Quiet Night....So Far It is 01:20 in the morning on my third of four nights and it has been quiet so far tonight. The last two night were not terribly busy either. I did two cases on Thursday night. The first involved a 12 year old girl. Some how she had broken a window and a piece of the glass had struck her right eye. The eye surgeons worked on her for about 3 hours. They were not sure whether she would be able to see out of the eye or not. The second case of the night dealt with an obese lady with a peri rectal abscess. That's butt puss in laymans terms. Her case only took about 20 minutes. Friday night I did two interesting cases. The first involved a 35 year old women who needed to have her gallbladder removed. Usually a routine case but this lady was also 16 weeks pregnant. A pregnant patient always makes things a little more difficult. I have to worry about not injuring the baby and yet still give the mom-to-be a good anesthetic. Fortunately most of the medications I would routinely use are not harmful to the baby. There are a couple medications like nitrous oxide that I don't give because they can increase the chances of birth defects or miscarriage. We checked fetal heartsounds before and after the case and both mother and baby did fine. My second case of Friday night involved a 20 year old women. She was high on methamphetamine and had been stabbed in the chest by her sister who was also high. Anytime I do an anesthetic on a drug user it is more difficult. There tolerances of my medications is altered from the norm. Drug users often require more pain killers than a normal person while they often need less muscle relaxant. Methampethamine and cocaine users are very prone to having very high heart rates and blood pressures. In some cases these patients have been known to have heart attacks during surgery. When they brought the patient up she was already partially sedated so she was quiet and somewhat cooperative. However at the end of her surgery she woke up like some 2-5 year olds do. She was screaming and fighting and almost rolled herself off the operating table onto the floor. I quickly sedated her and she was placed in restraints in the recovery room. She still screamed a lot and was verbally abusive to the recovery room staff but she couldn't hurt herself or anyone else. I heard that the police were waiting to speak to her later in the morning. Well it is now 01:40 in the morning and there are still no cases needing to go to the OR. I guess I will go eat my lunch now.

Sometimes We Lose I only did one case last night. About midnight they brought up a 27 year old man who had been in a bad car wreck. We heard that the firemen had a difficult time getting him out of the car. He already had a breathing tube in as well as chest tubes placed on both sides to reinflate his collapsed lungs. He felt cold to the touch and it turned out his body temperature was down about 10 degrees. His right arm and both legs were obviously broken. When the surgeons opened up his abdomen it was full of blood. It turned out that he had a large liver laceration and a ruptured spleen. The surgeons worked as quickly as they could to stop the severe bleeding while I gave the patient blood as fast as I could. Because of his decreased temperature his blood was not clotting normally. I gave him 20 units of blood as well as other blood products. we started getting blood in his breathing tube as well. The surgeons finished in the abdomen and the ortho boys stabilized his fractures. It was decided to take him to the ICU to further warm him and correct his coagulation problems. I had a monitor on him as we went down the hall towards the ICU. His heartrate suddenly dropped from 85 to 35. We rushed into the ICU and started coding the man immediately. He was pronounced dead about an hour later. It was felt that he might have had a chance if they could have gotten him to the hospital sooner. Two more nights to go.

Stupid is as Stupid Does I finished my last of five nights last night. I did two cases both of which took less than two hours so overall it was not a bad night. My second case of the night involved a man with a strangulated umbilical hernia. This means he had a defect in the abdominal wall near his belly button that caused a pouch to form on the inside. Unfortunately a segment of his small intestine got into the pouch, twisted and had its blood supply cut off. This is terribly painful for the patient and can be life threatening as the piece of intestine will die and the patient will get septic. In this mans case the surgeons had to remove about 8 inches of small intestine. As this is a very small piece he should fully recover. My first case of the night is the patient who inspired the title of this particular blog entry. The comedian Bill Engvall talks about how "stupid people should have to wear a sign around their necks that says they are stupid. This will warn the rest of us to not have anything to do with them." Now I don't want to be disrepectful but my first patient of the night should get a sign to wear. He was a 42 year old man who told me he had only had 2 drinks. His blood alcohol came back at .22 so those must have been two really big drinks. After drinking his "2" drinks he decided to fire up his wood chipper and mulch up some tree branches at his house. I am sure you can see where this is going and yes he did get his right hand caught in the wood chipper. Actually he was pretty fortunate as things could have turned out much worse than they did. He lost the tip of his right index finger as well as most of the skin off the side of the finger. The finger was also broken in 2 places. The surgeons were able to set the breaks with 2 pins. He will have to get a skin graft to the finger at some later date. The surgeons said he would probably loose sensation in the finger as well as about 50% motion. I guess he is lucky it was just one finger and not his entire hand. Well I better get some sleep.

Busy Weekend It has been a busy three nights since I blogged about my cases on Wednesday. I guess I will summarize a few of the highlights. On Friday night at about 3 in the morning they brought a 14 year old boy up from the ER. He had been shot in the abdomen. The bullet had passed completely through his body exiting out his back above his hip. Fortunately he only had some easily repaired damage to his small intestine. The question I didn't get to ask was what was a 14 year old doing out at 2:00 in the morning to get shot in the first place. Saturday night I did a case that involved an 8 year old girl getting her appendix out. She arrived from the ER with her mother who spoke only a little English. Her mother's native language was Chinese. I thought we were going to have to wait for a translator to get a history and anesthesia consent. Then this cute little 8 year old girl started translating for me. The mom was able to answer all my questions and I was able to answer hers. The little girls appendix was ruptured but the surgeons were able to get it out. She will have to stay in the hospital a few extra days for IV antibiotics but should recover completely. Last night we had a trauma case that was rushed up from the ER. The 30 something man (who reeked of alcohol by the way) had fallen/jumped/ or been pushed off a balcony 20 feet to the ground. His spleen was ruptured and he was bleeding to death. I ended up giving him 10 units of blood and other fluids while the surgeons quickly removed his spleen. They explored the rest of his abdomen for other obvious damage and then he was packed up and taken to the CT scanner to check his head and chest. I didn't hear what if any other injuries he had but they did not bring him immediately back to the OR. If he had other injuries they must not have been life threatening. There were three or four other cases over the last 3 nights but they were routine. I better start getting ready to go to work. One more night to go.

Vascular Night Wednesday night was my first of 5 nights in a row. It was a busy night with two long vascular cases. Vascular cases are not one of my favorite kinds of cases. They are often long and tedious cases and sometimes unsuccessful even after hours of work. The first case I took over and finished involved a 53 year old man. The case had started at 3:00 in the afternoon and went to 2:00 in the morning. The surgeons were attempting to restore circulation to the mans legs. He has had similar surgery several times before. Unfortunately he has been uncompliant with doctors orders and still smokes and drinks both of which worsen his circulation. In the end the surgeon was able to restore circulation but he predicted that the man would have one or both legs amputated within 5 years. The second case of the night was also a vascular case. A 69 year old man had an abdominal aortic repair done 2 days before. He had been doing well in the Icu and then his blood count had suddenly dropped. The surgeons opened him up to find his abdomen was full of blood. A suture line from the earlier repair had torn open. Because his aorta is weakened (the reason he had to have the original surgery) this was a known possible complication. I quickly gave him lots of blood and other fluids while the surgeons worked to repair things. I was relieved by the day shift before the case was finished. I heard it went until about 9:00 and the man is back in the ICU.

Not a bad Weekend It is 4:10 in the morning here at work and I will be off in a few hours. Overall it hasn't been a bad weekend. Over the last 4 nights I have only done a few cases. I did two cases on Thursday night. The first was a 15 year old boy who needed his appendix removed. The second involved a 20 something year old with a gunshot wound to the abdomen. Both cases went well with no problems. Friday night I did the anesthesia for a 45 year old women getting a kidney transplant. She had been on dialysis for 6 years. We started her case at 03:30 in the morning so I was replaced by the day shift before it was done. Saturday night I did a case involving a young man who had been in a car accident. His only injury was to his left lower leg. Unfortunately his leg had been crushed in the accident and it was badly mangled. The fibula which is the smaller of the two bones in the lower leg was gone as was a large part of his calf. He had nerve and blood vessel damage to the lower leg. We worked on him for about 5 hours but in the end the surgeons were not sure whether he would end up getting to keep the leg. He will be evaluated over the next several days and will need further surgery to the leg. So far tonight I have only done 1 case. We removed the gall bladder of a 35 year old man without any difficulties. On another happy note, I will be attending a graduation ceremony this Wednesday. Those who regularly read my blog know that for several months I have had Air Force Nurse Anesthesia residents working night shifts with me. The goal was to give them experience doing trauma cases. On this Wednesday, after 2 and a half years of hard work, the 6 Residents will graduate. It is a nice feeling knowing that I had a small part in helping them reach their goal.