Monday, September 30, 2013

Dead Bowel

I am a Valkyrie.

My Uncle figured it out when I was about nine. He looked at me and said, 'They should play Ride Of The Valykries when you walk down the aisle.' He meant it as a compliment.

I take care of the half-dead.

That is my specialty--cardiac anesthesia. Just like in the ICU where codes are handled internally, and you don't hear it announced on the overhead paging system like elsewhere in the hospital, the same is true inside the cardiac O.R. suite.

People die. That is, their heart stops beating and the blood pressure falls to nothing and the end-tidal CO2 goes flat. But there is ACLS and everything else you have learned, so most times, but not always, we get our patient 'back'.

My favorite plan is to do everything possible to avoid the code in the first place.

I go to the store room and get boxes and boxes of the code blue drugs. Bicarb is my favorite, and so is THAM because you can use that when the lungs or liver are not functioning that great. I get like six boxes of bicarb, six of epi, six of lidocaine, and six of calcium chloride and line them up on my anesthesia cart. When I am really afraid of something not so great happening, I get the vasopressin. Five vials in one two-hundred-fifty cc bag of normal saline on a mini-dripper i.v. tubing, running wide open, gets lots of people 'back'.

The sickest patients come straight to the O.R. from ICU, and stop briefly at the door to get report from RT and nursing. I always ask where the lines are, when any next drugs are due, and the ventilator settings. Sometimes the patients are 'with it' but just as often they are not. Instead they are unresponsive and mechanically ventilated and on full pressor support.

The trick is to hook them up to the anesthesia circuit once you get them to the room. It breathes them for you, so your hands are free to help transfer the patient, arrange the pumps, and untangle the lines.

Many times I have a fresh i.v. set ready, and I find one spot to connect the i.v. to the patient and use that for all my medications I have to inject. Everything else just is too tangled, and once the patient is stable, I spend time carefully untangling the knots and twists so it 'makes sense'. I have a 'system' how I organize it--in the heart room it's the same time, every time, so in a hurry you know 'where everything is'.

Dead bowel is a fatal condition. It is a surgical emergency, and as you may imagine, the patients are pretty much the sickest thing in the hospital. The only things I can think of that are more sick is the ruptured AAA, the massive M.I., and the trauma patient (depending on what type). I once saved a six-year old girl who walked into a sliding glass window and severed her femoral artery. It was a wonderful case, and I was very busy taking care of her the whole time. The surgeons stopped the bleeding and repaired the vessel. I kept her from coding or going into DIC. She'll never know me, but I'll always remember her!

Sometimes most people have no clue about what I do for a living. I write this tonight for those who have an interest to know, to really understand how a life gets 'saved'.

For starters, did you know anesthesiologists 'grade' everybody that comes to the O.R.?

It's the ASA classification:

  • ASA 1 -- healthy, no medications, no major allergies
  • ASA 2 -- single medical problem or two, both treated and well-controlled
  • ASA 3 -- medical problems are severe enough to alter lifestyle. Burn ICU patient, any ICU patient, anyone on Dialysis, obstructive sleep apnea, difficult intubation all make someone an ASA 3.
  • ASA 4 -- will die without the operation; has a chance of dying even if gets it.
  • ASA 5 -- will die in next twenty-four hours whether gets operation or not--is given 'their chance' with the surgery
  • ASA 6 --organ donor, brain dead

As the ASA numbers go up, the anesthesia complexity and risk go up too. Add and E for 'Emergency Case'. The sickest that comes to the O.R. is an ASA 5E. Sometimes I wait until after the anesthesia gets started to make that final choice between 4E and 5E--if it's stormy, the patient gets 5E.

I'm glad I have my aromatherapy oils around my neck when it's a perforated bowel or dead bowel case. I put two drops on my mask, and I no longer retch from the stench in the O.R. ( Sometimes the rest of the staff in the O.R. and the surgeons ask for it too. I make a little happy face with the oils on their masks. But most of the time, surgeons noses are kind of dead to those smells, anyway...

When we finish a big case, we don't take the patient to PACU. We go straight up to the ICU. It takes a while to organize the lines onto the ICU bed, with the pumps and drips. Then we attach a transport monitor, and at the very last second, switch to an ambu bag on an oxygen tank. I squeeze that bag all the way to the elevator and back to the patient's ICU room.

Elevator rides can be frightening. Especially when there is an intraaortic balloon pump along with everything else. Sometimes I have to code the patient in the elevator, but that isn't very often. 

Although I sleep (and spinal or epidural) everybody, my skills are like the Valkyrie--I work with the half dead, keeping them alive, with everything I've got.

The last time I took care of someone like this, the patient's aura communicated with me, and said, 'I'm sorry! I ruined your night!'

How did they know I had to leave my favorite restaurant early because of the phone call and come back in for the case? That I had to go to the car and get my scrubs, change in the bathroom, and go? Did the people sitting happily with their families have any idea why I left? I had been sitting at the bar, eating a salad, and talking to someone who had to leave to go see a new movie (Rush, I recall). I have no idea why some people go to movies and I go rescue people from dead bowel. 

Sometimes a mystery is fun.

Aloha and mahalos,

Reiki Doc