The Juniors are Here! I realized that I had not added to my blog lately so here I am. We have been especially busy at work lately. Not doing more cases but beginning to train our junior Nurse anesthesia residents. It takes two and a half years to become a Certified Registered Nurse Anesthetist. You have to have a Bachelors degree in Nursing and several years experience to get into the program. Once you are in you spend the first year in the classroom. It is a long grueling year learning everything from advanced pharmacology, anatomy and physiology and anesthesia theory and technique. If you make it through the first year then you move on to a year and a half of clinical. It is another long and grueling time averaging about 60 hours a week at the hospital doing cases or preparing a thesis. When it is all over with you graduate with a Masters degree in Nurse Anesthesia. You still have to take and pass a certification exam before you are fully qualified to practice anesthesia. We have eight junior residents who started their year and a half clinical rotation this month. They looked like deer in the headlights when they started in the OR two weeks ago. Last week I had both a junior and a senior resident in the OR with me. The seniors will graduate this December and each has done about 1000 anesthetics. It was very interesting to watch the senior teaching the junior. I stood back and watched as the senior explained what he was doing to the junior. It is amazing to see how much confidence and skill the seniors have developed in the year that they have been here. I would let any of them do my anesthetic if I needed surgery. A year from now hopefully the new juniors will also be as skilled.

It’s Nice to be Appreciated About a month ago I did an anesthetic on a 70-year-old man. He needed to have an inguinal hernia repaired. His surgeon almost always does hernia repairs with a laparoscope. This requires that the patient have a general anesthetic. Unfortunately this patient had a long smoking history (bad lungs) as well as a significant cardiac history. He was not a good candidate for general anesthesia. It also turns out he had a son in law who was an anesthesiologist and a daughter who was a nurse anesthetist. They had told him to refuse a general anesthetic. The surgeon was a little ticked off when I told him he couldn’t do a laprascopic repair but he got over it. The patient finally agreed to let me do a spinal with light sedation. He was very nervous but the spinal went in easily and he and I spent the next 1.5-hour talking while the surgeon fixed his hernia. He thanked me when it was over and I took him to the recovery room. I went on to my next case and finished the day. Today I was in the OR when one of my coworkers brought me in a package from my elderly patient. In it I found a very nice fleece lined jacket. He told my coworker to tell me thanks again and then he left before I could get out to see him. I have had patients give me thank you gifts before. From boxes of candy to a ceramic skunk that decorates my moms yard. Every time it happens it just makes my whole day. It really is nice to be appreciated.

A Small Miracle At work today I was in the urgent room. We keep one operating room open for any emergency cases that come in during the day. Some days you may not do a single case while on other days you might be really busy. This morning I did an emergency case on an eight-year-old girl. Back in November she had surgery for a brain tumor. Her surgery went well but her brain was now making to much spinal fluid. To correct the problem a ventricular peritoneal (VP) shunt was placed. A VP shunt is a tube that is placed under the skin from the brain to the abdominal cavity. Excess spinal fluid drains out of the brain into the abdomen where it is reabsorbed. In this little girl’s case the VP shunt was malfunctioning. They brought the little girl up from the emergency room with her mother. She had not received any medications yet. She was almost unarousable. When I tried to speak to her she barely opened her eyes and she had a glassy stare. She did not respond to any of my questions. Her mother told me she had been like this for almost 24 hours. She didn’t even flinch when I started an IV on her. We moved her into the operating room where she was soon asleep. The surgeon worked on her for about 2 hours replacing the part of the shunt in her brain that turned out to be clogged up. I woke her up, removed the breathing tube and we put her on a gurney. She was still very lethargic and unresponsive but she was breathing well. A few minutes later we were in the recovery room and I was giving report to the nurse that would be taking care of her. Suddenly she opened her eyes, sat up and started crying for her mother and that she was thirsty. It was like you had flipped a switch and turned her on like a television. Normally I don’t like it when my patients cry in the recovery room but in this case it was music to my ears.

An Interesting Day I had an interesting day today. I was scheduled to do two anesthetic cases. The first involved a 31-year-old lady who was suffering from hearing loss in one ear. The surgeon thought the cause was a loss of movement in one of the three small bones in the ear. He was going to try and replace that small bone and hopefully increase the patients hearing. Before he started the case he did a quick hearing test and then was going to repeat the test near the end of the surgery to see if it had worked. He needed the patient to be semi awake with sedation to do the hearing tests. We call this Local/Mac anesthesia. It is harder to do than General anesthesia. With General anesthesia, especially on a healthy patient, once the patient is asleep and the breathing tube is in place its like cruise control on a plane. You have to continually monitor everything but the patient doesn’t move. With local/Mac the surgeon has placed numbing medicine in the area where he is working but the patient is still semi awake and can therefore still move. If the patient is over sedated they may not breath properly. If they are under sedated they may still feel pain or discomfort or they may forget where they are and try to get up or move. Unfortunately with my first case we had another problem that sometimes occurs when you are operating on someone’s ear. The surgeon injected the numbing medicine and started working on her ear. To get her ear numb enough to work on she must have also lost sensation to the equilibrium center in her inner ear. What this caused was a sudden onset of severe nausea. I gave her several different anti nausea medicines but none of them worked. It took several hours for the numbing medicine to wear off before her nausea finally went away. It is very frustrating to not be able to help a patient when you want to. My second case was the kind that I hate doing. The patient was an 18-year-old girl who a year ago was diagnosed with cancer. One of her salivary glands had enlarged and had to be surgically removed from her neck. She had to have 30 radiation treatments after the surgery. Now a year later they had found another small mass in her neck. She was scheduled for a biopsy which if the mass was cancerous she would then get a radical neck dissection. A radical neck would be an 8 to 10 hour surgery that would be very painful after wards and would leave a large ugly scar on the side of her neck. She would also have to get more radiation or chemotherapy. I had some time to talk to my patient before her surgery. She told me how she had just graduated from high school and that she planned to go onto college and then medical school to be a pediatrician. She hid her fear pretty well but I could see the worry in her eyes as we moved into the operating room. She went off to sleep easily and the surgeon started working. After about an hour and a half the mass was out and on its way down to the pathologist for testing. We all sat around for 30 minutes waiting for the pathology report. Finally he called and the results were good, no cancer! The surgeon closed the incision, which was only about 2 inches long, and I woke my patient up. She was still mostly asleep and I had just removed her breathing tube when I saw her lips moving. I leaned down and heard her ask, “What was it?” I told her it wasn’t cancer and she gave me the most beautiful smile I’ve seen in a long time. Sometimes I just love my job!!!