Monday, June 25, 2012

The Anesthesia Record

Everything I do in the O.R. I document on a piece of paper called an anesthesia record.

I am like a taxi cab, in a sense, because the minute I take you to the operating room, you are under my care directly. I take care of no one else but you until I take you to the recovery room, and transfer your care to an RN PACU nurse.

Most doctors who are not anesthesiologist (or CRNA nurse anesthetists) can't understand what is written on the anesthesia record. It is an important document, and I will point out the basics for you to understand.

First check the name and make sure it is a copy of your record. You will find your name, the surgeon's and the anesthetist's near the top. There will be a line for the proposed surgical procedure, and a line for the actual procedure performed. (Sometimes in the O.R. Plans change, depending on what is encountered in the surgery.)

On top of a series of tiny boxes lined up in a grid, you will find a time scale, reading from left to right. Underneath is a grid, like on graph paper.  Each small square stands for five minutes, and each big box stands for fifteen minutes. (Fifteen minutes is one unit of anesthesia time, and this is how we bill. There are also units assigned for the case and the complexity of the case).  Your blood pressure, pulse are charted every five minutes. Little carrot marks are systolic and diastolic blood pressure, and a dot represents pulse.

One of the things to watch for are when the blood pressure and heart rate are parallel and even like railroad tracks. This is often the case when your anesthetist is catching up. A real time chart would have ups and downs in patterns, with some random variation. This pattern is sometimes connected to what is happening on the surgical field. Blood loss, pulling on the peritoneum, or pressure and discomfort are just a few of these possible reasons for vital signs to change with time. You are asleep, but your body reacts to the surgical stimulus. Evening out this process is the meat and potatoes of anesthesia technique.

There are some cases on healthy patients that are uneventful, and tend to railroad track. But you would anticipate a drop in pressure as anesthesia begins and the patient falls asleep, a rise with intubation, and also a rise with the start of surgery. If there is a tourniquet, such as for orthopedic surgery, it is common to see a trending up of both blood pressure and heart rate during the course of the tourniquet use. They ramp up from the discomfort of a tourniquet.

On the right hand column, or sometimes below in little boxes, is the narrative of what was done in the anesthetic. On our record, there are lots of little boxes for one to check to save the anesthetist time. I am a writer, and I write more than most in my description of what I did. Box checking and hardly writing anything does not necessarily mean someone is not paying attention to you. It may mean that they just don't like to write. I document so that if anything were to happen to me during a case and someone had to step in, they would know exactly what anesthesia-wise has been going on.

On the left hand, there are lines with medications preprinted on them. These are common anesthesia agents. At the top is typically the gases, oxygen, air, nitrous oxide, and volatile agent (sevoflurane, isoflurane, or desflurane). Then come the different drugs. There you will know exactly what type of medicine you were given, and at what time.

You will also see patterns with the blood pressure and the medicines given. That is anesthesia, or a big part of it, after the airway management.

A big part of the anesthesia record pertains to airway. What was used, and how everything looked. We have ways of describing the anatomy and the equipment that was successful in getting a breathing device in place. That is also on the left hand side, in most cases. Underneath there are boxes for warming equipment used, what iv's and lines are inserted, and field avoidance (that is when anesthesia has no access to the head, for example, an ENT case). We also document controlled ventilation versus spontaneous ventilation rates and settings on the anesthesia machine.

Real anesthesia records get spills on them. In residency I discovered that anesthesia agent spilled on an anesthesia record can dissolve ball point ink! Sometimes they get blood. If a case was really a challenge, and possibly a patient passed in the operating room, there isn't much time to write while frantically managing the case. Sometimes, I print out the vital signs and make a new anesthesia record after that is more legible than my actual one in the OR. But I have not had to do this since my trauma surgery days.

Modern anesthesia machines have the ability to print out an automated anesthesia record at some facilities. Having done quality assurance for a department that transitioned to this form of documentation, I find it harder to extract the information. What is condensed in one page on a handwritten anesthesia record is clear and easy to focus. But off a printer, it takes four to six pages, and although the information is accurate, I find it more difficult to pull together what was going on. The meds don't line up with the vital signs, or the gases, as nicely. Furthermore, the automated record puts the burden on the provider to explain any irregularities in the hemodynamic trends. There actually are people who can watch the monitors from the computer room, and warning bells light up for them when an anesthesia provider is giving an anesthetic that has vital signs outside a threshold warning limit value. These computer monitoring people can talk to you through your screen and ask if everything is okay. These people are not medically trained, just technicians on the computer system. As a result of this technology, the anesthetist is placed in the defensive position, and where I worked, the surgeons would get annoyed and tell anesthesia to look at the patient, not the computer, as they were typing away to cover their you-know-what by documenting every little thing that is pertinent to the case.

Other things we document are the surgical positioning, which can be supine, prone, lateral, lithotomy, sitting, and prone jackknife. We check for pressure on the eyes and nose when the patient is prone, and check it. We record all fluid intake and output at the bottom, too.

It was a mystery to me when I was a surgery resident, the anesthesia record. It is my hope right now, that it will not be so mysterious if you ever have to look at one. Especially if that anesthesia record belongs to you.

It is my understanding that there exists a record for our experience in life, much in the way there is a record of what happens during surgery when anesthetic is given. There records of our life experience go across our entire lives. They are referred to as the Akhashic records. Some people are able to go to the great Hall of Records and look at them for individuals. However, no one is allowed to see their own during a current lifetime. I took a course online taught by Kevin Todeschi. He is in charge of the Edgar Cayce organization at this time. I was able to go through some guided meditations, and was surprised at how much 'stuff' from my past lives came up.

Whether you are into things like the Akhashic Records, or not, doesn't it make sense that in this day and age of video surveilance, that there might be some form of higher technology to keep track of what goes on in a lifetime? Isn't this the 'life flashed before my eyes' kind of information that some experience in a crisis?

One can never be certain. One can only hope to find out these kinds of miracles in due time.


Reiki Doc

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