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- Feb 20, 2008
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So I've been out of residency and fellowship for about 5 years. Split my time between pain and OR. I cover 2 hospitals one with CRNA's, one where the MD's cover alone.
The hospital with CRNA's gets the majority of big cases: ruptured AAA's, horrendous OB, etc. etc. Not a big deal here since there are plenty of people around. I've got 2 CRNA's in house and when we get badness coming in, we tag team all the tasks.
Well this case on the weekend at the other hospital, showed me that it ain't easy going it alone.
Get a call from my g surg buddy. 80 y.o. vasculopath pt. s/p cabg, stent, right CEA who had undergone a partial colectomy earlier in the week. This am had found him obtunded. CCM intubated him in the unit. Now he's got new onset afib, St depression's in inferior leads(trops not back yet, but will ineveitably come back positive), not moving his left side. G surg needs to open him up to check to see if there is an anastomotic leak that caused him to crump.
I go up to transport him. Pressures 80/50's HR 150. Pulse ox not picking up anything cuz his extremities are clamped down. No A line despite numerous tries by CCM. RT states that pH was normal and PaO2 was 200 on an FIO2 of 1. Access wise only an 18 on the left and a 20 on the right.
Take him down to the OR. Put him on my vent. Still can't get a pulse ox despite moving it everywhere nose, ear lobe, finger, foot. Start TV at 700 and PIP of 25 or so. Feel for a place to start an a line: nothing at the radial, nothing in the antecubital, can't feel much at the brachial. Not enough anyways to confidently think that I can get an a line.
Crack on some vapor. Relax him. Set BP to cycle every minute. Do you insist on an a line? Where? We've got a site rite at this hospital for a central line. No TEE (and by now having not done a TEE since residency, I probably wouldn't know how to turn on the machine, let alone get a view) No swan in this OR.
What to do? what to do?
My question for everyone is how would you prioritize your tasks? Keeping in mind, that you are alone. The circulator and surgeon are nice people but pretty much useless in terms of helping.
FYI I didn't insist on an a line before we started...something that I did regret to a degree afterwards.
The hospital with CRNA's gets the majority of big cases: ruptured AAA's, horrendous OB, etc. etc. Not a big deal here since there are plenty of people around. I've got 2 CRNA's in house and when we get badness coming in, we tag team all the tasks.
Well this case on the weekend at the other hospital, showed me that it ain't easy going it alone.
Get a call from my g surg buddy. 80 y.o. vasculopath pt. s/p cabg, stent, right CEA who had undergone a partial colectomy earlier in the week. This am had found him obtunded. CCM intubated him in the unit. Now he's got new onset afib, St depression's in inferior leads(trops not back yet, but will ineveitably come back positive), not moving his left side. G surg needs to open him up to check to see if there is an anastomotic leak that caused him to crump.
I go up to transport him. Pressures 80/50's HR 150. Pulse ox not picking up anything cuz his extremities are clamped down. No A line despite numerous tries by CCM. RT states that pH was normal and PaO2 was 200 on an FIO2 of 1. Access wise only an 18 on the left and a 20 on the right.
Take him down to the OR. Put him on my vent. Still can't get a pulse ox despite moving it everywhere nose, ear lobe, finger, foot. Start TV at 700 and PIP of 25 or so. Feel for a place to start an a line: nothing at the radial, nothing in the antecubital, can't feel much at the brachial. Not enough anyways to confidently think that I can get an a line.
Crack on some vapor. Relax him. Set BP to cycle every minute. Do you insist on an a line? Where? We've got a site rite at this hospital for a central line. No TEE (and by now having not done a TEE since residency, I probably wouldn't know how to turn on the machine, let alone get a view) No swan in this OR.
What to do? what to do?
My question for everyone is how would you prioritize your tasks? Keeping in mind, that you are alone. The circulator and surgeon are nice people but pretty much useless in terms of helping.
FYI I didn't insist on an a line before we started...something that I did regret to a degree afterwards.