It’s been more than three months since I last wrote here, but between a very tough exam session (yes, in French!) and six tough weeks of rotations, I didn’t have the time nor the strength to write. I exploited the weekend to jot down a few lines about something that happened to me this week. I wasn’t sure whether I should write once again a “story” about what happened to me in the hospital, but considering I received a lot of support after my previous post I decided I should. In the worst case, I’ll stop here and be glad someone enjoyed the first one.
The doors of the ICU slide open, and we start heading towards the room designated to our patient. Three nurses welcome us and direct us to the right bed, and soon they’re detaching cables on one side and branching them on the other.
We step away and go to the cubicle where the ICU doctor is waiting for us; we read on her face that she’s already heard a report of the operation, but she waits for us to start talking. She’s a post-graduate, must be 28, year more year less, and I’m once more somewhat surprised at how much responsibility young doctors are faced with here. It’s 6 p.m. and her night shift has just started: she’ll be together with a resident and another post-graduate (PG, for short; they’re the ones doing specialty training) for 30-35 ICU patients through the whole night, and we surely didn’t just hand her over a quiet one.
The anesthesiology resident who’s with me sits down next to her and makes a very tired summary of what had just happened: woman, 46 years old, brain surgery for removal of a “voluminous haemangioma” (it was written like that on the operation report) of 70x65x68 mm; the mass had been completely removed and the control CT scan just after the surgery showed a large haematoma in the frontal lobe, but it was no bigger than the tumor had been. From time to time the resident asks me for confirmation of what he says, but I’m so worn out that I absent-mindedly say yes to everything.
The patient had entered the OR at around 8 a.m. and had found two anesthesiologists (the resident, who we’ll call Hugh, and a visiting doctor from West Africa), me, a nurse and a couple room assistants. I had discussed the case with Hugh the previous afternoon before leaving, and I knew more or less how the situation would unfold: large brain mass meant huge risk of bleeding, so the first step was to put in some venous access lines. He planned two peripheral catheters and a central one in order to replace all the volume she was going to lose. On the other side, the patient was young and in good health, so I wasn’t too worried about the outcome.
I’m at my eight day of rotation in anesthesiology and I’m starting to find my way around, so I try to help out around the room doing whatever I’m told and above all I try not to get in the way. Hugh asks me to try putting one of the peripheral lines while his African colleague sets all the materials for the central one, and the rest of the room personnel position the patient correctly and branch the cables to monitor her parameters. I go to operating table and take the woman’s arm scouting for veins; I do not find any easily accessible ones, and considering I’ve just done it once in my life I decide to call Hugh for help. He patiently does it in my place while I try to distract the woman in my heavily accented French.
Things proceed orderly for the next few minutes: I take the oxygen mask from the ventilator machine and place it loosely on the patient’s face; Hugh administers her a cocktail of anesthetic and curarizing drugs, and we gently whisper to her to breathe deeply and think about a faraway place. She drifts off to sleep.
As I had told Hugh earlier, the goal of this week is for me to learn how to correctly ventilate a patient with a face mask and balloon, and succeed in intubating at least once; it’s Wednesday already and I still haven’t reached my goal, so I take the opportunity and grab the balloon as the breath pattern of the woman becomes more and more shallow. I grip her mandible, lean back and pull it up with my weight, and start insufflating and oh my God it’s working look at that chest going up and down and – ahem, sorry.
1-2 minutes pass like this until the nurse hands me the laryngoscope. I take off the oxygen mask, grab the laryngoscope, open the blade with a fluent gesture, open the patient’s mouth, and insert the blade, stopping… like, halfway through. After several seconds of struggle I haven’t even managed to displace the tongue, so Hugh tells me time’s up. I give up the tools to him and he deals with it far quicker than I would have. I let out just a tiny bit of frustration at my 5th or so failed attempt at intubation, and watch as our African colleague inserts the CVC. A few minutes later the surgeons arrive and the room is all set up.
The operation starts and I help out here and there if I’m asked, but I mainly spend time with Hugh, who has been explaining to me loads of stuff since the beginning of the morning. I find him much inclined towards teaching and I’m happy I decided to stick with him that day.
The first three hours pass with a rather solid routine of changing fluid bags hanging over the patient and taking arterial blood gas samples, but some tension is starting to build up behind the monitors: for the past half an hour, Hugh had been gradually increasing the output of the noradrenaline pump and had had to administered a bolus of ephedrine. Nevertheless, the patient’s mean blood pressure is barely above 70mmHg and her heart rate has passed 100bpm.
Noon approaches and the operation is nowhere near over; the surgeon assistants warns us that the tumor has been bleeding heavily and it’s about time to start transfusing red blood cells. Hugh makes a phone call to the transfusion lab while his colleague withdraws a fresh arterial blood sample for me. I take the syringe, get out of the room and reach the analyzer; after I insert the sample I wait and watch as a few numbers pop out of the screen: her pH is already below 7.3 and hemoglobin has fallen straight from 10.5 to 7.5 in the last hour.
I rush back into the room and give the strip of paper to Hugh who appears to be more and more stressed. The hemodynamic parameters haven’t changed but I see that the patient’s been given vasoconstrictors once more, and that the blood aspirator reservoir has been changed twice, meaning that at least two liters of blood must have already been drained.
Half an hour later, in spite of a third peripheral venous catheter having been inserted, the trend of the parameters doesn’t seem to change. I see Hugh take his phone and say he’s calling the head of the department for help. I stop for a second and take in the view of the whole room: while just an hour before everyone had been sitting down as the surgeons were going through their procedure in a relaxed silence, now the large chamber was bustling with activity. Both anesthesiologists were on the phone, one calling reinforcement and the other ordering blood derivatives to transfuse; nurses and OR personnel were running around substituting empty fluid bags and preparing a sterile table as the chief had commanded the placement of a femoral catheter.
A second resident arrives to lend a hand preparing other drugs, and a few minutes later the chief enters the room; he hastily scrubs up and sets a sterile field for the insertion of the new catheter. With a mean blood pressure hovering around 40 and bpms above 120, the patient is in a state of severe shock and nobody knows how it will end.
In the middle of all the chaos and activity, I was going through an internal conflict: on one side, in front of a person who was on the brink of death, I had a burning desire to help; on the other side, what could I do? It’s hard to admit it, but after only 4 years and a half of studying medicine, I don’t have the necessary knowledge and experience to accomplish anything in such a situation (or, for what matters, in half of the everyday medical problems which are presented to me); furthermore, being only my second week there, I didn’t even know where all the material was or how some of the machines in the room worked, as these things are taught nowhere in the university curriculum.
I forced myself to stay out of the way, and exclusively popped in when Hugh called me. He was remarkable. Despite the frenzy that was affecting everyone he took a few seconds to give me small tasks I could fulfill, like fetching drugs, checking RBC and plasma bags that were arriving to the room, and registering drugs that were being given on the computer.
At this point, with a fourth large IV line put in the femoral vein, the stand at the bottom of the bed has more fluid bags hanging from it than there are balls on a Christmas tree. After several minutes of BP values crashing at 30/15, blood pH at 6.9 and blood bags accumulating in a corner of the theater, things start to turn for the better: all the parameters improve slowly, the chief leaves the room in the hands of the two residents and the African doctor (and of poor me). The patient has bled around 10 liters, and had been administered almost twice as many.
The surgeons resume their work now that the patient is more stable, and since it’s already 2 p.m. the second resident decides it’s time for everyone to eat something, so she goes to fetch food. I have brought some pasta from home so I ask permission to exit the room. Everything outside is quiet and it seems somewhat unreal to sit down at a table and eat, my thoughts still returning to what had happened in the past few hours. I quickly clean up my lunchbox and head back to the OR, where I find Hugh finally sitting still for the first time since 10 a.m. He looks like he could call it a day and go to sleep already, but I suppose everyone does.
I sit next to him, and he tells me something I think I’ll remember for a while: “Learn this: if things are ever going bad, first of all call for help. What is good about anesthesiology here is that, if one of us needs help, we stick together.”
Shortly afterwards, as if to prove the point, the second resident comes back and tells Hugh to take a break and eat the lunch she’s brought him. He hesitates a bit and tries to stay around as long as possible, giving her a detailed account of what had happened in the hour during which she had been out. “Had she been thirty years older, she wouldn’t have made it” he says before leaving.
Right now all the parameters are at a respectable level but we can’t loosen our focus yet, as since the surgeons have restarted their work the patient has bled even more; it’s about three in the afternoon, we’re all tired and a bit sluggish, but we’re in control of the situation once more.
Then, as if nothing had happened, it’s finished: the senior surgeon gets up from his chair and takes off his gloves. He sits down at a desk and starts writing the report of the operation, while his younger colleague “closes things up”.
The remaining two hours are regular administration, and at 17.30 we’re ready to leave for the ICU. We stop first at the CT scan, two floors below, to have an idea of what was the effect of removing a mass of more than 6.5cm in diameter from the brain of our patient, but seen that she was in shock for more than half an hour it’s not impossible that her brain might have sustained injuries, either transient or permanent. The scan shows that the situation has drastically improved and the intracranial hypertension she had before the operation should disappear with the reabsorption of the haematoma. We head to the elevator and the doors close behind us with a whirr.
The following morning:
Between one patient and the other, the two residents and I meet in a corridor of the operating quarters; together we sneak down to the ICU to see how the woman is doing. We reach her room but don’t go in, and just say hi and wave from beyond the door. She’s awake, eating, and she gives us back a confused smile. At first I wonder if she recognizes us, but after a couple of seconds I’m sure she doesn’t: our face had been covered by caps and masks when she had come into the room; likely she had already been stressed enough to forget about us had we been wearing clown costumes. We step away, exchange a couple of words with the attending intensivist, and go back upstairs, all three of us forcing ourselves not to grin.
P.S.: if you got this far, thank you. I just want to use the last couple of lines to express how much I appreciate all the comments I received so far. It makes it all feel worth it.
Emergency medicine physician, graduated in Pavia. After going through six tough years of med school, I know how valuable information and encouragement can be; so here I am, trying to provide a bit of both with my posts.
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