As some of you recall from the Life Or Death Quick Decision Making thread, I posted an experience of mine that was really, well,
life or death.
Refreshing your memory, patient was a dude having a total knee arthroplasty.
This case was serendipitous from the start since with this particular orthopedist, cases are done almost exclusively under regional anesthesia. To be honest, I can't remember why we elected a general anesthetic for this particular patient. I remember he was extremely obese but in my practice that's not a contraindication for regional. Previous extreme back surgery maybe? Patient refusing regional? Honestly I do not remember. For whatever reason we put the dude to sleep. Which may have saved his life. More on that later.
CRNA Diane and I are doing Chase's (ortho dude) cases today. This general anesthetic kinda ruins our rhythm; normally I've got the patient epiduralized in the holding area 15 minutes before the room is ready. Now, on our third case of six, we've got a general. It's gonna set us back some time but not much....
ASIDE: I'll do whatever I can to make the cases disappear quicker. I figured out long ago it takes about ten minutes from start to finish for the circulator to place a foley. What if I put the foley in in holding after I placed the epidural? Hmmmm....ten minutes saved....times six cases (divided by two, to be honest, male foleys only, not dealing with the geriatric green smoke vaginal counterpart, sorry, I have my limits.)
From a time conservation viewpoint, this general anesthetic *******s me since he's not rolling into the operative suite already with a surgical plane of anesthesia on board. And a foley.
Oh well since in the end, looks like someone above was looking out.
Rooms ready, we roll back.
Uneventful induction.
Surgery proceeds.
I go about my daily tasks...pre ops, in PACU taking care of s h it, blah blah blah.
Pager goes off. I don't hear it, I feel it, since my pager is always on vibrate. That BEEP BEEP BEEP makes me wanna run in a corner somewhere and start rocking back and forth. Hence the vibrate mode.
Glancing down, pager reads
Needed in OR 12.
Thought processes start in my mind. Diane is a seasoned CRNA. Older. She's been doing this gig for twenty years plus.
Diane never calls.
Which means somethings wrong. Remarkable when you're an MD in a supervisory practice how you learn to gauge the severity of the call solely based on which CRNAs you are working with. Diane is in the group that revels "DUDE IF I CALL, THERES SOME S HIT HAPPENING."
Realizing this, I literally walk away from my tasks in the PACU and head for room 12.
Breaching OR 12's door, nothing strikes me as awry, giving me an emotional "whew." Maybe Diane needs to pee I think, walking around the vast tables of orthopedic instruments, careful not to contaminate them, heading for the front of the bed.
"I dunno," Diane says. "Somethings not right. Pressure is down around ninety for the last ten minutes or so. See the graph?"
Diane presses buttons on the monitor, changing the real time hemodynamics to a retrospective graphical display.
"See how he's been one twenty systolic for the entire case? I've bumped him with pressors and he's not responding. Still ninety despite the pressors."
I actively look at the graph. She's right. Ten minutes ago the graph prominently displays a change. Usually not a big deal, but the fact that she's given pressors without a response is a big deal.
Funny, this anesthesia business. How one minute you're thinking about what kinda dinner plans you have and the next minute you are pondering a life or death differential diagnosis.
Back to the serendipity of this case:
With this orthopedist, it's all regional, Dude. With some exceptions. This case was an exception.
I'm in the room when the end tidal CO2 tracing disappears. I glance at the surgical field. The joint is in.
HAD THIS BEEN A REGIONAL, THERE WOULDNT'VE BEEN AN END TIDAL CO2 TO DISAPPEAR.
I grab a stethescope. I hear breath sounds bilaterally. Theres fog in the tube. I cycle the blood pressure cuff. It cycles, giving me the dashes on either side of the slash, no numbers though, then starts to cycle again.
I feel for a carotid pulse.
There isn't one.
Summarizing in my brain for a few seconds before I make a drastic decision, I think: I walk in. Diane, because of her seasoned experience, had already sensed a problem, which in itself raises a red flag. Orthopedic case....hammering...possibility of intravascular emboli...loss of ETC02...no discernible carotid pulse....
I take a deep breath. This is what I get paid for.
"Chase?"
"Yeah?"
"I gotta start CPR."
Chase makes a startled eye contact with me and says
"HUH?"
I reply.
"I gotta start CPR."
Chase's joint is in but he's got work left. Despite this, he backs away from the operative field.
"Give a milligram of epi now!" I say to Diane as I start CPR on patient dude's chest.
"Need some help in here please! Call one of my partners in here right away," I say with a pointed voice to the circulator. She's on the phone in a millisecond. Before I know it, Chad my partner is in the room.
"Whatcha need?" Chad says.
"Total knee. Lost end tidal." Chad sees me doing CPR so he gets the gravity of the situation.
At this point I've been doing CPR for, s h it, I dunno, a cuppla minutes. Diane squirted in the milligram of epi as soon as I called for it, which was, uhhh, a cuppla minutes ago.
I stop CPR and feel for a carotid.
"Gotta pulse!" I exclaim.
"Gonna put in an A line for ya," Chad says, hurriedly acquiring the tools needed for his task.
Chase the orthopedist emerges from the wall.
"Bill, I'm gonna finish, if thats OK," he says.
"Yeah dude," I reply.
This is about as intense as this anesthesia biz gets. We've just experienced a witnessed cardiac arrest during a knee replacement. A team of medical professionals jumped on the emergency quicker than Tiger Woods jumps on a stripper. Now we're tidying up. Chase is closing his operative site. Chad, my partner, deftly places an A line. I'm Trendelenberging the bed so I can place a right IJ TLC. Which I do.
Chase the orthopedist is done. He removes his space suit helmet and pops off his scrubs.
My partner Chad is still in the room, A line placed, ready and willing.
My central line is in.
Patient's hemodynamics are OK at this point.
Theres a chill in the air of OR 12. Everyone is thinking the same thing: Did the patient's brain take a hit?"
No way to tell. Next on the agenda:
Transport to ICU 12.
Done.
Rough case. I didn't sleep well that night.
I was awarded in the morning at 0630 when I walked into the ICU to check on Patient Dude.
"Jesus Christ," the night RN started.
"He awoke about four thirty. Since then he's been unmanageable."
I saunter into ICU 12. My eyes focus on a patient that looks like he should be walking out of Wal Mart with fishing lures just purchased. Certainly not a dude habitating an ICU bed with an endotracheal tube sticking outta his mouth!
"Dude, hows it going?" I ask the patient, the patient that just yesterday had a cardiac arrest during a knee replacement who now lives in the ICU, an ominous detour to say the least.
Patient dude locks on my eyes, unable to speak because of the endotracheal tube,
BUT I KNOW.
I know he's OK.
Despite whats happened, dude is in ICU, intubated, all kinds of monitors on him.
He wants to write, I gather from his hand motions.
Nurse provides paper and pen.
I await as Patient Dude writes on the paper. This act, in of itself, settles me. But theres more joy to come.
Patient Dude writes feverishly on the paper and hands it to me, wide eyed, endotracheal tube sticking out of his mouth.
I read his scribe:
"Doc, my chest hurts! I had knee surgery! Why does my chest hurt?"
I read the scribe. I hang my head and grin. And shake my head. I write back.
"Something from your knee flew into your heart and caused something bad. We handled it. You're OK."
Dude, still smoking the endotracheal tube, read what I wrote.
He scribbled again.
"Thanks, Doc." it said.
"You Da MAN!" I wrote back.
Hence the end to this remarkable, albeit true story.
Dude fully recovered, despite experiencing intraoperative cardiac arrest.
Walked outta the hospital.
End of story......ALMOST.....
remember from the other thread I said there was a
SURPRISE??
Uhhh...
Dude was scheduled a year later. For his other knee.😱😱
Yep.
I tried to talk Chase out of it. I talked to the patient personally.
About the risks.
Of another surgery.
Patient Dude still wanted it. He had recovered so well from his initial knee surgery 🙂laugh🙂 and that knee felt so good from the recovery, he wanted the other one done.
Absolutely.
SO...
Vascular surg dude put in a greenfield filter before the second knee operation. Don't know if it was warranted or if it helped.
But we put the dude to sleep for his second knee replacement.
He walked out alive and happy.
AGAIN.
"This concludes our story, ladies and gentlemen. It's a true story. For better or for worse."
