Middle of The Night It is 03:30 in the morning and I am at work. It was pretty busy here at first but for now it is quiet. I started the night with a difficult case on an 84 year old man who was in poor health. He had an incarcerated inguinal hernia which means he had a loop of small intestine trapped in the tear of a hernia. He had a bulge the size of a baseball on the left side of his groin. Normally I would simply put the patient to sleep for this kind of case. In this case however the man's heart, lungs and kidneys were in such bad shape that putting him under general anesthesia was very risky. Instead I lightly sedated the man and the surgeons injected local anesthetic to "numb" up his groin. The case took about 2 hours but his vital signs remained stable throughout. My second case of the night involved a 51 year old heroin user with a large abscess on his thigh. These are easy cases usually but unfortunately the emergency room personnel had been unable to get an IV started even after multiple attempts. The anesthesiologist and I both made several attempts to start an IV. We tried on both arms, one leg and even his neck unsuccessfully. I finally got one started on the backside of his forearm and we were then able to do his surgery. That is it so far tonight. A couple of updates. The young man I wrote about in my last blog entry with the multiple gun shot wounds is still in the hospital. Unfortunately the surgeons had to amputate his leg below the knee. Otherwise he is expected to recover fully. I have been using the CPAP machine for about two weeks now and it is amazing the difference it makes. I had not realized how tired I was most of the time. The only problem I am having is with the mask itself. I wear the kind that is triangle shaped and fits over my nose. I have some slight redness on the skin around my nose where the mask touches me. I am not sure if it a slight allergy problem or just skin irritation from the mask rubbing the skin while I sleep. If it doesn't get better I may have to call the sleep center and try a different style of mask. If however it comes down to the redness or sleeping without the CPAP I will choose the redness.

Try Again and Again I realized I had not blogged in a while so let me review some of the goings on of the last two weeks. Back on the 2nd of February I blogged about my sleep study to test me for sleep apnea. I got the study results last week and indeed I have sleep apnea. The doctor told me that even though I don't realize it I "wake up" about 70 times per hour when I sleep. He also said that my oxygenation level which should stay above 95% dropped to about 75% on several occasions. The doctor prescribed a CPAP machine for me which was delivered to our house by a respiratory therapist last Friday. I have only wore it for a couple of days so I am still getting used to it. Thumper says she has not heard me snoring and I did feel less tired at work last night so maybe this will be a good thing. Speaking of work I finished three nights in a row this morning. Friday night was pretty uneventful with just a few minor cases. One involved a young female heroin user who managed to break her needle off in her butt. I lightly sedated her and the surgeons added local anesthetic before they carefully explored and removed the needle fragment. Saturday night started out quiet but about 02:15 in the morning a 17 year old boy was rushed to the operating room. He had multiple gunshot wounds to his abdomen and legs. He was barely conscious and his blood pressure was low at the start of the case. When the surgeons opened him up there was a lot of bleeding. He had damage to his intestines, three holes in his bladder and damage to the femoral artery of his left leg. We worked on him for over 4 hours. By the end of the case he had lost 9000 milliliters of blood. I had given him over 30 units of blood products as well as lots of other fluids. The surgeons were starting to close when I was relieved by the day shift. When I went into work last night I learned that the young man was back in the operating room. He had lost the pulse to his left leg and the surgeons were attempting to restore the circulation. I took over the case and we finished a little after midnight with circulation restored to the young man's leg. About two hours later they brought the young man back from the ICU again. With the circulation restored his lower leg had swollen significantly. The skin of his calf was swollen hard to the touch. The surgeons had to perform a fasciotomy to relieve the pressure. I ended up doing three anesthetics on this young man in less than 24 hours. As I was getting ready to come home this morning I heard that the surgeons were considering bringing the young man over to the operating room again. To maintain the circulation in his leg they had placed him on heparin which is a blood thinner. Unfortunately because of the blood thinner he had started bleeding into his belly again. If the surgeons can not stop the bleeding they may have to take him off the heparin and risk loosing his leg to save his life.

Hole in his Heart Last weekend I blogged about the young man with the gunshot wound through his heart that we were unable to save. Last night I did a case involving another young man with a gunshot wound to the chest. Unlike last week this young man was still conscious and able to speak as we rushed him into the operating room. I put him to sleep and placed a breathing tube in his mouth and the surgeons opened his chest. This young man's heart had also been hit by a bullet. The difference this time was that the bullet had not passed completely through his heart but only grazed the left ventricle. To repair the hole the surgeon had to hold the patients beating heart in his hand while he stitched. Each time he placed his hand on the heart the heart rate would slow significantly from around 90 to 30 beats per minute. He would make a stitch or two and then let go of the heart and allow the heart rate to go back up. Then he would grab the heart again for another couple of stitches. It took about 12 stitches to repair the hole in the young mans heart, done one or two at a time. The young man will need further cardiology studies and may need further surgery but he was doing remarkably well after they closed him up and we took him to the intensive care unit. My other case of the night involved another young man. we were told he had been in some sort of fight. He was able to walk home afterward but started complaining of severe headache and nausea at home. His family brought him to the hospital where he lost consciousness. It turns out he was bleeding slowly in his brain. The slowly increasing pressure first caused his headache, then nausea and finally loss of consciousness. In the OR the surgeons opened his skull to relieve the pressure, remove clotted blood and stop the bleeding. I was relieved by the day shift nurse anesthetist before this case was finished but the patient was doing well when I left. Two more nights to go.