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Thursday, October 31, 2013
What I Do Better Than Anybody In Anesthesia
'The patient is CRAZY!' the PACU RN confided to me about our next patient. She had just come back from the ER to talk to them. It was an emergency case and had to go.
Apparently the patient was freaking out over the i.v. and very tearful and trying to stop the life-saving surgery. Family member was present.
I smiled inwardly, because in anesthesia one does not have to deal with an awake patient for much length of time! I relaxed and went back to the O.R. to set up for the case.
It isn't my favorite thing in the world to do, but what I do best out of anyone I know is how to handle the difficult patient.
It's the combination of my heart, my experience, my expertise, and Reiki. Even before I learned Reiki, all of the fibromyalgia patients at my old hospital knew me and made special request for my presence with them when they had to have surgery. Not that fibromyalgia patients are crazy--far from it! These souls are shell-shocked and battle-weary from a medical system that doesn't 'figure them out', offer much in the way of 'cure', and sort of marginalizes them in the process…they get 'difficult' after going through all that.
For my greatest effectiveness in this potentially challenging situation, I started Reiki on myself and the team before I even set foot in the Emergency room.
It was with some hesitation I went to see the patient; I didn't know what to expect. All I knew is there was a condition inside that would be lethal in about six hours, and I had to do everything possible to 'talk them down' and into the surgery. (The patient and family gave consent, but from the consent to the operating room, with a frightened one, takes very delicate 'negotiation' to keep them from 'freaking out'. There is a lot of room for anxious imagination before anesthesia is induced, you see.)
The patient was sitting bolt upright in bed, almost in fetal position, and rocking to console themselves. I knew there was a lot of ativan on board because I had looked at the chart; but with chronic anxiety and xanax use, our i.v. anxiolytics don't 'go too far'.
The loved one was on the phone with a cousin. She handed the phone to me. Apparently the time before last was a 'bad experience' in the anxiety department, but the time after that (the last time) was 'okay'. I was requested to follow the protocol, including family member presence on emergence in PACU.
This is a tough call. I can request it, but I can't guarantee it because it is the recovery room nurse's 'turf' and her call alone. I explained this delicately, and the family understood.
I went back to the O.R. and got my drug box. I opened the lock and placed it on the mayo stand next to the gurney in E.R. I explained to the patient I was going to give medicine through the i.v. and asked permission to touch the i.v. port.
The key to the anxious patient is to explain, to demonstrate, to move slow and to ask permission every step of the way. If your ego is back in the parking lot, this is no problem whatsoever. If your ego is on your white coat, both you and the patient are going to have a Long Day…
Slowly I titrated (gave small amounts looking for the effect) midazolam….gently talking the whole time. 'I want you to feel better. I don't want you to cry--it's going to make ME cry!' Two of versed (normal dose), slight improvement in the shaking all over with fear. Patient was asking to 'just go outside for a smoke'… No way, sorry! Four of versed. Visible improvement, but still tearful and rocking. Six of versed. A decent 'baseline' but would be lost with any move of the patient toward the O.R. when the next surge of anxiety would hit. Eight of versed. The window of opportunity was open and would last about five to ten minutes…before the drug was absorbed by the system and anxiety returned.
Family member escorted to exit of ER. An ER nurse Sandy, came to give our patient a hug right before the O.R. double doors. If you know how packed that ER was, and you knew how many patients Sandy was carrying (and mine was not one of them), you would be as impressed as I am at her compassion for our patient.
In the O.R., I only put on two monitors. I did not put the oxygen mask on the patient. I induced anesthesia gently and with lots of 'fair warning' while the patient was sitting up. As unconsciousness fell, we eased the patient on their back, and I started with mask ventilation to improve the oxygen surplus since there was no effective pre-oxygenation by the patient. It wasn't easy to get the breathing tube in, but it went, and the case was on.
A quick phone call to recovery room got the charge nurse to go to the ER to get the ativan I needed to give again in the i.v. before emergence, or 'waking up' from anesthesia.
The case had been life-saving, but uneventful, and the family had been informed by texts by me the whole time of when to expect 'waking up'.
Here are the transcripts of our texts:
Me: Hi (name), we are closing. Ativan is on board and PACU agrees with family presence in recovery. I'll let you know when we are out of the Operating Room. Dr. (me)
Family: Thank you Dr., that's wonderful news! (family member) is on the way and will be there shortly.
Me: In recovery, extubated 'deep' therefore still 'under' anesthesia. (this was family request)
Family: Thank you. I spoke to Dr. (surgeon). Sounds like everything went amazingly well. 1.5 hour surgery, laparoscopic not open, and no colostomy bag. Any guess on when they will wake up? (I promise not to hold you to it!)
Me: Whenever her ativan wears off, it's up to them…
Family: Thank you for the deep approach, you really do know how to take care of your high anxiety patients.
Me: That's because I have it too. Namaste.
Family: Thank you for sharing that with me. I know it will help our loved one greatly when I tell them. They still feel so ashamed, especially when encountering persons who do not understand this is a medical condition. Namaste. / /
Me: No need to be ashamed…anxiety hurts. Just let them know it's possible to feel better. I am way better than I was many years ago. Xo---I think it helps me take better care of my patients, and in a way, is for me, a blessing.
Family: You are so kind. I know your words will be very meaningful to them. I am absolutely sure that helps you take care of your patients better. Which as you say is a blessing for you but also a blessing in their lives. Our loved one has been struggling with this for several years and it is not any better. In fact it's worse due to additional problems that sap their resources such as divorce, disability (broken bones requiring two surgeries), periods of unemployment, financial problems, etc. Our loved one is unable to take almost all medications due to extreme side effect reactions. Interestingly their mother was the same way with meds although the mom doesn't suffer from anxiety disorder. It's so hard to find doctors who understand that our loved one needs to find a non-chemical solution. Sometimes they are impatient with them for not trying yet another medication, which sets up another cycle of self-doubt and shame. Did you benefit from cognitive behavioral therapy or any other forms?
Me: Yes. Talk therapy helped somewhat. I didn't take meds because I had a friend on Buspar and it didn't help. What helped the most was surrendering to the process and allowing myself to heal. It is slow. I think you might want to read All Is Well by Louise Hay and Mona Lisa Shulz, M.D. It has disease plus affirmations, like regular medicine plus holistic. Dr. Shulz is a psychiatrist who is also a medical intuitive. I think affirmations might be good for your loved one. Dr. Peter Levine has good work online for healing from PTSD. I took a class from him. Namaste.
Family: Dr. it is surely God's hand in our lives that has brought you to us today. Thank you so much for all this good information. Our loved one is also diagnosed with PTSD. Namaste.
This is NOT part of my job as an anesthesiologist!
Texting family members--offering advice--this is not anything I will ever be compensated for!
Yet it is the Right Thing To Do.
It is putting MY HEART on the line, out there, and connecting it to others to permit the Healing Process to HAPPEN.
There is no healing for Anxiety without kindness and unconditional Love. Medications only buy time and decrease symptoms.
You know, I asked the family member right before we left for the O.R., 'what happened to your Loved one?' They were like, 'It's been this way forever!'. I rephrased it, 'Something awful must have happened to them for them to get like this.' The family member, a niece, had no idea what it was.
I did. I've lived it. In this life and in the one immediately before this life. I don't have to explain it to anybody. I only have to know enough to recognize and to treat anxiety effectively, with all the skills I have at my disposal. Reiki is an incredible layer of relaxation and healing on an energetic level, which is non-chemical and has no side-effects. It makes anesthesia so much more effective in situations like this.
It is what I do best.
And I've earned the right to say so!
Aloha and Mahalos,