No one cares how much you know until they know how much you care

A few years ago I went in for an appendectomy. I was laying on the OR table and I'll admit I thought to myself that there was a chance I wouldn't wake up. I knew it was a small chance but just the thought made me a little anxious. Just before induction the anesthesiologist grasped my hand and held onto it until I drifted off to sleep. I remember being comforted just knowing someone cared. A couple weeks ago I got to be on the giving end instead of the receiving end and I was reminded of the need for compassion toward our patients, especially the kind of compassion that they can feel. Prior to a patient getting an IV and arterial line she told me she was nervous and didn't like being stuck with needles.  I told her I didn't like needles either and in fact most people don't like needles. While the anesthesiologist was trying to get the arterial line in on her left wrist I took her right hand and held it. I just thought she would probably want something to squeeze, at least I know I would if I were in the same situation.  The attending had a difficult time getting the line in the wrist.  After making several attempts with the ultrasound he decided to try the brachial.  As they were prepping for the brachial she looked at me and said "this looks serious."  She was right, it did look a lot more serious than a simple radial arterial line. I explained that they were doing the same thing that they tried to do in her wrist but that they have to do a sterile prep when they are trying to access the brachial artery. That seemed to calm her down some. She squeezed my hand several times throughout the procedure. Unfortunately the attending anesthesiologist was unsuccessful in his attempts so we would have to do the line in the OR after induction. After the procedure was over I hadn't really given much thought to my efforts to comfort this patient until she had a complication with her surgery and had to return for a second surgery a few days later (this is the patient I wrote about who had the chyle leak). I didn't get a chance to see her in preop the second time but I helped with the anesthesia in the OR. After we transferred her to the OR table I grabbed her hand to help her move toward the head of the OR table (at this point she's had 2 mg of versed and 100 mcg of fentanyl). 

As soon as I grabbed her hand she looked up at me and said "Travis, right?"  I was shocked. I said, "Wow! You remember my name! I'm so impressed."  She began explaining how nice I was to her while she was being "tortured." I didn't realize that I would have that kind of impact on a patient simply by showing compassion. I remember interviewing at a couple DO schools and they put a lot of emphasis on the power of touch.  It should be a greater part of our practice. It does make a difference. I'm not saying we need to hold every patient's hand but we should be sensitive to the needs of our patients and if they need comfort we should act with confidence. I am reminded of a famous quote by Theodore Roosevelt: "No one cares how much you know until they know how much you care."

The Tube is in But no Capnography

We had a case the other day for a patient that had just had a lung lobectomy of the right upper lobe three days prior. She was subsequently diagnosed with a chyle leak when they observed a milky fluid in her chest tube drain (See image on left).  Chyle is a fluid consisting of a mixture of lymphatic fluid (lymph) and chylomicrons that has a milky appearance. Chyle leaks are uncommon but can be an adverse result of trauma to the thoracic duct (lymphatic vessel) during thoracic surgery.  Interestingly, in order to help the surgeon identify the leak they feed the patient ice cream the night before the surgery and intraoperatively, anesthesia inserts an OG tube and delivers a half-pint of heavy whipping cream.  I never thought heavy whipping cream would ever be part of our arsenal. 

Coincidentally, I was involved in the anesthesia for both surgeries. This patient was a 365-pound female but surprisingly she was not a difficult intubation the first time.  The second time was a different story. We all assumed this would be a straight-forward intubation just as before, regardless we still had the videoscope in the room and ready to go if needed. The anesthesia personnel consisted of the resident, two anesthesiologists, and myself. After induction the resident did the laryngoscopy with a MAC 3 blade, had a grade I view, and advanced the endotracheal tube (ETT) past the vocal cords.  She did not get condensation return in the tube and capnography was negative. She listened for breath sounds and said she could hear breath sounds but the anesthesiologist said "you're not it" and pulled the tube. The anesthesiologist handed the tube and blade with the videoscope to the other anesthesiologist while we re-oxygenated the patient. The same thing happened. The other anesthesiologist took over and made the third attempt and got the same result. She asked for the bougie, passed the bougie through the vocal cords, removed the videoscope, advanced the ETT over the bougie and past the vocal cords, removed the bougie and got the same result, no condensation and no end-tidal CO2. In all of the cases we were able to move air in but with some resistance. The next attempt the anesthesiologist used a new ETT and left the videoscope in place while removing the bougie to make sure that the bougie wasn't taking the ETT out while it was being withdrawn.  After confirming that the ETT was in place the thoracic surgeon advanced the bronchoscope down the ETT and saw a significant amount of mucous. He suctioned several globs that were quite thick and near the carina.  After suctioning out the mucous we were finally able to get end-tidal CO2 on the monitor. The conclusion by the anesthesiologist and the surgeon was that the mucous was making a ball-valve at the tip of the ETT every time it was advanced. In other words, air could be pushed past the mucous in one direction but whenever air tried to go back through the tube the mucous would close off the tip. Thinking about this more this patient could easily have received significant barotrauma if the anesthesia team continued to force air in without getting air out in return.

Intubating a Myasthenia Gravis Patient

We had a patient with myasthenia gravis who came for transthroacic removal of his thymus.  Because the disease is an autoimmune disorder the thymus can be removed to help control symptoms relating to MG. In MG, antibodies bind to acetylcholine receptors decreasing the number of functional acetylcholine receptors that results in an increased sensitivity to nondepolarizing muscle relaxants (NDMRs) and a resistance to succinylcholine. Often times we don't paralyze these patients because they already have muscle weakness and combined with volatile agent are adequately relaxed for laryngoscopy.   I presume this was the assumption my attending was working under when he decided to allow my preceptor to intubate without providing muscle relaxant.  We were also placing a double-lumen tube (DLT) which made the situation even more risky. While advancing the DLT past the vocal cords the patient began to bite down on the laryngoscope. The attending told her to leave it in but she felt it was best to try to pull it out, which she did. Unfortunately the patient lost about 1mm of tooth from the top of his lower incisor.  Looking back on the mishap I wonder what things we could have done differently.  Would putting in a bite block before laryngoscopy be wise or would it just get in the way? Would using an LTA kit have helped dampen those reflexes since the patient didn't start biting until she past the DLT past the vocal cords? Did we find out enough about the patients severity of the disease before the procedure? Could we have given sux or a NDMR?  Baby Miller suggests that we can.

Measurement of neuromuscular function in patients with myasthenia gravis treated with pyridostigmine demonstrates resistance to the effects of succinylcholine. The ED95 is approximately 2.6 times normal. Because the dose of succinylcholine commonly administered to normal patients (1.0–1.5 mg/kg) represents three to five times the ED95, it is likely that adequate intubating conditions can be achieved in patients with myasthenia gravis using these doses. The mechanism for the resistance to succinylcholine is unknown, but the decreased number of acetylcholine receptors at the postsynaptic neuromuscular junction may play a role.

What do you think is the best approach? Is there anything you would have done differently? Comment below.

Resources

Hey guys! Dr. Harder at the Leavenworth VA gave me 10 GB of books and resources for me to distribute to the students in the program. I am trying to upload them on google docs and maybe drop box so they will be easier to access. I have uploaded a few to google docs and have sent the links to Melanie to forward to all of the students in the program. If you any of you guys are in the KC area right now and would like to meet up so I can just transfer the files to your computer or want me to send you the links, please text me! Thanks.

Communication Crisis

Stephen R Covey's book "Seven Habits of Highly Effective People"  states that Habit number 5 is "Seek First to Understand, Then to be Understood."  This is the lesson I learned Friday when the patient who the resident had just put a central line in went bradycardic and hypotensive.  I don't recall perfectly the sequence of events but I was asked by the attending physician to administer 1 mg of phenylephrine.  Yes you read that right, 1000 mcg of phenylephrine.  I questioned it too.  I turned to the resident and asked if that was what she heard and she said "yes, 10 CCs"  So, with some reservations, I gave the whole stick of phenylephrine.  I watched the blood pressure climb but nothing too significant.  A short while later the heart rate dropped and the attending gave atropine. Although the heart rate started looking better the blood pressure was low again so I was asked for a second time by the attending to give another 1 mg of phenylephrine. Being new to this situation I assumed she knew what she was saying since this was the second time she had said the same thing.  I proceeded to push 10 CCs of phenylephrine but before I got halfway she yelled at me, "Stop! What are you doing! I said two CCs!"  To which I responded, "But you told me to give 1 mg!" She came to where I was standing took the syringe from my hand and withdrew as much phenylephrine as she could.  The patient probably got 400 to 500 mcg phenylephrine maybe even a little less.  I went and stood out of the way while I watched the blood pressure climb to somewhere around 250 systolic.  The patient supposedly went into PEA for a few seconds after which the attending gave a few ineffective one-handed chest compressions.  The patient's vitals soon normalized and all was well.  Meanwhile I got an earful from the attending.  Paraphrasing her words she said, "We never give 1 mg of phenylephrine! Why would you give that much?!  We never give that much at once!  I shouldn't have asked you to even do it!  Even if I told you to give 1 mg you should never give 1 mg!"  I apologized to her and told her I should have communicated better. I couldn't get it out of my mind the entire weekend.  I kept shaking my head in disbelief whenever I thought about it.  However, I am thankful for the experience because I know I will never give a drug that I am told to give without verbalizing it.  Hopefully you won't either.

Buretrol Basics 101

So I was asked if I knew how the buretrol worked because my preceptor could see I was fumbling with it, I gave her a hesitant "yes..." to which she responded, "Do I intimidate you?" Of course I responded in the negative when I probably should have said "Yes, all of my preceptors intimidate me."  I digress.

So here is what I know about the Buretrol.  Feel free to add your own comments below. You have probably all seen this contraption during your heart rotation (maybe this is more for myself and my posterity).  They are more commonly used for pediatric patients to limit the amount of fluid given to peds. I also read that they were used before pumps were available.

At the heart institute we give amicar and protamine through the buretrol. The buretrol should never be turned upside down. Also, if you want to draw fluid from tubing below the buretrol you must go very slowly otherwise it will pull a fair amount of air into the tubing. It is a better idea to just get fluid from another line if one is available. To empty the buretrol (and not withdraw fluid from the bag above) clamp the tubing between the bag and the buretrol and open the vent on the top of the buretrol making sure the tubing distal to the buret is unclamped. To fill the buretrol you can either inject directly into the buret through the male luer lock on top or open the vent and allow fluid to run from the IV bag to the buret with the tubing clamped distal to the buret.

I know this isn't rocket science but there you have it... Buretrol Basics 101.

Anesthesia: A Comprehensive Review

During lunch today I was talking to a resident who told me about this great study app for your iPhone or iPad.  It is called Anesthesia: A Comprehensive Review.  It is an actual book, but they turned it into an app.  It contains over a thousand test questions and immediately after answering your question it will explain the answer.  Although not advisable, he said that some residents used this book alone to study for the boards and passed, so it is pretty good.  You can download it for free to test it out, but then you have to pay $89 for the whole thing.  Yes it is expensive, but I am assuming that everyone will be looking into additional study materials at some point, so it is worth looking into.

Leavenworth VA

4101 4th St. Trafficway, Leavenworth, Kansas 66048
Update:
Guys locker is the first one on the bottom left. It will be labeled with sticky notes
Girls Locker is #26, labeled with Dr. Rays name. Its in the bottom row, immediately to the right when you enter the locker room.

OR 601 machine check should work most of the time. If there is a problem, let the CRNA, Joe, or the anesthesiologists know and they will help you with it.

In the GI lab, Dr. Lozenski likes to use the propofol infusion pump and Dr. Harder likes to bolus.

Its pretty cool to work with Joe because he will literally just sit back and let you run the case. Most of the time, he isnt paying attention but will help you if you need it. Dave, the other CRNA, doesnt take AA students.

If I can think of any other tips, I will write them down here! 



Here is a copy of all of the information emailed to me: (THANK YOU GINA, BILLY, JESSIRAE, MATT and ALEX)

"Before OR:

Should get an email from Loyd Tovar Loyd.Tovar@va.gov outlining what to do before starting your rotation. If you don’t hear from him, I would email him

Directions to the OR:

            Park in the main parking lot and go in the front entrance. Once inside turn left and go to the elevators at the end of the hallway. The OR will be on the 6^th floor. The passcode to get into the OR is 7874

Once in the OR:

            There will be a set of double doors on your right. Go down to the other set of double doors but not through them and the women’s locker room will be on the left.

            Anesthesia office: go left once in the OR and it will be on your left

Staff:

            There are four main anesthesia people at LVA are Dr. Harder, Dr. Lowsenski, Dr. Ray and Joe (CRNA). Mostly I worked with Dr. Harder and Dr. Lowsenski. Dr. Ray does pain management so you may get a chance to do blocks with her

Dr. Harder does a great job of texting you cases the night before her number is (913)406-0145. Just shoot her a text before your first day there

There are a lot of other OR staff, they are very friendly and love having students.

Schedule:

            Cases start at 8:30 everyday. I arrived at 7 to set up the rooms at stock up because they don’t have an anesthesia tech. Mostly you will be working out of OR 0601 and 0602 (the two at the end of the hall). 0603, second to last on the right side, was used mostly for eye cases

            You can find a schedule in the break room and the preops are in the anesthesia closet

Door Codes:

            Main OR: 7874

            Anesthesia Closet: 45

            Most other door codes: 251—break room, supply rooms, etc.

Setup:

Machine: Pretty much sets itself up for you, similar to heart institute. Just follow directions on the screen. Be sure to check positive pressure afterwards (like on regular anesthesia machines) and CO2

Equipment:

            Have one of every blade (MAC 3 or 4 and Miller 2)

            Extra Suction catheters

            Suction tubing

            Yankauers

            2 of every size of LMA

            3 or 4 non rebreathers

            3 or 4 nasal cannulas

            2 or 3 of every ETT

            nasal/oral airways

            OG Tubes (all of the above are in the drawers in the anesthesia machine)

            Syringes—all sizes

            Needles

            ECG pads for nerve stimulator

            TB syringes (these are on the pyxis)

            Esophageal temp probe

            stylets (these on the RIGHT side of the pixis)

Drugs: In the pyxis, which the instructor will have to sign in for you to get drugs out. I would check your drug counts in the morning to make sure that they aren’t off. Sometimes the Pyxis thinks there are 2 or 3 of a drug left and there are none.

Begin forwarded message:

From: "Babcock, William E. (UMKC-Student)" <webm8d@mail.umkc.edu>

Date: November 25, 2012 8:33:37 PM CST

To: "Yarbrough, Regina Denise (UMKC-Student)" <rdyy96@mail.umkc.edu>

Subject: Fwd: Leavenworth VA

Begin forwarded message:

Hey Gina. Here is the info that Matt forwarded to me. Dr. Harder's cell phone # is 1(913)406-0145..Just give her a text and let her know who you are. She knows that you will be coming, so just give her a buzz and she will tell you what cases you will have. She usually will text you the cases for the next day from this point forward. If you have any questions just let me know.

-Billy 

From: Matthew Vlach <vlachmatthew@gmail.com>

Subject: Fwd: Leavenworth VA

Date: October 29, 2012 5:43:03 AM CDT

To: "William E. Babcock" <webm8d@mail.umkc.edu>

This is what Jessirae sent me and it helped. The newest anesthesiologist is dr. Lozenski. She is awesome. Let me know if you have any questions. Good luck

Matt

Begin forwarded message:

From: "Frerichs, Jessirae N. (UMKC-Student)" <jnffm5@mail.umkc.edu>
Date: September 29, 2012, 4:32:31 PM CDT
To: "Vlach, Matthew D (UMKC-Student)" <mdvq48@mail.umkc.edu>
Subject: Fwd: Leavenworth VA

Matt,

I'm forwarding you the info that Alex sent me that was so so helpful. I have a few things to add as well:

Locker room is to your right through the first set of double doors. It's down the hall to the left. If you reach the second set of double doors you have gone too far

Anesthesia office code is 45. You won't need this the first day but you will to drop off anesthesia records on Dr. Harder's desk

Anesthesia supply closet code is 251.

Employees break lounge is 251 also. They have extra copies of the schedule in here on the table. After I got dressed I'd go straight there to see which OR I was in.

Pyxis: make sure when you do draw up all your drugs in the morning that your Pyxis still has an extra propofol in it and an extra glyco. We had a few instances where the Pyxis failed us and we had to go running out of the room to get more drugs during an emergency. From then on I just made sure we had extra of an emergency drugs available to draw up on top of what I prepared for the case that morning.

The staff loves students! All were very friendly except the CRNA Dave that you will never have to work with.

Continue to make UMKC look good! Dr. Harder thinks very highly of our program and the students from our school. I gave Dr. Harder your cell phone number but she may ask you for it again on your first day so she can text you your cases the night before.

Hope this helps!

Jessirae
Sent from my iPad

Begin forwarded message:

From: "Treat, Alexander J. (UMKC-Student)" <alexandertreat@mail.umkc.edu>
Date: September 3, 2012 8:53:21 PM CDT
To: "Frerichs, Jessirae N. (UMKC-Student)" <jnffm5@mail.umkc.edu>
Subject: Leavenworth VA

Yo,

So here’s a little rundown on the Leavenworth VA that I gathered in my 3 weeks there…

The staff:

Dr. Harder is the OR anesthesiologist you will usually be working with each day.  She’s fresh out of residency, but worked in the military as an airborne surgeon previously.  She really seems to like teaching and she’ll let you do a lot. 

She told me to give you her phone # and said that if you have any questions tomorrow (or whenever) to call her:

(913) 406-0145

Dr. Ray Works with pain management and usually isn’t in the OR/anesthesia office, but she knows how things work up there and really likes students so don’t hesitate to ask her questions.

Joe is a CRNA.  You might work with him if he has some good cases.  He’ll probably let you do the most out of anyone.  He’s really laid back.

Frank?  Albi is the other CRNA.  He’s retired mostly and comes in like 1 day a week and won’t teach AA students.  It’s a political thing, but he’s still really nice and helps out a ton.

Schedule:

I usually came in around 7am every day and got set up.  The OR is on the 6^th floor of the hospital at the far left end (if you walk in through the main entrance).  The passcode to get into the OR is 7874.  If you don’t know the schedule you can hang out in the anesthesia office until Dr. Harder or Joe arrive. 

Most of the time you only have 1 or 2 cases and you’re done by 1pm.  So even though you’re there every day, it’s not too bad.

Setup:

Leavenworth doesn’t have a Robman, so basically you have to stock the room every day.  I almost got burned a couple times by this so just do a double check on some of these things. 

Esophageal Stethoscopes (far right side of the pyxis) – She likes these over nasal temp probes basically whenever you have a tube.

Suction catheters

Yankeurs

OG Tubes

(above 3 are in the bottom of the anesthesia machine)

ECG Pads for the nerve stimulator

The machine is baller and checks itself—I think you guys had these or something like them at MAHI—so just do your thing, and make sure to check positive pressure and CO2 (Dr. Harder will ask)

Drugs (dr harder will have to open the pyxis before you can draw drugs):

Propofol 20ml syringe

Lidocaine 10ml syringe (1%)

Zem 5ml

Sux (if indicated) 10ml

Neosynephrine 40mcg/ml (10mg into a 250ml bag of N/S, then draw up 10ml syringe from the bag.  She likes to use clean syringes so you can use the same bag throughout the day)

If you need ephedrine she likes 5mg/ml

Versed 2mg – in pyxis

Fentanyl 50mcg/ml – 2ml – in pyxis

As far as idiosyncrasies or pet peeves, Dr harder is pretty cool.  She likes having people she can teach.  Leavenworth was really different from Liberty.  The staff actually seems to like students and are pretty awesome.  If you have any questions text me tonight or tomorrow morning and I’ll try to help out.

-Alex"

This rotation has been pretty fun and like a vacation. I get out around 1:30 at the latest, no weekends, and the machine checks itself out! Pretty awesome. There has been an email going around for some information on the VA. I can either post it here or I can email it to whoever needs it.  Some things not on the email is that the machine in OR 601 will say there is a leak. The only way to override it is to remove the adapter between the machine and the circuit, then attach the circuit directly to the machine. This will make more sense when you see it. Dr. L gave me a book to read over regional anesthesia. Its pretty awesome and straight to the point. The book is called, "Ultrasound Guided Regional Anesthesia" by Grant and Auyong. I tried to look for the book through the library website, but did not come up with this exact book. They did have others though. If I think of anything else, I will add it to the blog.

Ask and ye shall recieve...maybe.

I was with residents all week so all I got to do was IVs, intubate, and do ACTs.  Unfortunately there are three residents rotating at MAHI right now so the only hope I have of doing a central line is if I'm with Pam or Morgan. I asked Dr. Williams if I could do the central line since it was Friday and I hadn't done much of anything.   His response was classic: "Probably not."  Then he went on to say that he would take a look at the patient and make the judgement from there.  From my parenting experience when I tell my kids "probably not" it usually means "not a chance."  On the bright side the patient turned out to be very difficult and Dr. Williams commended me later for having the courage to ask and promised me he'd get me some central lines.  Here's to hope!

The Leak Whistle

I can already tell that Children's Mercy is going to be a great rotation!  One of the interesting things I learned on my first day was how to check for a leak after intubating a pediatric patient.  As you know, after intubating a pediatric patient you need to check to make sure that there is a 15-20 cm H2O pressure leak.  No leak indicates an oversized tube that should be replaced to prevent postoperative edema and croup, while too much of a leak can prevent proper positive pressure ventilation.  After intubating and checking for breath sounds, put your stethoscope over the trachea right above the sternal notch.  As you slowly increase pressure using your APL valve, watch your pressure gauge and you will hear a very loud and distinct whistling sound when you have reached your leak pressure.  It is pretty cool.  Also, word of advice, make sure you have and always bring a stethoscope while on your pediatric rotation, you will finally be getting a lot of use out of it!

Main-stem intubation happens 10% of the time

I right main-stemmed one of my patients. Neither me, the resident, nor the attending noticed until the patient started desating later on in the case.  Nothing significant but she went down to 96% from her normal 100%.  The resident asked the attending why she was desating and Dr. Hudson asked him what things could cause a patient to desat. He was only able to name a couple reason (monitors not on correctly, increased MetHb) then Dr. Hudson said. "But you did check breath sounds after intubating, right?"  Well we didn't but the resident just paused, not answering, when the surgeon chimed in and said "her left lung appears to be somewhat deflated"  Bingo!  We pulled back the tube and we were back up to 100% in no time.  When we brought the patient back to preop and gave our report one of the nurses found out that the "student," as she affectionately called me, main-stemmed the patient.  Now, whenever she sees me in the ICU she will tell everyone around her that I main-stemmed the patient because I didn't check for breath sounds after intubating.  It appears that she is doing it all in good fun but if she keeps doing it I am going to start to wonder.

Take home message:
Tip of endotracheal tube (red arrow) projects below the carina (blue arrow) into the bronchus intermedius on the right.

Prolonged R or L main-stem intubation can lead to atelectasis in the hypoventilated lung and pneumothorax or tension pneumothorax in the hyperventilated lung.

Always check breath sounds even if the resident you are with doesn't