Saturday, April 27, 2013

'Moments of Sheer Terror'

Anesthesia is jokingly referred to by others in the O.R. as 'long stretches of boredom interrupted by moments of sheer terror'.

Would you like to know about some of those moments?

The Laryngeal Mask Airway, or LMA, is a mask that is inserted into the throat and sits on top of the glottis (opening in the windpipe where the vocal cords are).  Created by Archie Brain--I kid you not--the shape of the device was made by studying the casts made of the glottis and hypopharynx (just above the glottis) on cadavers. It is a well-known fact that a very small percentage of the population is 'different' from the majority of the population when it comes to the fit of the mask.

I have used LMA's daily since 1998, and never a problem.

Until recently. I had a patient who was terribly frightened for surgery. 'I have never had anything wrong with me!' they said, with angst. 'This is the first time in a hospital!'

I smiled inwardly. I know these types. They think because they never go to the doctor they are healthy. Giving anesthesia to someone like this is like opening Pandora's box: there are lots of undiagnosed diseases that are untreated and waiting to show up under the anesthetic for me.

For example, the ones who had 'asthma as a kid' have had some of the most dramatic cases of bronchospasm on waking up. Untreated asthma for decades sometimes does that. Treated asthma, that is recognized in the medical history, allows me to give breathing treatment in advance in the holding unit to decrease the risk of problems with a general anesthetic.

Can you imagine what it is like when you insert an LMA, it goes in fine, and it doesn't work? Your patient is apneic--this means 'not breathing'--and all that tight mask on your face before falling asleep buys me time to work with the airway while you are apneic. It stretches it from thirty seconds to about five minutes time.

At first I look at the monitor for end-tidal carbon dioxide, or CO2. No wave form. Not good. I adjust the LMA and check for end-tidal and mist in the tube. Nothing. I remove and replace the LMA. Nothing. Oxygen saturation is starting to drop. I know it can fall steeply.

I pull the LMA, insert a big green oral airway, turn the flows of oxygen up, add some inhalational agent (the propofol only works for about five minutes and I want to keep the patient asleep), and ask the nurse to squeeze the bag while I hold on to the mask and open the airway. I also ask for the Glide Scope to be brought to the room.

The nurse, is afraid. I have to coach her and calm her until my anesthesia technician comes into the room. The nurse is shaking. I see end-tidal on the monitor, and even though the sats continue to drop (this is normal, it dips before it goes up), I reassure the nurse. See? We are back to 98%! Good Job!

She hands over the bag to the anesthesia technician the moment the technician arrives. I get the Glide Scope ready, and secure the airway in under thirty seconds, with no desaturation. I use an endotracheal tube. I tell the surgeon, who is making comments the whole time, ones I don't really appreciate while I am working hard to get oxygen into somebody, that the patient is okay and everything is fine!

This is my typical 'moment of sheer terror', desaturation upon induction of anesthesia for some reason. It was first time for LMA. The patient did fine and woke up with no problem. This is bread and butter anesthesia, folks. This type of thing doesn't happen every day, but when it does, my reflexes automatically get to work and I know what to do. I just do it.

A highly different kind of moment of sheer terror happened for the first time recently on a patient who one may call a 'train wreck': multiple organ systems diseased with serious ramifications. This one had the vibe, as I call it. Every cell of me experiences dread at the thought of having to work on their case.

The vibe is almost always caused by the presence of dark negative entities in the patient. I can feel it through the computer, and sense it in the nurse that is giving me report.

In this situation, I accept my assignment, and do the best I can. This time it was a direct admit from ICU into a new O.R. I hadn't set up yet. Scant time to evaluate the patient, even less to clean and set up for the case. I did have my new clean meds drawn up and labeled in their syringes, though. I had prepared ahead during the case before.

This patient had the ability to be violent towards caregivers. It was documented in the medical record. This patient was heavily sedated by the ICU nurse. You had to wake them up to get them to talk to you as you examined them.

Induction was surreal. The sedation was useless when the face mask was applied to the face for pre-oxygenation. The patient got agitated, and demanded nasal cannula. That is not enough for getting oxygen in before surgery. We compromised with the mask being 'right over the face'.

This is a technical problem that I have to deal with every day. Room air is twenty-one percent oxygen. Safe pre-oxygenation requires one hundred percent oxygen. That is why the mask is fit tight. In a patient who has obstructive sleep apnea, this is crucial, and non negotiable. That is, if they are not going to hit you. If they are agitated, you back off, and hope you can secure the airway quick.

Glide scope was in the room, and ready. I only use this equipment on people with sleep apnea or difficult airways.

But guess what? During the induction--that is where I give the big dose of Propofol and also paralyzing agent--while I am watching the pulse ox reading of oxygen saturation like a tiger stalking their prey, it stops! All of the other waveforms are fine. The patient is apneic, I have thirty seconds or less, and I can't see how my oxygen in the blood is?! Quickly I scan the lines to the monitor: the little sticky probe had fallen off the finger right at that instant! We got the finger clip on, adjusted it, and IT would not read, either!

I redid the connections checked the main connection to the monitor, and it got it to work. All of this was in twenty seconds. Sats were dropping but not rapidly yet.

In the next ten seconds I got in the tube. Just in time. There were no desaturations. I secured the tube, and coordinated turning the table with the head away from me as required for the case. There are a lot of lines and wires to watch, most importantly the connections to the ventilator and breathing tube. Sometimes even the O.R. table gets hung up on the cables on the floor. I had to ask the nurse to unlock the bed because she had locked it on top of my EKG cable. It's annoying, but do-able, having to turn the table. I have my system and it always works for me.

It was just after this rush, when the case was settling in, that I did Reiki.

Remember, there are dark negative entities in this patient. They were having fun with me on induction, trying to make me stress.

(Even before I learned Reiki, I had the reputation of being the most 'Zen' of all the anesthesiologists in residency. Cardiac anesthesiologists are calm in all situations. Even my fellowship program director hired me because of my ability to stay calm when he 'fired a few cannons at me' during the interview. This skill is needed when bad things are happening and the surgeon is yelling at you while you are trying to save the patient. In a word, it is FOCUS in the face of overwhelming risk to your patient.)

I got in to the aura, and chicken that I am, called for my guides, the Guides of Compassionate Healing, to help. I make the connection, and they or Archangel Michael if it's really scary, go in and clear out the dark entities for me.

Not this time.

Go in. You talk to THEM.

Are you sure? Is it safe?

Yes.

So I was like, 'Hello? Um...this is your chance to go to the Light! No questions asked! If you don't you might get taken to get vaporized in the Galactic Central Sun!' and trying to make my Spirit voice all cheery and positive. 'Times are changing, and it is okay to come out. Here, take my hand.' 

I offered both of them, and was not sure what these Dark Entities were going to do with me.

They seemed tired, defeated, and given up the fight. They made poor eye contact and came forward. They each took a hand. The entire GCH team was behind me. I walked with the two a few steps, and gently handed them over to the team that was waiting for them. I felt great Love in my Heart, for these brave souls who stepped 'out', and came toward the Light. I felt surprise that they listened and everything went okay. I felt gratitude for the team putting me up to it in the first place. I understood that the Dark entities were gone, but the remaining Negative entity removals were to be coordinated by the team over the next few weeks.

And I felt a golden, sweet honey energy from the patient, as if it was the end of a play, and the actor who played the villain comes out for the curtain call; you can tell they are nice and just played the part to make the play more fun. I was amazed at what a powerful soul was hiding underneath all that Train Wreck. The green chakra was very big and bright, possibly the brightest I have ever seen.

All of this took thirty seconds. Spirit work is like managing the airway. When you do it long enough, you gain skills, and speed is one of them. I was watching the surgery, the patient, the monitors, and the anesthesia machine the whole time I was doing Reiki--well, a form of it : ). I also gave morphine in the middle of the thirty seconds because I noted that the blood pressure had gone up (readings were every three minutes). I just put the Reiki on pause like you would something on your digital recorder at home.

So there you have it: moments of sheer terror, two on the airway, and one with Spirit/Reiki/Light.

How was the wake up in the last patient? Did I get hit? No. The morphine did the trick.

But the foley broke apart in a way I have never seen it happen when we wheeled the patient out of the door from the O.R. The nurse had to get gloves to fix it...

Namaste,

Reiki Doc

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