckily the gynae was quite fresh too so the op took about 20 minutes longer than usual, which was more than enough time for the little bit of muscle relaxant to wear itself off.

Soon she was back to her chatty self as if nothing untoward had taken place, and I was calling myself every kind of fool. How could I make such a mistake?? Why didn't I read the label?? Why did I draw the drugs up differently??

The gynae never noticed and I never mentioned it. I repeatedly asked the patient if she was fine, and when she eventually sighed and said: Ok, if you must know, I am absolutely starving and would love a cup of coffee!! I finally relaxed. Still felt like a dog though ...

When I discussed it with the prof, and told him that perhaps I wasn't cut out for this job, he told me that at some point we all make mistakes but that the important thing was to recognise it quickly, deal with it correctly, and learn something from it. Also, never ever to underestimate the power of the midnight angels watching over us...

The pyjama drill

A loud shrilling noise drags me away from my much-needed slumber... What's going on?? Where am I ... and what on earth is that grating pandemonium?? ...

Ah yes, my phone ... I am on call tonight ...

I answer just in time. A dehydrated two-year old needs an IV infusion and the exhausted ER doctor's numerous attempts were unsuccessful. It's 1am.

Thank God it's not theatre! With a bit of luck, I can be back in bed in about an hour! Reluctance almost kills me as I roll out of bed. I put on my bright pink MAD DOGS tracksuit (which in my opinion is still in a respectable condition), my authentic NIKE's, wash my face and brush my teeth. I barely brush my hair, and don't bother with anything else eg make-up or contact lenses. At this hour it's speed vs elegance!! I do hear my dad's voice echoing around in my head though ... always look good when you leave the house, you never know who you might see .... grab my glasses and go!

My brisk walk across the parking lot towards the ER, is disturbed by loud calls?! It's the security guard!! And he is really upset!! Oh, what now??

Dr, whats wrong?? Are you alright?? Yes, I am fine, what are you making such a racket for??
Dr, how on earth could you came to the hospital in your pyjamas?? He doesn't wait for an answer, just barges on! In your pyjamas, I cannot believe it!! WHY??? What is SOOOOO urgent??
What are you talking about? This is a perfectly respectable tracksuit!! It's Mad dogs!! Do you even know what that is?? It's not exactly cheap you know!! And even if I was wearing pyjamas, what's it to you??

I march on feeling truly offended. It's after one in the morning for crying out loud! What did he want, my sunday best??

At least the parents of the little kid are too distraught to notice my unsuitable attire, and perhaps the sisters know better than to comment cause nobody says a thing. After settling the fiesty little screamer (and indirectly her mom) with some magical Barney juice (a touch of dormicum mixed in a bit of calpol, with the exact same shade of purple as the dinosaur), lady luck smiles my way. Despite what I am wearing .... the IV goes in on the first attempt. As always I say a little mental prayer of thanks, cause these drips have a sure way of keeping you humble at times.

Great, now I can dash off home!! But first I must pass via that security guard once again.... Ah, what the hell, I can do this!!

Hey doc, you can't leave yet, the gynae has just walked in. I told her you were here and it looks like she might need you. Ok, double great.

Back in the ER I notice a man hurriedly filling in an admission, and preop form. Is this for the gynae patient? Yes, she is my wife and it looks like a c/section. From somewhere behind me I hear, Sir, this is our anaesthesiologist. Oh man ...

I cringe a bit inside, (my dad's gonna have a fit if he ever hears about this), but pretend that my now infamous Mad Dogs, is actually Versace or something, and head down to theatre to change.

At least my blessed scrubs lend and air of control and comfort, even if they're a far cry from being elegant or fashionable. In fact they look worse than my pink trascksuit, but just because they are scrubs, that seems to make it ok??!!

Anyway halfway through the c/section the gynae asks if the kiddie is ok. Perplexed I tell her that she is just fine. The security guard told me that you had to get here stat, so you came in your PJ's? Well ... good news sure travels fast!! By tomorrow morning I will most probably have come to work in my underwear !! And I bet that sleaze-bag didn't even mention my state-of the-art NIKE's?? I coolly lift my eyebrow and say, I assume that you're intelligent enough not to fall for that, but rest assured that if the need ever arises, not even my pj's will stop me.....

I am soooooooooooooo going to kill that guy.............

A Medley of Morals

Perhaps it's an arbitrary notion. Perhaps it's due to working in the public sector for too long. Perhaps it's personal hypersensitivity. Perhaps I'm just crazy, I don't know ... but I've always felt that the concept of human rights, is something that doesn't bode well for me. This is a personal view and not intended as a political remark / opinion in any way. It's just that, I have yet to gain an advantage from that little phrase on any level, personal, or professional. It's almost as if I'm always last in line when so-called human rights are being dished out ... and by the time I get to the front of the cue, there is nothing left.

Any professional knows that personal issues and opinions, have no place at work. You do what you are trained to do, to the best of your ability. But where, and how, does one actually draw the line? What happens when your morals clash with that of your patient? When what you're expected to do goes against everything you believe? When your freedom of choice is forfeited for that of another? When someone else's human rights are considered at the expense of yours?

What then?????

I have a problem with abortions. Having witnessed first-hand, both, the double-edged sword of infertility, as well as the divine grace of adoption, it is something that I personally cannot condone. Especially when it is exploited as a form of contraception! And please, I am not generalizing, and I am not judging. All I am saying is that I want no part in it. Perhaps it's a bit cowardly of me, or hypocritical even, I'm not sure. But something dies inside me everytime I contribute to an elective abortion.

In my opinion, no woman ever gets over it anyway. Every single patient I've ever anaesthetized for this, has woken up crying ... barring one. It's something that I've constantly noticed over the years, without fail, and it never seizes to affect me. The reasons why a woman would choose this specific route escape me, yet I fully understand that the decisions are hers to make. She has the right to chose, and she has to live with the consequences of her choices. But, at least her choices are being considered ...

What about mine?

Don't I have the right to protect myself emotionally? Why do colleagues stare at me as if I'm a two-headed, lazy monster when I decline these cases? More often than not, I get bullied into doing them anyway! My professional position supposedly puts me in the upper ranks of the food chain, but what's the point? Even there, my freedom and my rights are at times controlled by others. Add to that the frustration of not being able to discuss the situation openly with the patient ( I refuse to upset any patient before an induction, plus she is basically the gynae's patient, not mine), and I have to ask: Where is the human rights in that??