Monday, November 23, 2009

Some of the News That's Fit to Print

So here are some updates to a couple of previous characters in the ongoing story of me: 
I went to visit the woman who survived a monster asthma attack. She was transferred to the high risk pregnancy unit from the ICU. We had something of an odd conversation. She, her gratitude evident by her beaming  smile, me, just trying to avoid inflating the whole story into an epic by engaging in small talk. I was somewhat embarrassed by the accolades I've been receiving lately subsequent to the event.
The OB/GYN's wanted her to remain hospitalized in the high risk unit until she gives birth. But the woman decided she wanted to be at home.  She is receiving preventive therapy, and feels well.  I voiced my concern that if she goes home to her village in the north, she is still 20 minutes away from the nearest hospital, even when there is no traffic. However, she was adamant not to remain hospitalized.  I wished her well and she thanked me again.
You might remember The Teacher's Pet from the incident and angel. The Pet has been removed from the premises. My unfortunate experience with her was just the beginning of a series of problems other doctors from the department experienced with her.  The most serious of the incidents is as follows: Allegedly (and I stress allegedly, because I am informed by word of mouth) a patient who she anesthetized suffered a serious complication.  This could happen to anyone.  The problem is that she allegedly manipulated the anesthesia record to shift the blame to a young resident.  This is immoral to say the least, and stained her character and reputation. She was given the choice of either being fired or leaving of her own volition. She chose the latter.  This is quite a blow to her career.  She was mainly hired to perform research, and now she will be working in a non-academic institution. So, basically, her career has been flushed down the tubes.  I wouldn't wish such an outcome on anyone, but she brought it on her self and has no one but herself to blame.
The Pet is no longer in the building.
I feel vindicated.

Monday, November 16, 2009

I could get used to this.

Today I was pleasantly surprised to receive the following extremely moving letter which I have translated to English (and edited for clarity):

Dear Dr. QuietusLeo,

Although it has been a month since you anesthetized our son Y, better late than never.

We wish to express our great appreciation and gratitude for your professionalism in anesthetizing Y despite his suffering from a slight cold and some coughing. The anesthesiologist we met in the pre-op clinic expressed his concerns with proceeding with the operation on the appointed date and we understood that the anesthetic would be more challenging that that of a healthy child. (Note: With young children there is almost never a window of opportunity when they don't have a runny nose-Q.L.)

We wish to express our great appreciation and gratitude for your attitude toward us, the worried and frightened parents. The manner in which you addressed T when she was with Y in the recovery room - calmly, with confidence and empathy - provided us with the realization that our child was in excellent hands - not just professionally but also caring.  The manner in which you spoke to me (the father-Q.L.)  calmed me and conveyed confidence to the sweet child in my arms.

Immediately after Y was anesthetized by mask N (the father-Q.L.)  exited the room, you asked hem to return to give the child a kiss. This seemingly trivial act, resulted in N feeling confident in leaving his son in the care of strangers.

With your permission, we would like to add - that when we were taken from the ward to the OR we were under great psychological pressure, even panicked - not because of the operation but because of the anesthesia. Had we met the doctor who would take responsibility for the anesthesia we would have been calmer.

Please convey our gratitude to the young doctor whose name we don't know (a young resident-Q.L.) who worked under you that day and also approached us with a smile and empathy (Done that and told the boss too!-Q.L.)

May there be more doctors like you,

The L. family.

I've said it once, and I'll say it again.  I was only doing my job.
But the pat on the back is very, very, very appreciated.

Saturday, November 14, 2009

The Mother of all Asthma Attacks

I was on call in the delivery room. The phone rings and the secretary announces that there is a woman in the maternity ER in critical condition.  All eyes were on me.  "Oh, you mean me?" By the looks on the midwives and obstetricians faces the answer was affirmative.
I hastened down 4 stories and entered the ER. "Where?" A nurse pointed to an examination room.
Entering the room, I make eye contact with the senior obstetrician on call, a good friend, "what's the story?"
"A nurse from medicine, 32 weeks pregnant, just got off her shift with her husband, also a nurse when she fainted, they brought her in here."
One look at the woman tells me that she is having the "Mother of All Asthma Attacks"(tm). She is very agitated and is literally turning blue.
"Let's intubate, give her 100% oxygen, draw up 200 mgs Propofol and 100 mgs scoline." While the nurses prepare the syringes, I connect the bag-mask-valve apparatus to oxygen.  The patient is making an effort to lie down (usually, patients with breathing difficulty try to sit up) a sure sign that she is about to crash.  The syringes ready, I nod to the obstetrician, "Give it all."  He injects the contents of both syringes, within seconds the woman is motionless, anesthetized and paralyzed.
This is the moment of truth, I call out: "cricoid pressure" (to prevent aspiration of stomach contents). I place the laryngoscope into her mouth - a perfect view of the glottis, the entrance to the trachea.  I see the snowy white bands of the vocal cords forming an upside down "V".  The epiglottis just above poised to cover the glottis during swallowing to prevent aspiration.  The two buttons of the arythenoid cartiledges at the base of the glottis.  Most importantly, the void between the vocal cords, the space where the endotracheal tube is to be inserted.
Without averting my eyes, I extend my hand, "tube!"  My friend places the tube in my hand in the correct position for intubation (God bless him!). I slide the tube into the trachea, remove the laryngoscope, inflate the cuff, attach the bag, squeeze and simultaneously auscultate over the epigastrium.  It feels like ventilating a brick wall.  Left lung breath sounds, very wheezy, very very.  Right lung sounds the same.
The pulse oximeter, measuring the patient's oxygen saturation, changes tone from tenor to alto to mezzo-soprano, to soprano - 100% oxygen saturation.
We start giving bronchodilators.  Eyebrows are raised when I employ a trick I learned from one of my professors: Intranasal salbutamol. Unorthodox, but effective, especially with such extreme bronchospasm. Given usually by inhalation, in such conditions, little drug would get to the bronchi, but given intranasally, the drug is instantly absorbed into the blood stream and flows to the bronchi by the back door so to speak.
The obstetrician does an ultrasound, the fetus is very sluggish, he voices his concern that the fetus suffered severe hypoxia along with the mother.
Within a few moments the drugs take effect and it is easier to ventilate.  After 15 minutes there are no signs of bronchospasm. A repeat ultrasound shows normal fetal movement.  Everyone sighs with relief.
The ICU doc on call comes to transport the patient to the unit.
The next morning after an exhausting call, I visit the woman in the ICU, she is extubated and fully conscious. I introduce myself and tell her my version of the events of evening last.
The ICU docs congratulate me on the "save". The senior says, "You realize you saved her life?"
I somnolently nod through the post-call haze. I think to myself that it was just plain luck.  She was lucky that the asthma attack occurred so close the hospital.  Had they made it to the evening rush hour traffic, the results might have been much more tragic.

Oh, yeah, and happy second blogoversary to The Sandman.   
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