The paucity of my posting is not for lack of inspiration, it is for a plethora of fatigue. I haven't had any downtime for a year and half. And it's taking its toll. The director of the OR lambasted me and even accused me of sticking a knife in his back (all due to a simple misunderstanding). He also remarked that I've been in a bad mood lately. Sure, I told him, every time I ask for some time off, the head of anesthesia said no. I had to find out my self that one needs to request vacation time almost a year before. In 2009, I used up only 6 vacation days - the least of any anesthesiologist in the department (including residents). So sue me for being cranky.
The good news is, that I am now officially on vacation. YooHoo!!!!!
Last week, when I was a the end of my tether, I had a case that reminded me why I like my job. A middle aged foreign worker was scheduled for excision of a dermoid tumor on his upper abdomen. The surgeons said that it was superficial on CT but it may have increased in size and involved the ribs since the scan was performed. In addition they were planning to take a free flap from the opposite side to close the resulting defect in the abdominal wall. A very painful procedure to say the least. I discussed with the patient my plan to use a combined anesthetic technique, meaning, combining a general anesthetic with a thoracic epidural especially for post-op pain control. The thoracic epidural is a more difficult technique compared with a lumbar epidural because of the anatomy of the spinal column. For a concise discussion I refer the reader to my fellow blogger Anesthesioboist's excellent post on "Epidural Elegance".
I prefer the thoracic epidural not only for thoracic procedures (obviously), but also for upper abdominal procedures since this area might be missed by a lumbar approach. The benefits of epidural anesthesia is mainly for its "morphine sparing" effect, that is, there is less of a need for IV morphine (with all its side effects), but also for excellent post-op pain control. I usually use a continuous drip of a local anesthetic (with or without an opiate - I prefer with) and "rescue" doses self administered by the patient if the pain increases. This is called PCEA - Patient Controlled Epidural Analgesia.
The procedure went smoothly, no rib resection was necessary. In addition, the surgeons decided to forego the free flap and close the defect with a skin graft from the thigh. I was concerned that the thoracic epidural might not cover that area, but I gave him a good loading dose. A couple hours later in recovery when the patient was completely coherent, he was smiling and completely pain free.