Simulation Scenarios and Clinical Lessons Learned

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CHAPTER 8 Simulation Scenarios and Clinical Lessons Learned

“Try it, you’ll like it.”

Exhortation by his siblings to make Mikey eat a suspicious-looking cereal

—TV commercial from the 1990s

This is the meat of the matter. No muss, no fuss, just one monster collection of simulation scenarios, 50 in all. They unfold as if you were there, in the examining room, the OR, or the ICU setting. Watch and listen along as the scenario develops, the residents try to puzzle it out, and the instructor dissects the whole shebang afterward during the debriefing. A summary at the end of the chapter touches on the main clinical lessons learned.

SCENARIO 1. A preop surprise: dealing with a provocative patient

The examining room has a standardized patient (an actor playing the part of a patient).

The resident picks up the chart and looks it over before going in to talk to the patient.

Case. A 47-year-old woman is scheduled for total abdominal hysterectomy. Large fibroids in her uterus have led to heavy bleeding and anemia. There is a history of chronic hepatitis for which she is on steroids, prednisone 20 mg/day. Every time her GI specialist has tried to wean her from the steroids, her hepatitis flares up again. Her SGOT is 90 (she always runs high per her GI clinic chart). Her hematocrit is 27.

Resident goes into the examining room

“Hey, Doc, you’re pretty good looking. You know, they’ll be taking out the baby carriage but leaving the playpen. What do you say?” She winks.

“Uh,” the resident stumbles, “OK, um.”

“Aw come on Doc,” the patient says, “don’t be shy.”

The resident soldiers on, “I’m Dr. Thompson, I’ll be your anesthesiologist, I just want to ask you a few questions and do a brief exam.”

“Sweet pea, you can examine me in my briefs any day and twice on Sunday!” the patient says.

“Have you ever had any trouble with anesthesia, or has anyone in your family ever had any trouble with anesthesia?” the resident asks.

“Well,” the patient says, “I got in trouble back when I was a teenager, but I don’t think it was no anesthesia doctor did it. Might have been Dr. Love though. You mind if I smoke?” She pulls a pack of Marlboros out of her purse.

“Um.” The resident looks up at the ceiling to see if there are any smoke detectors.

“Good, I like a man who doesn’t mind a little second-hand smoke,” the patient says, “my Daddy smoked all the time, prob’ly blew smoke rings in my crib, never did me no harm.”

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FIGURE 8-1 Dig in. As an instructor, remember this—The worst simulator scenario is still pretty good. (Sort of like sex, even when it’s bad, it’s still pretty good.) So don’t worry about getting it perfect. As a student, remember the same thing—The worst simulator scenario is still pretty good. No matter how you flounder, you’re still going to learn.

The patient puts a cigarette to her lips, is just about to light up, when the door opens.

“Simulation over!” the Simulator instructor says.

Clinical lessons learned from scenario 1

Simulations do not have to all involve high-tech mannequins with preprogrammed vital sign aberrations. Actors playing the part of patients make for great simulation too, particularly when the resident isn’t looking for this turn of events.

This resident probably thought he would go into an OR setting and end up coding a patient with an intraoperative MI. Instead, he was detoured to an examination room where he had to do a preoperative evaluation. The chart had some stuff worth exploring—hepatitis, steroid use, anemia—so the resident was probably formulating a line of questioning related to these points.

Hepatitis—“Any sign of easy bruising or bleeding?” Concern here centers on the all-important coagulation factors produced by the liver.

Steroid use—“Are you still taking steroids all the time?” Such a patient would not be able to produce a “stress response” of steroids during the perioperative period, so she would need steroid coverage in the OR.

Anemia—“Are you dizzy or short of breath? Do you feel worse now than usual?” With all the bleeding from the fibroids, this low hematocrit of 27 may be new, and the patient won’t have any compensatory mechanisms in place. She may need transfusion preop. On the other hand, if this has been a slow, long-term bleed, the patient may be “used to” such a low hematocrit, and the need to transfuse is less urgent.

BOX 8-1 Provocative Patient

• Legal landmine
• Keep professional
• Get other person in room

Then what happens?

The patient acts inappropriately, taking the interview into forbidden territory. Sexual innuendo and suggestion? What is this? What the heck is the resident supposed to do? This is a bolt from the blue. The resident stumbles, mumbles, and is completely lost with this bizarre twist.

What was an exercise in pharmacology and physiology (hepatitis, steroids, anemia) has turned into an exercise in professionalism (how to interact with a provocative patient).

“But, but …” the resident thinks, “I thought the Simulator was for … was for … you know, V-fib and stuff like that!”

Here’s how the debriefing goes.

Debriefing. “Hey,” the resident demands, “what was up with that? You guys are supposed to teach me how to handle stuff in the OR.”

“Oh, is that all we teach you?” the instructor asks. “Aren’t we ‘perioperative physicians’? Does that not include the preoperative and postoperative arena as well?”

“Well,” the resident admits, “yeah, yes I guess so.”

“And as an ACGME accredited program, don’t we have to teach you all the core clinical competencies?” the instructor asks.

The resident nods, lips tightened, and face has turned into a “Oh, that ACGME stuff again” mask.

“And is not one of those competencies ‘professionalism’?”

Defeated, the resident’s shoulders slump. “OK, OK, you made your point.”

“Good,” the instructor can’t muffle the triumph in his voice, “what, to your mind, is the definition of a professional? We’re teaching ‘professionalism,’ so, after all, I guess we should know what a professional is, shouldn’t we?”

“Well,” the resident says, “a professional is someone who … someone who went to school and … oh hell, I don’t know.”

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FIGURE 8-2 A. Losing your professional aplomb. B. Get another person in the room—that should re-establish equilibrium. C. And if that extra person senses a lack of professionalism, then by all means a stern lecture is in order.

The instructor says, “Pros adapt. That’s the simplest definition of a professional and the best way to teach professionalism. Pros adapt, period.”

“In anesthesia that means we adapt when the airway’s difficult, we secure that airway by hook or crook, or, more appropriately, by fiberoptic or scalpel, when it comes down to it. We adapt when the lines are difficult—we go central line if we have to, we ask for help, we get a Site-Rite machine. We are pros, we adapt, we find a way.”

“And sometimes we have to adapt outside the operating room or ICU. We have to adapt to a sudden, disturbing fork in the road. But we are pros, we find a way.”

BOX 8-2 Why a Standardized Patient?

• Person-to-person interaction
• Explore behavioral issues
• Test flexibility

“Now here, you have something you never expected. A woman who had you thinking of liver disease and blood counts, and all of a sudden she comes at you from an entirely different direction. What do you do in such a case? What does a pro do?”

“Pros adapt,” the resident says.

Down comes the instructor’s fist on the table with a bang, “Damn straight you adapt! You’re a pro now and that’s what pros do!”

Now the resident is all smiles, but a cloud crosses that smiling face.

“Uh,” the resident says, “how, precisely, do I adapt? Um. Sir.”

The instructor is shaking his hand out now, he overdid it on the table, “Thought you’d never ask.”

“What is the crux of the problem you are facing?” the instructor asks.

“She’s being inappropriate,” the resident says, “she’s saying things of a sexual nature, which simply do not belong in the discussion. And nowadays you think, ‘Oh God, she’s going to sue me and said I touched her and who knows what else!’”

“Right,” the instructor says, “so how do you cool down the discussion, what would change the dynamic in the room? What would undo this enforced intimacy, this awkward and unprofessional jam you’re in?”

“I don’t know.”

“What resources do you have in a preoperative setting?” the instructor asks.

“Well,” the resident is looking around the room, trying to visualize the holding area, “there are holding area nurses.”

“And …” The instructor is letting the resident “find his own way.”

“I guess if I asked one of the holding area nurses in the room,” the resident is putting it together, “then with the extra person there listening the woman would probably chill out a little.”

“Anything else?”

“I’d be, sort of, ‘protected,’ because there would be someone else there, in case later the woman said I did something wrong,” the resident says.

“Bingo!”, the instructor says. “Getting an extra person in the room is the best protection for you. That should straighten the woman out, get her back to the questions you need to ask her—bleeding questions, all the stuff you need to know—and that extra person also provides you great back up in case of false accusations.”

Summary. Anesthesia does not just mean administering anesthetics and fixing vital signs. Anesthesia encompasses the entire perioperative experience, pre-, intra-, and postop. So a simulator experience that trains anesthesia personnel should include the whole shooting match, and that includes dealing with patients.

All kinds of patients.

Most patients are appropriate, but some aren’t. We deal with the whole population; and we, as professionals, must adapt no matter what problems we run into.

Provocative, like this patient
Litigious
Anxious
Mentally challenged from congenital or acquired cerebral problems
Threatening, as anyone who’s worked with the prison population knows

So a simulator session would include such a patient. Dealing with them is difficult, but deal with them we must!

Note how the Simulator session and the debriefing session mesh quite well with teaching the ACGME core clinical competencies—especially the “tough to teach” competencies such as professionalism and communication skills.

Note also how the debriefing session is not a straight didactic: “You did this right/you did this wrong. Got it? Good bye.” At a good debriefing session the resident thinks things over, looks at the gray areas, and then is given the time and freedom to eventually find the answer themselves, with guidance from the instructor.

SCENARIO 2. Headache with attitude, an intracranial bleed

“Get to room 3 right away!” The resident goes into the OR.

Case. An intubated patient is on the operating table, an arterial line is in, plus a 16 gauge IV. An anesthesiologist is at the foot of the table trying to straighten out the lines. An infusion pump running nitroprusside is on the IV pole, but it came disconnected and is dripping onto the floor. Two surgery people are placing pins on the head, and there is an obvious sense of agitation in the room.

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FIGURE 8-3 Why oh why could the blood pressure be so high? Ooops! The nipride is disconnected. Sound unlikely? You’d be amazed how often this simple glitch occurs (kinked or disconnected lines, malfunctioning pumps).

On the monitors, there is an arterial line, but you can only see the “bottom part” of the arterial line trace. The number on the art line reads a nearly incredible 300/160. The patient is tachycardic to 120.

“Big bleed in the head,” the neurosurgeon says, pointing over his shoulder at a CT that is up on the view box. A huge bleed is apparent. The OR table is turned around 180 degrees, so the feet are by the anesthesia machine and the head is up by the surgeons. The head is cranked down with the chin touching the clavicle.

The anesthesiologist in the room doesn’t notice the disconnected nitroprusside or the sky-high blood pressure.

Now the surgeon looks up and sees the blood pressure, “Holy shit, is that right? What the hell are you guys doing up there?”

Just as the surgeon says that, the heart rate drops to 100, then 80, then 60, then 40.

“Hey, he’s bucking!”

The resident in the room reaches over to the drug cart, grabbing a syringe of rocuronium and another of Pentothal. Running around to the IV, the resident pushes the Pentothal and rocuronium, wham bam, one after the other.

Opening the patient’s eyes, the neurosurgeon says, “Hey, look at this.”

After opening the IV wide open to carry in the Pentothol and rocuronium, the anesthesia resident goes up to the head of the bed and looks. The left pupil is blown.

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FIGURE 8-4 Careful with positioning. If you hyperflex the neck and have the chin touching the clavicle, you can stretch vessels supplying the spinal cord and end up with a quadriplegic patient. Rule of thumb? Two fingerbreadths separation between the chin and clavicle for each 70 kg of body weight. Another trick? Put your own head in the position you put the patient’s head in. If you are uncomfortable, the patient is too. For that matter, this lesson applies for all positioning. If you don’t like it, the patient won’t.

The heart rate drops to 30.

The blood pressure drops down from the stratosphere, now down to 200/120.

Up go the drapes, and the surgeons go at it.

“Hey, this brain is tight as a drum skin, what are you doing up there?”

The anesthesia resident looks at the end-tidal CO2. In all the excitement, the ventilator wasn’t checked: 55, the end-tidal monitor says.

The resident increases the ventilation, asks for some mannitol. After a few minutes, the surgeon’s report: “That’s better.”

At the same time, the heart rate increases to 60.

“Simulation over!” the instructor says.

Clinical lessons learned from scenario 2

Haste makes waste, never more so than in a medical emergency.

Getting called into a room with a 4+ disaster is a hair-raising experience, enough to discombobulate the best practitioner. Everything is happening all at once. Everything is going wrong, and everything needs fixing now, sooner than now, more like 10 seconds ago. You try to organize your thoughts along the ABC line; but with surgeons yelling at you, a blood pressure that could launch a Titan V rocket, and a Medusa’s head of lines, it’s hard to do the right things in the right order.

If only you could press a freeze button, you could make order out of chaos. But fate has not handed us such a magical button. And a critically ill patient doesn’t hand you that most luxurious of gifts—time.

And things happen in a rush. Stuff gets disconnected, but, hey, you were in a rush to get the patient over to the table. If you took all the time in the world and made sure absolutely everything was neat and tidy, the patient might die a neat and tidy death.

Let’s look in the mind of this anesthesia resident during the debriefing from this scenario.

Debriefing. The instructor opens the discussion, “What were your priorities in this case?”

BOX 8-3 Controlling Increased ICP

• ABC—fix all three
• Stop bucking
• Pharmacologic measures

“Like any case,” the resident says, “a quick survey, focusing on the ABC. It was evident the patient was in extremis and needed cerebral decompression as soon as possible.”

“Did you listen to the chest to make sure the endotracheal tube was in?” the instructor asks.

“No, I could see that there was end-tidal CO2, so I knew the tube was in the right place,” the resident says, “and I saw the saturation was 100%, so I went right to the most pressing issue, the ‘C’ part, a deadly high blood pressure.”

“What were you thinking?”

“With the big bleed the surgeon mentioned,” the resident says, “I envisioned the compensatory mechanisms the body uses to maintain cerebral perfusion pressure. Because the intracranial pressure was high secondary to compression from the hematoma, the body raised the systemic blood pressure in an attempt to keep the rest of the brain supplied with blood.”

“So why try to get that pressure down?”

“At 300 systolic, the strain on the heart would be unbearable and would lead to a cardiac arrest within minutes. Also, if this cerebral bleed were from a ruptured aneurysm, that pressure of 300 would turn that torn aneurysm into a fire hose, pouring more blood into the brain.”

“What was your goal?”

“Get the pressure down to something the heart might be able to tolerate,” the resident says, “say a systolic of 200 or so. Still high, so you could still get cerebral perfusion, but not so high that it places the heart at risk.”

“But you didn’t have time to look everything over, did you?”

“No, the patient bucked, indicating he wasn’t paralyzed. That bucking is bad for increased intracranial pressure. The patient was at risk for cerebral herniation with that huge bleed. When I first got in the room, I feared that might happen, as indeed it did.”

“How did you know?”

“At first,” the resident says, “the patient had hypertension, increased intracranial pressure, and tachycardia, so he didn’t have the classic Cushing’s triad. But that changed after the patient bucked. Then the patient did develop the classic triad of blood pressure elevation (to keep cerebral perfusion pressure up), increased intracranial pressure (from the bleed), and reflex bradycardia (the heart’s response to the high blood pressure).”

“So what did you do?”

“The nitroprusside was disconnected, so I couldn’t use that to drop the blood pressure, so I reached for Pentothal to drop the blood pressure and rocuronium to paralyze the patient and prevent further bucking.”

“Would nitroprusside have been your first line to drop the blood pressure?” the instructor asks.

“No,” the resident says, “nitroprusside is a dilator and can increase cerebral blood flow and hurt our intracranial pressure picture. Pentothal is good for decreasing the cerebral metabolic rate of oxygen—a good drug in this setting. Plus, Pentothal helps drop the blood pressure.”

“What did you think about the head positioning?” the instructor asks.

“I didn’t like it,” the resident says. “Extreme flexion of the head with the chin touching the clavicle is too extreme. That can cause stretch of the vessels supplying the spinal cord and can lead to spinal cord ischemia. I would have preferred to reposition the head, making sure there were at least two fingerbreadths of space between the clavicle and the chin for each 70 kg of patient body weight.”

“But you didn’t do that.”

“No,” the resident says, “the patient herniated, as evident by the pupil dilating unilaterally. The brain was getting squished down into the foramen magnum, and death would result in minutes, so it was more important to get that head open and drain the blood as soon as possible. Truth to tell, it would have been all too easy to forget about that later on.”

“When troubles come, they come not as single spies,” the instructor says, “but in battalions.”

“Amen to that,” the resident says.

“And once the head was opened, what was the next problem that appeared?”

“The surgeon complained of a ‘tight head,’ indicating that I needed to do what I could to reduce brain volume. That means adequate drainage, no kinking of the head or neck vessels, hyperventilation, and osmotic diuresis.”

“But the CO2 got away from you,” the instructor observes.

“Yes,” the resident admits, “guilty as charged. With all the excitement of the herniation, I forgot to check all the details, and I had inadequate ventilator settings. Once I saw the high CO2, I increased ventilation to drive the CO2 down and help shrink the brain.”

“But not too much, right?” the instructor asks.

“Correct,” the resident says, “I would aim for an end-tidal CO2 of about 25 to 30. More severe hyperventilation could result in cerebral ischemia, plus the resulting respiratory alkalosis could impair oxygen delivery.”

“These neuro cases are real physiologic showcases, aren’t they?”

“Don’t you know it.”

Summary. Hours of boredom, moments of panic. So goes one description of anesthesia. An impending cerebral herniation certainly qualifies as one of the “moments of panic.”

In this case, a patient had been rushed up to the OR, probably from the CT scanner, with a life-threatening intracranial bleed. In the zippety doo-da transfer to the OR table, a nitroprusside drip had gotten disconnected, unmasking a horrific hypertension that could kill the patient, well, a second time if the herniating brain didn’t kill him first. Talk about double jeopardy!

Into this high stress simulator scenario an anesthesia resident arrives, just when everything starts to fall apart. A quick assessment and quick thinking brought all the important points into focus (tube’s in, pressure’s high, patient needs paralysis), although a couple of other points did escape this initial scan (making sure to undo the severe neck flexion, hyperventilating).

The resident demonstrated a good understanding of intracranial pressure, cerebral perfusion pressure, and the signs of herniation. Actions were quick and appropriate, a nimble response to a tough case.

SCENARIO 3. Local in the wrong locale, intravascular injection during an epidural

The overhead speaker says, “Anesthesia to labor room 2, anesthesia to labor room 2 to top up an epidural.” Into labor room 2 goes the anesthesia resident.

Case. On a labor table, a pregnant patient with attached epidural is groaning (through the speakers in the mannequin). The patient’s feet are up in stirrups, and the OB is sitting in front of her, holding forceps.

“Hey,” the OB says, “glad you showed up. I could use a little help here. Your epidural is no great shakes.”

“OK,” the resident says, “how are you doing, ma’am?” As the resident speaks, she looks around for the anesthetic paperwork—preop evaluation, anesthetic record detailing the epidural placement, dose and rate of local anesthetic given and running.

“Bozhe moi,” the patient groans, “bozhe moi, boleet, boleet! Rebyonik vilyezaet!”

“Oh yeah,” the OB says, “she just moved here from Minsk. She only speaks Russian or Ukrainian or something.”

The patient is connected to a blood pressure cuff, a fetal heart rate monitor, and a pulse oximeter.

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FIGURE 8-5 Language barrier—what do you do? Do you just pretend that there isn’t a problem? Not an effective plan. There are a lot of creative ways around this—get acquainted with the hospital’s translation service. Find a relative who can function as interpreter. Best answer—learn the language yourself! A little involved, to be sure, but a great way to impress people at cocktail parties.

Lost in the paperwork, the anesthesia resident says, “Uh huh.”

The anesthesia preop outlines the case.

More of the case. A 22-year-old G1P0A0, previously healthy woman appeared for delivery. Good prenatal care, no complications. Takes vits. Translator—husband (patient is Russian speaker only). Airway, Mallimpotti 2; labs pending. Patient currently at 3 cm dilation and in discomfort. “Plan—combined spinal epidural. Case fully discussed per translator, detailed risks/benefits/options. Patient agrees to proceed.”

Vital signs were normal, and the patient was not morbidly obese. If ever there were a routine case, this was it.

The anesthetic record detailed an unremarkable course.

“Patient given fluid bolus, FHR checked and monitored throughout. Patient sat up, prep/drape, local placed at L3–4. Loss of resistance technique used to identify epidural space. A 25 g pencil point needle used through Touhy needle, clear CSF, no paresthesias. Fentanyl 15 μg was injected after a positive aspiration. Spinal needle withdrawn, epidural catheter placed, Touhy withdrawn, catheter secured. Aspiration negative for blood or CSF, test dose without adverse reaction. Infusion of 0.125% levobupivicaine (10 cc/hr) with 5 fentanyl (5 μg/cc) begun.”

“Good pain relief, patient stable, FHR OK throughout.”

So far, so good.

But now the OB was complaining, in English, and the patient was complaining, in Russian.

“OK, is the husband around?” the resident asks, “my Russian is not too good.”

“He was here all night,” the OB says, “he’s conked out in the lounge. Listen, honey, this here epidural is not winning any Nobel prizes for pain relief, can you do something to help me here? Baby needs a little help with these forceps, and mom isn’t going for it.”

“Um, OK,” the anesthesia resident says, “my name is Dr. Nelson, not ‘honey’.”

“Bozhe moi, pomogeetye mnyeh, rebyonik vilyezaet, rebyonik vilyezaet!” the patient shouts.

“Fine,” the OB snaps, “I’m so happy the political correctness, thought and mind control Gestapo have shown up to make sure I don’t step on any feminine sensibilities, Doctor Nelson. Now make this god damned epidural work!”

“Boleet, boleet! Akh da, gdye moi moozh?” the patient shouts.

Dr. Nelson goes to the head of the bed, looks at the epidural catheter and notices that the infusion tubing has come disconnected from the cap. In sterile fashion, she reconnects them.

“So,” the OB still has attitude in his voice, “can you help me or not, or do you want me to do like they did in Gone with the Wind, and just put a knife under the bed so it cuts the pain in half?”

“No need,” Dr. Nelson says, “the epidural became disconnected, I’ll have to rebolus.”

“Oh great,” the OB says, “well make it snappy, I’ve got to get these salad spoons on.”

Dr. Nelson draws up a syringe of 0.25% levobupivicaine, connects to the tubing, aspirates, then injects 5 cc. She waits a minute, then injects the other 5 cc.

“Chto eto!” the Russian woman says, “Chto sluchilas? Mnye ochen … chto eto zvonok?” Then she falls silent.

The fetal heart rate monitor drops to 40, the patient’s pulse oximeter stops beeping.

“Hey!” the OB shouts, what’s going on here? What did you give?”

Dr. Nelson gives a sternal rub and shouts at the patient, then reaches down for a pulse, there is none.

“Oh Christ!” the OB shouts, then drops the forceps, goes up to the chest, and starts CPR. “Call a code!”

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FIGURE 8-6 Know your fetal heart rate strips! Baby dumpling is heart rate-dependent. So when that heart rate drops, baby dumpling is in big trouble!

Dr. Nelson looks around for a laryngoscope, an Ambu-bag, anything.

“Simulation over!” the instructor chirps.

Clinical lessons learned from scenario 3

Dr. Nelson faced a prickly path in labor room 2.

She was “inheriting” an epidural, so she had to come up to speed on that.
Her co-worker and fellow doctor treated her dismissively.
Things were coming to a clinical head, or, more precisely, an occiput, as the woman was in need of a forceps delivery.
A regional anesthetic was in use, and there was a language barrier.

And that was just the start of Dr. Nelson’s troubles.

The debriefing picks up the thread.

Debriefing. “So,” the instructor says, “how do you think that went?”

Dr. Nelson’s head is hanging down, “Not too good, I think I killed them both. 200% mortality. Not a stellar performance.”

“Relax,” the instructor reassures, “be glad she didn’t have twins. Then it would be 300%.”

“Thanks,” Dr. Nelson groans, “I feel a lot better.”

BOX 8-4 Language Barrier

• Symptoms?
• Instructions?
• Communication?

“Before we get to the thrilling conclusion, let’s go over things from the start. What was the situation, and what were your concerns when you came through the door?”

“Pregnant patient, so you think about all the concerns there—full stomach, possible difficult airway, any sedation you give to mom you give to the baby, decreased FRC so the patient can desaturate quickly. Plus we have an epidural in, so you are always thinking—is this in the right place, is it working, could it be intrathecal, could it be intravascular?”

“Right,” the instructor says, “so you have the physiology of pregnancy on your mind, the pharmacology of epidurally infused local anesthetics and narcotics on your mind. But then, it’s not like we do things in a library, is it, a physiology textbook on one side, a pharmacology textbook on the other?”

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FIGURE 8-7 Believe it or not, the fruit and vegetable world provides us with some partial-task simulators. The epidural needle gets a loss of resistance as it goes through the skin into the, the (what do you call it?), the banana meat? The banana essence?

“No,” Dr. Nelson says, “there is the human factor.”

“Aah yes,” the instructor agrees, “and what are the human factors at work here?”

Both the OB and the patient (the Russian speaking technician who was providing the voice for the simulator mannequin) enter the debriefing room.

“Well,” Dr. Nelson starts out, “the OB was a demanding asshole of a chauvinistic pig.”

“I try,” the OB says.

“So I had to deal with his ‘woman-doctor-as-honey’ comments and still try to keep a professional head on my shoulders and assess the patient.”

“Let’s give the devil his due, Dr. Nelson,” the instructor says, “let’s look at things from the OB’s point of view and add a touch of real world to this scenario.”

The OB chimes in, “I mentioned the husband had been up all night; guess what, I had been up all night too. So now I’m wiped out, I don’t have my ‘Mr. Perfect’ hat on because I’m frustrated with a poorly functioning epidural. And yes, I said a stupid thing. You could kick my ass on this, and I guess you’d be within your rights, but keep in mind, I am your referral base. And if you go ape every time someone says something stupid in the hospital, then you’d better transfer to Perfection Memorial Surgery Center, where everyone is always considerate and kind and wonderful 24/7. And let me know when you find that place.”

Dr. Nelson bristles, “I thought I handled it OK, though. I made my point without going to the Supreme Court, and I passed over his ‘thought Gestapo’ swipe.”

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FIGURE 8-8 Some parturients are somewhat, um, short for their weight. So to practice this sometimes difficult epidural placement, use a fruit that is also somewhat, um, short for its weight.

The instructor says, “Touché, you did that. What was the other human factor going on here?”

“Russian. The woman spoke Russian, and that really hurts my ability to ask for symptoms,” Dr. Nelson says.

“What do the textbooks say about that?” the instructor asks.

“Some say that a language barrier is an absolute contraindication to using a regional anesthetic!” Dr. Nelson says. “In theory, that is right. How can you ask about ‘ringing in the ears, a funny taste in the mouth’ and other subjective signs of an intravascular injection of local anesthetic?

“But on the OB floor, that is just plain not practical,” Dr. Nelson continues. “What are you going to do—a general anesthetic on every patient with a language barrier? The prime dictum of obstetric anesthesia is doing everything in your power to avoid general anesthesia, with the risk of airway loss and hypoxemic catastrophe. So we do the best we can, using whatever translation services we can—family members, nurses, orderlies—you can even get some translation services over the phone nowadays.”

“But there is still that risk,” the instructor says. “There is still that concern that the patient is saying something that you need to know, but you can’t understand it.”

“Yep,” Dr. Nelson admits, then turns to the Russian technician, “What were you saying, anyway?”

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FIGURE 8-9 Our obstetric friends can also tap the fruit basket to practice their skills. Here a banana demonstrates how a C-section is done. Prep, cut open the peel, take out the banana, close up the peel. Then weigh the little darling and give him a cute blue cap. Maybe clean him up a little too.

“Turns out I was saying something important,” the technician says, in perfectly unaccented English, “I was saying, ‘It hurts, the baby is coming.’ The whole controversy here swirled around dosing me up for a forceps delivery. But while you and the OB were sniping at each other, the baby was coming down on his own, obviating the need for forceps and for the dose-up.”

“Oh,” both OB and Dr. Nelson say; neither had been privy to what the Russian speaker would say. Damned clever twist he came up with. No one had been thrown by the fact the voice was that of a man. Oh well, pros adapt, as they say.

“All right,” the instructor says (wow, even he didn’t know about that sneaky little tweak—better remember that at Christmas bonus time). “We talked about the pharmacology and physiology and the human factors. What else heaves into view as we get toward the end of our little morality play?”

“Equipment,” Dr. Nelson says.

“Why do you say that?” the Russian speaker asks.

“When I dosed the epidural, despite giving the local anesthetic in divided doses, the local anesthetic either went intrathecally—causing a total spinal and plummeting blood pressure—or intravascularly—causing cardiovascular collapse,” Dr. Nelson says. “Either way, I needed to resuscitate the patient, and that means having resuscitative equipment nearby—intubating stuff like endotracheal tubes and laryngoscopes, Pentothal to stop seizures.”

“Did you have any of that stuff?” the instructor asks.

“Oh, I didn’t check,” Dr. Nelson admits. “That, I should have done. What was that you were saying, anyway?” Dr. Nelson asks the Russian speaker.

“I said, ‘What’s that, what happened, what is that bell?’ Then I stopped. I was responding the way a patient might respond to an intravascular injection of local anesthetic, when they first feel funny, then they might hear ringing in their ears, then they lose consciousness. I would seize too, but the simulator mannequin can’t do that yet.”

BOX 8-5 Intravascular Injection of Local Anesthetic

• Stop injection (duh!)
• Cardiovascular and respiratory support
• CPB if necessary

“Anything else you might have done differently?” the OB asks. “Like when the code started and I went up to the chest to start compressions?”

“I don’t follow you,” Dr. Nelson admits.

“How effective are chest compressions in the still-pregnant patient?”

“Oh yeah,” Dr. Nelson tumbles to it, “chest compressions in the pregnant patient are ineffective until the baby is out. Better to deliver the baby right away—your forceps might have been able to snag it—then the chest compressions are much more effective.”

“Righty-oh,” the instructor wraps it up.

Summary. A simple epidural and anticipated forceps delivery encounters some turbulence. Dr. Nelson has to brush off a snippy and demeaning comment, focus on the patient’s needs, work through a language barrier, and handle an intravascular injection of local anesthetic.

Just thinking “To hell with it, the husband is asleep” left both OB and the anesthesia resident blind to extremely important information. That baby was coming, and there was no need for them to do anything! Also, the subjective symptoms of the intravascular injection escaped Dr. Nelson.

Routine practice means making sure you have all your “rescue stuff” nearby. Dr. Nelson was caught short when disaster struck. Plus, in the “who-wouldn’t panic” mode of a code, Dr. Nelson forgot a fundamental principle of CPR in the pregnant patient—get the baby out before you do chest compression.

The final lesson: When injecting local anesthetic, stick to this rule—every dose is a test dose. Never slam in a gallon of that stuff because if it goes intravascular you could be in deep Kimchee.

Maybe next time they should do that “knife cuts the pain in half” trick from Gone with the Wind.

SCENARIO 4. Help from across the drapes, hypoxemia in the OR

“Any anesthesiologist to OR 18, any anesthesiologist to OR 18 stat!”

A CA-3, a senior anesthesia resident, answers the call and goes into OR 18.

BOX 8-6 Obstetric Pain Relief

• Regional
• Parenteral
• Knife under the bed?

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FIGURE 8-10 Stat call? When an anesthesiologist calls for help stat, it is the real McCoy. Lost airway, cardiac arrest, whatever it is, they need that extra hand and they need that extra hand right now.

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FIGURE 8-11 Fly to the room if you can. That extra pair of hands and that extra brain might be just the thing to save your anesthesiology partner, and, lest we forget, save a patient as well.

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FIGURE 8-12 The best part about being the “second person in the room” is that you always look good. If you save the day—great. If you don’t, well, then at least you showed up and tried.

In OR 18, a CA-1, a junior resident, is at the head of the table, hand ventilating the patient. The patient is intubated, the drapes are up, and everyone is in mid-operation, two surgeons operating and the usual surgical team doing their thing.

“Hey,” the first surgeon yells, “lend a hand here. Bozo here just graduated clown school and made a wrong turn into my OR.”

That cracks up the other surgeon, and he chimes in, “Blood-brain barrier, right. How about the blood-brainless barrier!”

They get back to work.

“What’s up?” the senior resident asks.

Hand ventilating and cranking his head around to the screen, the junior resident says, “Look at the STs.”

On the EKG, a tombstone pattern of ST elevation is present. Ischemia that a blind man could see.

The CA-3 looks over the vital signs, oxygen saturation 100%, BP by cuff 85/50, pulse 130.

“Why are you hand-ventilating?” the senior asks.

“Well, he’s ischemic, so I figure he’s going to arrest. I know you hand ventilate in an arrest, anyway, it seemed like a good thing to do,” the junior says, flustered and shook.

Flipping the ventilator switch from manual to automatic, the senior resident says, “Relax, let the ventilator do the work. You have to figure out what’s going on, free up your hands.”

“Now why’s this guy ischemic?” the senior asks.

An audio alarm goes off, both reach up to silence the alarm.

“OK, this is a liver resection, that’s what it says; and they’re losing a lot of blood. I’m trying to keep up, but I think I’m behind,” the junior says, then hands the senior the preop. “This guy’s had a couple stents, he’s 70, so he’s got ischemia. I mean he’s a setup for ischemia, and now this.”

Another audio alarm goes off. Again, both reach to silence the bothersome alarm.

“You guys OK up there?”, the first surgeon asks, now a shred of concern in his voice. “The blood looks a little dark here.”

Taking charge, the CA-3 decides he’s had enough from the knife-wielders, “Yeah, we’re fine, see if you can slow down that bleeding. They did teach you to tie in school didn’t they? Or do you need Velcro on your shoes?”

Two alarms now go off, and both get silenced in a split second.

“OK, let’s look all this stuff over, that’s the way you do it when things go south in a case, go it?” the CA-3 soothes the CA-1. “ABC, always start with ABC.”

He looks around, “Tube’s in, so we got A and B, now the C part needs a little work,” the senior says, pausing only to push another “silence alarm” button.

“I’m not kidding you guys,” the second surgeon says, “this blood really does look dark!”

“Yeah yeah,” the CA-3 says, “sure it does. We got it.”

On the EKG, the STs are even higher.

“Listen, this is all about myocardial supply and demand, and right now there’s too much demand—look at that heart rate—and not enough supply—look at that blood pressure,” the senior explains. “Hang blood, keep transfusing until that heart rate goes down. They’ve obviously lost a ton resecting that liver.”

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FIGURE 8-13 ST troubles. When ST segments go down, it usually means subendocardial ischemia. That is not good. When ST segments go up, it usually means transmural ischemia. That is not good with capital letters. And those capital letters can go to these capital letters—RIP.

From the other side of the drapes, the surgeon suddenly appears and bursts between the residents. “What in blue blazes is going on up here, I tell you the blood’s dark, and no one pays attention to me, do you even have this ventilator on, I don’t see the chest rising!”

“Hey,” the CA-3 is bristling with territoriality, “what are you doing….”

“Wait,” the CA-1 says, “he’s right.” Reaching over, the junior resident turns on the ventilator. The senior resident had switched from manual to ventilator but had not turned the ventilator itself on.

A look of triumph on his face, the surgeon goes back to the other side of the curtain.

“We’re done!” the instructor says.

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FIGURE 8-14 When it comes to ischemia, go for the myocardial oxygen supply/demand teeter-totter. Decrease the demand (beta blockers) and increase supply (improve oxygenation, transfuse). If you’ve fixed everything you can fix, you have to go to the big guns—revascularization by stent or even CABG.

BOX 8-7 Ischemia Treatment

• Increase O2 supply
• Decrease O2 demand (beta blockade!)
• Think of teeter-totter

Clinical lessons learned from scenario 4

“Any anesthesiologist to OR 18!” is enough to send chills down any anesthesiologist’s spine. No one puts out such a call unless the ship has hit an iceberg, the car is plummeting over the cliff, the airplane’s wing just fell off.

But call it you must, if in trouble. And respond you must, if you hear it.

The junior resident was overmatched by circumstances. (After all, you can’t know it all at the beginning—that’s why we do residencies!) So he put out a call to his more senior colleague.

Upon arrival, the senior resident pegged the problem—blood loss, low blood pressure, high heart rate—all the classic signs of hypovolemia. Couple this with a patient prone to ischemia, and you get, no surprise, ischemia. The heart is banging away, trying to compensate for the low blood volume, so that places a high demand on the heart. But supply is short—the patient has bled a lot, so there is low oxygen content. Also, the pressure head pushing blood down the coronaries is low, so the heart is going into oxygen debt.

Presto-chango, ischemia prone myocardium is now ischemic myocardium.

Never fear, senior resident to the rescue!

The debriefing reveals just how good a rescue he delivered.

Debriefing. “What were you thinking when you called for help?” the instructor asks the CA-1.

“I knew from the preop that this patient could develop problems related to his coronary disease. Then when the surgeons, well actually the circulator, reported a lot of blood loss, then I saw the low blood pressure and the STs, and it started to be too much too fast,” the CA-1 says, “so I sort of ‘went to ground,’ hand ventilating and getting someone to help me.”

“Did you think you would need an a-line for this case?” the instructor asks.

“Well, the surgeon said he had one of these kind of oscillating Harmonic Scalpel things, that cauterizes as it cuts, so you shouldn’t lose much blood,” the CA-1 explains.

“But he did.”

“Boy howdy, he did,” the junior says.

“How would you rank your interaction with the surgeon? Were you able to communicate effectively with him or the surgical team?” the instructor asks.

“Not too well, they were bugging me, mostly, and not much help,” the junior says.

“Does that matter?” the instructor asks.

“Yeah, I mean, the OR is not meant to be a fight about pecking order,” the junior says, “the patient sort of trumps all that.”

“Listen,” the surgeon, now sitting in on the debriefing, says, “you might not like getting a little static from your surgery buddies, but I got news for you. That’s exactly what you’re going to get when you graduate from here. Private practice medicine is not a cruise on The Love Boat.”

Then the surgeon, still imperious and strutting from the OR scenario, turns to the CA-3, the cavalry that was supposed to ride in and save the day, “Help me out here, just what was your role in this fiasco?”

Looking at the instructor for guidance, the CA-3 holds his hands palms up, “Here I stand, hat in hand.”

“No need for martyrs here,” the instructor reassures, “just go through what you were thinking.”

“Right away, the surgeon is getting under my skin,” the senior says. “So I figure I have to rein him in or shut him up, one or the other, so I can fix this obvious case of myocardial ischemia.

“I’m going through the whole teeter-totter thing—oxygen supply here, oxygen demand there—and I wanted to even out that teeter-totter so the patient’s heart can have an adequate oxygen supply and get out of the ‘ischemic zone.’”

“So what did you do?” the instructor asks.

“Well, I knew we’d need to do something fast, the usual thing is to get the blood pressure up in a bleeding patient—turn down the anesthetic agents, check and hang blood, give pressors, put the head down,” the senior explains. “And having the CA-1 all tied up hand-ventilating wasn’t doing us any real good. So I went to free him up.”

“And that’s when I made the mistake, I turned the one switch but didn’t bother to turn the second switch, so the ventilator was off,” the senior says.

“Why did that happen?” the surgeon asks in, of all things, a reasonable tone.

“Distraction, too much happening at once,” the senior explains. “The surgeon is riding me, the CA-1 is giving me the doe eyes, the ‘help me, I’m a drowning puppy and no one can save me’ look.”

“Hey,” the CA-1 protests.

“Sorry,” the CA-3 apologizes. “So anyway all this stuff is going on, and alarms are going off, which I stupidly shut off rather than paying attention to.”

“And now the surgeon is actually telling you something important,” the instructor says, “that the blood is dark.”

“Right,” the senior says, “but I lump that in with all the other crap he said, and I completely blow it off.”

“So how do you sift the wheat from the chaff in a case like that?” the instructor asks, “How do you tell the real deal from static?”

The CA-1 picks it up, “It’s tough, but I guess you have to forget the ‘attitude’ thing, you have to weigh each thing as it comes in. He might say 10 snippy remarks, but when that 11th one says, ‘The blood is dark,’ you have to pay attention to it.”

“That you do,” the CA-3 says.

Summary. Anesthesia providers learn the drill of myocardial protection early. Keep the patient well oxygenated, keep other “supply-side” factors (hemoglobin, blood pressure) favorable. Keep the “demand-side” factors favorable too—avoid tachycardia and keep the blood pressure normal.

But there’s many a slip “twixt the cup and the lip.” Even someone perfectly versed in “myocardial lore,” such as this CA-3, can drop the ball on something as fundamental as turning on the ventilator!

Throw in a “Chatty Kathy” surgeon, some interpersonal edginess, mix in a little anesthesia defensiveness, and add a dash of a junior resident who’s a little lost, and you have all the ingredients for “disaster soup.”

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FIGURE 8-15 Anesthesia is a humbling profession. As soon as you think you’re slick, you slip. Pride goeth before the fall and all that. If you do blow it (everyone does, sooner or later), eat your humble pie, learn your lesson, and move on.

Final lesson? Even a surgeon who bugs the heck out of you can walk right up and save the day for you. Who, after all, noticed the chest not rising?

Sometimes you have to give the devil his due.

SCENARIO 5. Too much of a good thing—narcotic overdose

“Doctor, could you step over here,” the ICU nurse says, “there’s something you need to see here.”

The patient is lying in bed, the ventilator is at the side of the bed but not connected to the patient. There is a subclavian central line in the patient, a face mask for oxygen is on, an EKG shows normal sinus rhythm, and the pulse oximeter shows 89%.

As the resident picks up the chart, the nurse fills in, “This is a 30-year-old road warrior who came in last week with open tib-fib fractures, pneumothorax, the whole nine yards. Miracle of miracles, he had a helmet on, so no head injuries, and the C-spine cleared.

“Yesterday he had a central line placed for long-term antibiotics. He was extubated yesterday too; they just haven’t moved the ventilator out yet. He’s with it enough to have visitors, and one just left.”

The resident looks over the chart, it’s all there, just like the ICU nurse said.

“So what’s up?”

“He just doesn’t look as good as he did a while ago, he’s less responsive, breathing slower, his sat is pooping out. Something happened, I just can’t peg what it is.”

Going up to the head of the bed, the resident shakes the patient’s shoulder, “Hey! How you doing sir?”

A groan, nothing more.

“Is this guy on PCA narcotics?” the resident asks.

“Yes,” the nurse answers, “but we haven’t changed the dose or lockout interval.”

“And you say he had these long bone fractures in his legs, and he’s been bedridden all this time?” the resident asks.

“Yes, he’s on subq heparin, all the usual DVT prophylaxis,” the nurse reports.

The patient is taking slow, deep breaths but appears in no respiratory distress, no accessory muscle use, no rapid, shallow, pained breaths.

“Do you think we should intubate doctor?” the nurse asks.

“Um, let’s get an ABG first, and get suction up here in case he vomits.”

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FIGURE 8-16 Patient fails to awaken? Look for the three major “families” of causes—pharmacologic, metabolic, and neurologic. Don’t use this “budget Narcan” to wake the patient: Slapping the patients silly is counterproductive, illegal, and makes us look stupid.

With more shoulder shaking, the patient arouses a little more, “Hey, sir what gives?”

“Good s***,” the patient says, then goes back to sleep.

The resident looks at the fingernails, looking for splinter hemorrhages or other things that might indicate a fat embolus.

“Let’s get a CXR,” the resident says, “maybe the pneumothorax came back or something.”

“ABG results,” the nurse says.

“Not terrible,” the resident says. On the blood gas slip, the Po2 is 95, Pco2 52, pH 7.32. Not perfect by any stretch, but this is one beat-up patient.

Now the patient is opening his eyes a little more, taking more frequent breaths, and his sat is coming up a little.

On the view box, the repeat CXR goes up—nothing abnormal, no reaccumulation of pneumothorax.

Now the patient looks OK.

In almost an apologetic tone, the nurse says, “Sorry doctor, must have been a false alarm. He looks about the same now. Must be one of those things.”

“Simulation over!” the instructor says.

Clinical lessons learned from scenario 5

Residents going into the simulator are always keyed up to do something. And if you’re geared to do something, anything, you are a real setup to jump the gun, to overtreat, to blow it with (as Alan Greenspan would say) irrational exuberance.

So this resident enters an ICU scenario where something is just not “quite right.” An ICU nurse senses “something is wrong in the state of Denmark,” but she can’t put her finger on it.

So she calls in Dr. Sherlock Holmes to unravel the mystery.

But then, nothing happened.

Or is that actually so? Did our sleuth miss something? The answer appears during the debriefing. And the answer is elementary, my dear Watson.

Debriefing. “What were your concerns when you entered the ICU?” the instructor asks.

“The ICU nurse said something is wrong with the patient,” the resident says. “And when a nurse says ‘Something’s wrong,’ it’s a red flag. The ICU nurse is right by the bedside observing the patient. They usually have a nurse-to-patient ratio of one to two or even one to one if a patient is critically ill.”

“In a perfect world,” the ICU nurse says. “But I don’t know if you’ve noticed lately, there is a nursing shortage—Hello—earth to doctor! I get put one to four all the time, even with the sickest of the sick.”

“Point well made,” the instructor says, “so the nurse can’t have eyes glued on the patient every second of every minute. But still, if they say there’s been a change, then you put full faith in their observation.”

BOX 8-8 Mystery Narcotic Injection

• Access—CVP
• Access—friend’s visit
• Opportunity

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FIGURE 8-17 Hello, wake up, there is a nursing shortage! In the simulator, try to reproduce some of the “real life” shortcomings that residents encounter out there. An ICU nurse with little experience misses an important blood gas or doesn’t notice the ventilator is malfunctioning. Anything that happens “out there” should happen “in here.”

“Amen,” the resident says. “It’s criminal to blow off a concerned nurse and say, ‘It’s nothing, forget it.’ I may not figure out what’s wrong, but I sure as hell will try to figure it out.

“So, OK, it’s to the bedside and ABC, always, always, always,” the resident says. “Get right up there, see that they’re moving air, see that they’re protecting the airway, make sure all their vital signs are stable. Once you assess and fix anything immediately life-threatening, there’s always time to sit back and filter the data and figure out something more subtle.”

“Was he moving air, was he protecting his airway?” the instructor asks.

“Not great, not great,” the resident says, “he only groaned when I touched him the first time, and he had a kind of ‘narcotized’ breathing pattern. Deep and slow.”

“So were you thinking narcotics?” the nurse asks.

“No, not really. You said he was on the same PCA, the same lockout and dose,” the resident says, “so why now should he get a slug of narcotics.”

“Did you look at his eyes to see if he were miotic?” the instructor asks.

“No, I guess you could say I should have, but that PCA information just didn’t seem to jibe with a narcotic overdose,” the resident explains.

“So where did you go from there?”

“Get a blood gas, get a CXR, especially since he had that recent pneumothorax, and hover by that bedside, suction in hand, because I wasn’t positive he could protect his airway if he vomited,” the resident says.

“Then why not intubate?” the instructor asks. “Wouldn’t you do that in the trauma bay if someone were not protecting their airway, if they were barely responsive? That’s, what a Glasgow coma scale of 8 or so?”

Moving his head back and forth, the resident says, “Yes, just about, I just wasn’t quite, ‘there’ yet in terms of ‘OK, this guy no way is protecting his airway.’ I seemed able to get a little something out of him. So I opted for watchful waiting. It’s gray, but that’s where I went.”

“And it turned out OK, didn’t it?” the instructor asks.

“Well, yes, his first ABG wasn’t too great, but he seemed to improve with time, so watchful waiting seemed the right thing to do.”

“And pulmonary embolus, fat embolus, did they work out?” the instructor asks. “Did they ‘land any punches’ on this patient?”

“No,” the resident says. “I voiced them though, because here is a guy with long bone fractures, but he’s a week out, and his fractures have been fixed, so you figure fat embolus is unlikely. Same with a pulmonary embolus; he’s a setup, being bedridden and basically immobile, but he is on DVT prophylaxis. I’ll give that to the orthopedic docs, they always pay attention to the danger of PE.”

“So we’ve gone round in circles,” the instructor says, “and we’re back to a big, fat, nothing. Is this just a ‘mystery swoon’ in the ICU?”

“I don’t know,” the resident offers, “is this one of those ‘null scenarios’ I’ve heard about? You don’t really do anything, and you expect us to freak out and intubate the patient when we don’t have to and we kill the guy when we should have done nothing?”

“Think again, kiddo, you forgot the most important diagnostic equipment in our armamentarium,” the instructor says.

“You lost me.”

“Your ears,” the instructor says, “your ears. What you are told. Let me go over some of the dialogue again.”

Here, the videotape of the scenario is played, and the instructor stops at a few crucial spots.

1. The camera focuses on the central line.
2. “He’s with it enough to have visitors, and one just left.”
3. Slow deep movement of his chest.
4. “Good s***.”

“Put it together for me, doctor,” the instructor says.

“Oh man,” the resident hits his forehead. “His friend used the central line to give him a hit of something, maybe heroin. Definitely some kind of narcotic.

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FIGURE 8-18 Something is awry, something’s not right, but just what could it be? When an experienced ICU or PACU nurse “smells a rat,” you are well advised to investigate. Always believe bad news and prove that it is not bad news before you move on. Those hunches and “gut feelings” are more often right than wrong.

“Then it all makes sense, the slow breaths, the altered consciousness, the hypoventilation, the fact that everything wore off and he got back to normal.

“And of course he could slip it in when the nurse wasn’t looking, it wouldn’t take but a few seconds.”

“That is it.”

Summary. “There are none so blind as those who will not see.”

We all know the signs of narcotic overdose, particularly after doing anesthesia for any length of time. And once you open your eyes to that possibility, the signs all fall into place—breathing pattern, blood gases, sleepiness, eye signs.

But you have to think of it. You have to get the roadblocks out of your brain and just let the diagnosis happen.

This resident did a lot of good things—right up to the bedside, hover around paying close attention to the ABC, ordering the appropriate tests, suspecting the right things. But the resident was almost too close.

The resident needs to take a little step back, out from among the trees, to get a better grasp of the forest.

The patient just changed.
What just happened that could account for the change?
Think of all the typical things, yes, but pull back a bit, think of other things too.
Be aware of everything that affects the patients, even the visitors!

And then you can see.

SCENARIO 6. Bad beginnings, inducing with an infiltrated IV

A beginning cardiac fellow is in the operating room. An oxygen mask is on the patient, pre-oxygenating prior to induction. Anesthesia machine—OK; airway equipment—OK; drugs including resuscitative drugs—OK.

On the pre-operative report, salient points are—airway OK, ejection fraction 35%, very tight aortic stenosis with an aortic valve gradient of 0.5 cm squared. The patient takes Metoprolol. The patient is scheduled for an aortic valve replacement. An arterial line is in, and the patient came down from the floor with a 20 g IV in his left hand.

From the overhead speaker, “Dr. Kettle is in the hospital and says it’s OK to go ahead.” (Dr. Kettle is the cardiac surgeon listed on the preop chart.)

The arterial trace shows a narrow upstroke, and a blood pressure of 170/90. The heart rate is 80.

Using the medication recognition system, the cardiac fellow goes through a careful, titrated induction, watching the blood pressure all the time.

Midazolam (2 cc), with the goal of giving the patient some sedation and chipping away at his/her memory bank.
Fentanyl (2 cc), a small amount of narcotic, aiming to blunt the sympathetic response to intubation, yet not so much that the systemic vascular resistance falls. Maintaining systemic vascular resistance is key, as a drop in blood pressure in the face of tight aortic stenosis means death for the patient.
Etomidate (5 cc, that is, 10 mg), a sedative hypnotic that maintains hemodynamic stability.

“How are you doing sir?”

No response from the patient. His eyes are closed.

The blood pressure is still up there, 170/80. The heart rate is creeping up there, 100 now.

The fellow starts mask-ventilating the patient, then gives rocuronium for muscle relaxation. As the heart rate climbs, ST segment depression—hard to detect when laid against a backdrop of left ventricular hypertrophy—starts to occur.

“This heart rate has to come down,” the fellow says, to no one in particular. Picking up a syringe of esmolol, he gives the patient 50 mg. The heart rate comes down to 70, the STs look a little better, the blood pressure drops to 130/60.

During intubation, the blood pressure rises back to 170/85, the heart rate doesn’t budge, and the STs look the same as at baseline. Endotracheal tube placement is confirmed with bilateral chest expansion, bilateral and equal breath sounds, and the presence of end-tidal CO2.

“Phew,” escapes the fellow’s lips. The big bugaboo, induction, is over, and the patient with severe aortic stenosis is still alive and kicking.

Thank God for small favors.

Dr. Kettle comes through the door of the OR.

“What the hell is that?” Kettle asks, pointing to the endotracheal tube.

“Uh, the endotracheal tube,” the fellow says.

“I know that, I want to know what it’s doing in my patient!” Kettle says, a measure of displeasure evident in his voice.

“Well, well …” the fellow stutters.

“You induced this patient with tight aortic stenosis with a 20 g peripheral IV—is that what you did? What would you have done if the patient crashed—resuscitate him through that pencil lead of an IV?” Kettle has little trouble being heard.

The fellow looks troubled.

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FIGURE 8-19 IVs are not trivial. Face it, we induce with IVs. They are our superhighway for drug delivery, volume, and blood resuscitation. Don’t piddle around with a crummy IV. The very patient you induce with a bad IV is the same patient who will suddenly need a good IV when something goes wrong.

“You stick a central line in these patients. This is not some lap choly in an aerobics instructor! This patient is death waiting to happen. If you can’t get the line, which I suspect might be the case, then god damn it, you page me and I’ll put it in for you!” Kettle has a way with words.

“Uh …”

“Simulation over!” the instructor chirps.

Clinical lessons learned from scenario 6

Aortic stenosis is indeed a killer, and induction can be the “point of exit” for the patient. Too much induction agent, too much potent anesthetic agent and the systemic vascular resistance drops, the blood cannot make it out of its “pinhole” aortic valve fast enough, and the patient arrests.

Then you’re stuck trying to do CPR on a patient with aortic stenosis. As they say on The Sopranos, “Fuhgedaboudit!” The small ejection fraction of chest compressions (maybe 10%) can’t push anything out the stenotic aortic valve. You might as well forget it when an aortic stenosis patient codes. The only thing that might save him/her is a quick chest opening and jump on bypass.

And therein lies a tale.

The debriefing rolls out the tale for our delectation and instruction.

Debriefing. “Were you ready to roll on that induction?” the instructor asks.

“If you discount Dr. Kettle, which is nearly impossible to do,” the resident says, “then yes, I was ready to go.”

“What do you need—specifically, what do you need when inducing a patient with tight aortic stenosis?” the instructor asks.

“First, you need an understanding of what can wipe you out,” the resident says, “the pathology of the valvular lesion. Normally, you have a nice wide egress out of the ventricle, a valve that allows a lot of blood out. With stenosis, you have a teeny-weeny exit portal. So if you suddenly drop the systemic vascular resistance, you lose all your blood pressure.

“And that drop in pressure head is especially bad for the heart itself. A heart compensates for aortic stenosis by developing a thick, muscular ‘superman’ of a heart. It has to get thick just to push past that stenosis. But a thick heart requires a lot of perfusion pressure. Those coronaries have to feed a monster of a heart. So dropping the pressure sets up a vicious cycle—the heart isn’t getting blood out, and the heart isn’t getting enough supply, so things get worse and worse.

BOX 8-9 Inducing with Aortic Stenosis

• Maintain BP
• Prevent tachycardia
• Think “pinhole”

“So you have to be delicate, oh so delicate when you induce these patients.”

Kettle sits down, “Sound like you have the theory down pat, you want a little lesson in common sense, which does not seem to be very common with you.”

“Well,” the fellow starts.

“Well what?” Kettle is on a roll. “If this guy goes under, you will only save him if I crack his chest, and for that to happen I have to be standing in the room.”

“And when you give him that heparin and you’re pounding in the levophed to get his pressure up, you’d better have a central line because that 20 gauge thing won’t do you any good,” Kettle finishes with a flourish.

“OK,” the instructor says, “so Dr. Kettle didn’t go to the Dale Carnegie Charm School but can you concede that he may have a point?”

Nodding, the fellow agrees. “I got so caught up in the theory, I did forget the practical elements. A 20 gauge is insufficient to get me out of trouble. And god forbid it infiltrates, I’m stuck.

“And, truth to tell, for a tight aortic stenosis, I should have the surgeon in the room. This is just too spooky of a lesion to take on all by myself.”

Dr. Kettle nods, “That’s right, don’t forget, even a loud-mouthed, aggravating surgeon can be an ever present friend in time of need.”

Summary. The cardiac fellow gave a perfect recitation of all the tricky considerations that go into inducing a patient with aortic stenosis. And, during induction, the fellow delivered the goods, giving just the right meds in just the right order.

He achieved sufficient anesthetic depth, controlled heart rate and blood pressure, responded appropriately to threatening ST changes, and secured the airway.

BOX 8-10 If Aortic Stenosis Patient Codes?

• Call clergy
• Call relatives
• Call risk management

BOX 8-11 Surgeon a Pain?

• Not a unique circumstance
• Try to get along
• Enlist their help, believe it or not

Perfect, yet….

In our world of “what if’s”, the fellow didn’t have the ultimate backup ready to go. A monster line and a surgeon in the room. He was lucky, but next time he might not be.

Take a tip from the Boy Scout motto—“Be Prepared.”

SCENARIO 7. Needle phobia and placenta previa

“Doctor, could you step in here, we’re admitting a labor patient and you might want to see her,” the OB admitting nurse says.

The resident goes into the examining room, a pregnant patient is there (actress, not mannequin). An OB resident is standing beside.

“Hello doctor, this is Ms. Jenkins,” the OB leads in, “OK if I tell this anesthesia doctor a little about you?”

Ms. Jenkins says, “All the same to me, just make sure I get his name, in case anything goes wrong and I have to call my brother-in-law.”

“Ms. Jenkins’ brother-in-law is in, well, pardon the pun, in law. Ms. Jenkins has seen a lot of shows on Oprah about people being awake under anesthesia and people never waking up, and she wants to make sure she has your name written down and faxed to her brother-in-law in case she has to sue you later and she is, well … uh, dead, so she can’t exactly make the call, if you follow me.”

“I see,” the anesthesia resident says. She gives her name. “Any medical conditions I’ll be needing to know about to make sure we take the best possible care of Ms. Jenkins?”

“Uh, yes,” the OB continues, “Ms. Jenkins is a 24 year multip with progressive, painless vaginal bleeding. She is currently at 35 weeks’ gestation.”

“Have you …” the anesthesia resident starts.

“Ultrasound reveals a low-lying placenta partially covering the cervical os,” the OB resident says. “We will not be doing a manual exam, of course, until we have some other preparations in place.”

“Good.”

“I don’t want any needles!” Ms. Jenkins says, “You put me to sleep first, I hate needles! And they can’t ever get one in me either, stupid bastards. They dig around all day like they’re drilling for oil or something. You can sue for that, can’t you? Sticking you with needles all day? Just give me that mask and put me to sleep and then you can stick me with needles all day, and while you’re at it pull the baby out too. I don’t want to be awake for that either.”

The OB and the anesthesia resident step out into the hall for a moment.

“Don’t you be talking bad about me either!” Ms. Jenkins says, “You talk bad about me I’ll haul your ass in court, then we’ll see who’s laughin’!”

“So, clearly we have a situation,” the OB resident says. “And rather than blindside you, I thought I’d give you a little preview of coming attractions.”

“Thanks,” the anesthesia resident says, “is it shift change? Can I crawl out a window or something?”

“Hold onto your hat,” the OB says, “Ms. Jenkins may have an aversion to needles placed by others, but she apparently is no stranger to needles placed by herself.”

“Veins all shot up?”

“Yep.”

“Tox screen light up?”

“Like the Fourth of July.”

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FIGURE 8-20 A real dilemma, the super-needle-o-phobe. You’re painted in a corner, because they won’t let you put in an IV, but, come on, you need an IV. The simulator is the place to “act out” these dilemmas. Better to face this in a pretend situation before you have to face it for real.

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FIGURE 8-21 Danger, danger, Will Robinson! Here, an advanced robot signals danger ahead. You’d better talk over your plan before you proceed.

“What’s on board?”

“What’s not, that’s a shorter list.”

“And this previa spooks me,” the OB says, “I mean it’s hanging right there, low but low. No way we can go vaginal, no way José.”

“I’ll need some monster IV access” the anesthesia resident says.

“Yeah you will, this will be wet,” the OB says. “This could turn into the Red Sea, we might even need to do a hysterectomy. My crystal ball just says ‘Danger, danger, Will Robinson!’ this time. How you want to work this?”

“Well, I’ve got to go central, I’ll just plain need a central line, a cordis, something I can firehose blood in with,” the anesthesia resident says.

“She ain’t gonna like that,” the OB says. “We could talk to her until Mississippi votes for Howard Dean and she will still say no.”

“Get the pediatrician here,” the anesthesia resident says. “We’ve got to all ‘sing of self-same tenor’ on this.”

A quick call from the OB admitting nurse, and a peds resident shows up. Introductions all around and a quick update on the problems.

“Here’s the scoop, this will be ugly, but here it is,” the anesthesia resident says. “I’ve got a pregnant woman, full stomach, refusing lines, bad IV access due to IVDA, and I’ll be needing big time access in case she bleeds like no tomorrow. I’m going to have to sedate her enough to get a line in, and the road will go one of two ways here—either I can sedate her enough to get a real central line in, a big hogger, and then we’ll be ready to go. Or else I can sedate her enough—this will have to be IM, hate to say—to just get a teeny but ‘OK to induce general anesthesia but not to start cutting with’ IV.

“That’s where you both come in,” the anesthesia resident goes on. “If I can slam in a big line, make sure we have blood in the room, then we’ll induce and cut—the usual C-section way. You, in peds, will have a baby coming out that will have absorbed some of my IM meds, so you’ll need to support ventilation for a while.

“If I can only get a dinky line in, then I’ll induce with that, but don’t start cutting. Once she’s asleep, I’ll maintain her with general anesthesia—again, baby will come out sleepy so you may have to support for a while—then I’ll put in a big line. But don’t cut until I have that line.”

“Sound good?”

OB and peds nod.

“Simulation’s over!” the instructor says.

“But … but I haven’t done anything yet!” the anesthesia resident protests.

“Oh yes you have!”

Clinical lessons learned from scenario 7

The placenta usually implants in the body or fundus of the uterus; but when it implants near the cervical os, a condition called placenta previa occurs. Previous uterine surgery (most often C-sections) is the greatest risk factor for developing placenta previa.

From an anesthetic standpoint, the primary concern with placenta previa is volume replacement. Anesthetic management is debatable, some arguing against regional anesthesia, some for general, with the attendant concerns of general anesthesia in the obstetric population.

All this emerges during the debriefing.

BOX 8-12 IV Phobia Options

• Breathe down
• IM sedate
• CVP (easier than 1000 peripheral sticks)

Debriefing. “How do you think that went?” the instructor asks.

“Well,” the anesthesia resident is a little nonplussed, “I thought in the Simulator you actually did stuff!”

“True,” the instructor says.

“And I didn’t, really, do anything!”

“Did you think? Did you assess a difficult patient? Did you hook up with two different specialties and formulate a plan A and a plan B?” the instructor says. “Remember, this place is not a ‘partial-task trainer’ where we see if you can stick the tube in. They have intubating dummies for that. This is the place where you put it all together, and the main thing we want to see working is your brain!”

“Oh,” the anesthesia resident says, then looks around at the nodding OB and peds people. “Now that you put it that way.”

“What did you think when I called you in the preadmission room?” the OB resident asks. “We don’t usually do that, do we?”

“Well, I figured something bad was coming my way, but then, better to get a ‘head-up’ and try to work something out ahead of time,” the anesthesia resident says.

“No need to hold hands and have a harmonic convergence,” the instructor says, “but that’s part of the reason we put different specialties together in the Simulator. If we can each ‘peak under the hood’ of the other specialties, we can see their concerns, they can hear our concerns, and we can hear theirs, and everybody wins.”

“Ditto from the pediatric standpoint,” the peds resident says, “We are the last to hear about things a lot of times. It’s nice to be in on the planning stages so we’re not caught with our pants down.”

“Keep your pants up on the OB floor, please,” the OB resident says.

Everyone cracks up on that one.

“So lay it out for me,” the instructor says, “what went into the plan A and plan B you had?”

“OK first, forget the litigious bluster—one instructor told me, ‘Don’t worry if someone says they have a lawyer. Everyone has a lawyer, they just haven’t called the lawyer yet,’” the anesthesia resident says, yet again cracking up the whole debriefing room. Who said Simulation debriefings weren’t fun?

“Second, think of the physiology of pregnancy and all we have to keep in mind—full stomach, aspiration risk, quick desaturation due to increased oxygen consumption and decreased functional residual capacity, more difficulty intubating due to swollen and friable upper airway.”

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FIGURE 8-22 The simulator is there to squeeze your brain. What are you thinking? Why did you choose that option? Where were you going with that plan? This squeeze can be a little painful, but it’s ultimately to the good. Feel the pain and experience the gain.

“Third, think of the specific problems associated with this pregnancy versus just any old pregnancy—placenta previa, big time blood loss. And I have to be ready for that with lines and cross-matched blood.”

“Fourth, think of the specific problems associated with this patient versus just any old placenta previa—poor venous access and, really, an inability to cooperate.”

“How do you keep from jumping on the ‘judgmental train’ with a patient like this?” the instructor asks. “Don’t you just want to slap her around and say, ‘Snap out of it, you need this line so deal with it and shut up!’”

“Of course you do,” the anesthesia resident says, “but that’s where you show your professionalism.”

“Aha! Get the ACGME on the phone! We’re teaching a core clinical competency!” the peds resident chimes in.

“That we are,” the instructor gives a smug grin, then scribbles a note to make sure she documents this “ACGME coup.”

Going on, the anesthesia resident says, “The fact is, this is the way this woman is. From the IV drug use, from her upbringing, who knows. It’s not for me to unravel and it’s not for me to undo, but it is for me to deal with. So from a ‘I need you to cooperate’ there is only so much I can do. Yes, I will talk to her; yes, I will tell her how much better it would be if she would hold still; and yes, you can do a previa with an epidural anesthetic (controversial because in the face of massive hemorrhage you would miss her sympathetic tone). But if she just plain does not cooperate, then she just plain does not cooperate. She is no more capable of cooperating than a patient with congenital or acquired ‘cerebral insufficiency.’

“You don’t demand that a severely impaired trisomy 21 patient cooperate—you plan your anesthetic around the lack of cooperation. You don’t demand that a closed head injury patient or a multi-infarct dementia patient cooperate—you plan your anesthetic around the lack of cooperation.

“Same applies here,” the anesthesia resident says.

“Right you are.”

Summary. This anesthesia resident walked into a real minefield.

Pregnant patient, with all the physiologic changes of pregnancy to consider
Placenta previa, with the potential for big blood loss
Behavioral issues, drug use, drugs on board, no veins, no desire to cooperate, “looking for” a reason to sue.

But this resident entered this minefield in good company—an OB resident who planned ahead and a peds resident who wanted to be in on the advanced planning as well. With a (cheesy as this sounds) solid interdisciplinary approach, they came up for a good plan for taking care of a very tough patient.

And planning ahead is half the battle.

Whew, glad this difficult scenario is over. All three residents can now rest easy.

SCENARIO 8. No IV access in a difficult, bleeding patient

Ooops, spoke too soon.

This scenario occurs in the OR setting, the voice of the same patient coming through the mannequin’s speakers. OB is set up to do a C-section, the circulator has blood in the room, and peds is set up with bassinette and resuscitation equipment (suction, oxygen, airway equipment, drugs). The OB nurse is watching the fetal heart rate monitor.

Still no IV; to this point, the patient has gotten 10 mg of morphine IM and 5 mg of midazolam IM, so her voice comes across slurred but still protesting.

“You ain’t sticking my neck! You ain’t got my permission, no way can you do that!” the patient shouts.

Down below, the OB notices the bleeding has increased; on the monitor, the heart rate is up to 130 and the blood pressure is only 90.

“Um,” the OB resident says, “things might be getting worse here. I don’t think time is on our side.”

“I’m getting lates,” the OB nurse says. “For sure, these are lates.” The fetal heart rate monitor shows an ominous sign, late decelerations.

“OK,” the anesthesia resident says, “put out a call for help and that includes a call to general surgery in case I need a cut down for access.” Turning now to the patient, “Ma’am, fact is, to save you and the baby, that’s just what I have to do, there are no places left on your arm where I can put an IV. I’ll give you some numbing medicine and try not to make it too bad.”

The instructor’s voice comes over the intercom, “OK, the central line is in, but you had a hard time doing it and had to stick several times.”

Now the blood pressure is 80/50, the heart rate is 140, and the OB nurse is seeing sustained decelerations.

“We’re bleeding bad down here,” the OB resident says, “real bad.”

“You,” the anesthesia resident shouts to the OB nurse, “get extra hands in here, I’ll need someone helping me to check and hang blood. Right now, give me some cricoid pressure.”

The anesthesia resident picks up a syringe labeled propofol, just about hooks it in the line, then reconsiders. She picks up a syringe labeled ketamine and another labeled succinylcholine, and gives them one after the other.

“Quiet in here,” the anesthesia resident says.

After 30 seconds, the resident puts the laryngoscope in the mouth, lifts, and sees nothing.

“Shit!”

“What’s up?” the OB resident asks.

“No view,” the anesthesia resident says, taut as a piano wire.

She picks up another blade, repositions the head.

“Sustained bradycardia!” the OB nurse shouts. “Forty, I’m not kidding, 40!”

“Listen, I gotta get this kid out, I gotta get this kid out,” the OB says; he, too, strung up tight.

BOX 8-13 Placenta Previa

• Painless vaginal bleeding
• Big blood loss
• Need big IVs

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FIGURE 8-23 OK, you’re not always going to hit it off perfectly with the patients. You made your case, and they just don’t buy it. That’s happened before. Try to have a good plan B ready for just such an occasion.

“Nothing,” the anesthesia resident says. Behind her, the saturation drops into the 80s, the 70s. The nurse holding the cricoid pressure keeps looking back at the fetal heart rate monitor, and her hand pulls up from the throat.

“Keep that cricoid pressure on, god damn it!” the anesthesia resident says. “I know we have bradycardia, you don’t need to remind me, OK? You just keep that hand right where it is!”

The anesthesia resident mask-ventilates for a few seconds, then reaches back and places an LMA. The chest rises, and the sat rises to 90%. She turns on sevoflurane and says, “Cut! This isn’t perfect, but we’ll have to live with it. Keep that pressure on.”

Another resident walks in the room.

“O’Reilly from surgery, what can I do for you?” he says.

“The O’Reilly factor, great, just what we need!” the anesthesia resident says. “Congratulations, you’re now working for anesthesia. I’m shepherding this airway, I need you to hang blood. Just pretend like you’re in the trauma bay. OK?”

“Right,” O’Reilly says.

In the surgical field, the OB pulls out a baby, hands it to peds.

“Thick meconium,” the OB says.

“Got it!” the peds resident takes the baby away in a towel. In the bassinette, he suctions the mouth, intubates, suctions the endotracheal tube, removes it, then mask-ventilates. The baby, originally blue (via LCD displays in its face), pinks up.

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FIGURE 8-24 The amusement park that considers the parents is the amusement park with everything.

Up at the head of the bed, the anesthesia resident continues to ventilate via LMA with cricoid pressure in place.

“God all fishhooks,” she says, “we’re going to need the entire crew of Ben Hur before this case is over. I need someone to get me a fiberoptic. I want to secure this airway with an endotracheal tube. Is there anyone left in the city who isn’t already doing something for me?”

The door opens, “That’s all folks!”, the instructor says.

Clinical lessons learned from scenario 8

A good amusement park offers “something for everyone”—loop-the-loop roller coasters for the teenagers, merry-go-rounds for the kiddies, and Prozac for the parents. This case, too, offered “something for everyone” as the debriefing reveals.

Debriefing. “Where to start?” the instructor asks. “Maybe we are edging into the realm of ‘crisis resource management’ here?”

“I’d call it a crisis,” the OB said. Nods of agreement from anesthesia, peds, and the “walk-in” surgeon.

“You can elucidate all the factors of CRM, as they call it,” the anesthesia resident says, “in the cool and calm atmosphere of a lecture hall. But when the world is caving in around you and you see the patient dying right in front of you, you tend to get a little frazzled and start to forget stuff.”

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FIGURE 8-25 So many things to remember, so many problems, AAG! When everything starts falling apart, always go back to ABC and build up from there. Don’t let the “million things going on” distract you from the most important stuff—air goes in and out, blood goes around in circles.

“Well, here we are in the cool and calm atmosphere of the debriefing room,” the instructor says, “let’s go through those crisis resource management things right now.”

The peds resident starts out, “Global assessment, stepping back and seeing the big picture. Management of resources, having the right people do the right things.”

OB adds, “Communication, making sure you ‘close the loop’ when you talk to people.”

“Calling for help when you are sure you’re about to crash!” the anesthesia resident says, unleashing a pent up “need to laugh” in the room.

“That’s not an official CRM thing,” the instructor says, “but maybe it should be.”

The entire team now reviews the DVD of the scenario. It’s a humbling thing, watching yourself in a crisis. Stuff you never thought you missed, you missed. Plus, who are we kidding, the camera does put 10 pounds on you.

Peds speaks up first, “I like how right away our anesthesia heroine is calling for help. You really sense she is ‘marshalling the troops.’”

“That’s right,” the instructor says. “It’s no crime to say the things we do right in a Simulation scenario. There is a tendency to flog ourselves and just dwell on the stuff we do wrong. It is well and good to see the wrong stuff and correct it, but it’s just as important to see the good stuff and make sure you keep doing that good stuff.”

“What do you think was causing the hypotension?” the instructor asks.

“Bleeding,” the OB says.

“Bleeding,” the anesthesia resident says.

“Bleeding,” the OB nurse says, and the peds resident and the O’Reilly factor agree.

“Could it have been a pneumothorax?” the instructor asks.

“Ooooooooh,” the OB says.

“Oooooooooooh,” peds and O’Reilly say.

“Oooooooooooooooooooooh,” the anesthesia resident says. “That’s right, I had a hard time with the central line, so I very well could have dropped a lung. But then, there was all that bleeding.”

“Does bleeding preclude also having a pneumothorax?” the instructor asks. “It would be a wonderful world if just one problem happened at a time, but then, we are not given that luxury, are we?”

“No,” the anesthesia resident says, “we’re not. Wait, wait a minute, I would have felt higher inspiratory pressures. I would have had more trouble ventilating, wouldn’t I? Now come to think of it, I don’t think she didn’t have a pneumothorax.”

“Touché”, the instructor says, “she didn’t. But still….”

“Point well taken,” the anesthesia resident admits, “point well taken, I should have had that on my list. But I gotta tell you, with that difficult airway, my ‘dance ticket’ was already pretty filled up!”

“True,” the instructor says, “so take us through your thinking.”

“Well, ABC, and this is the classic OB dilemma,” the anesthesia resident says, “this is the very thing we study and train for and must always be ready to handle—fetal distress, can’t intubate.”

“But you were able to ventilate,” the OB resident says.

“Yes, I was,” the anesthesia resident says. “And the difficult airway algorithm recognizes the LMA as an imperfect—patients can still aspirate—but viable alternative in this case. So I swallowed hard and did the case with the LMA.”

“Let’s go over the peds resuscitation,” the instructor says. “Meconium means what?”

“Babies in trouble defecate, pass meconium intrauterine,” the peds resident says. “And this kid was in a lot of trouble; that sustained bradycardia meant inadequate ‘something’—oxygen delivery, perfusion of the placenta—something. So the kid defecates. If that meconium gets in the baby’s lungs, we have, in effect, aspiration of a very serious nature. The kid can go into respiratory distress syndrome, can die right then and there if you can’t ventilate him, or can go on to bronchopulmonary dysplasia, that is, chronic lung problems. A kind of COPD for the younger crowd.”

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FIGURE 8-26 Record the scenario, then look at it afterward in the debriefing room. Even if the residents do everything right (rare, but it happens), you can still look at the DVD and learn something. Studying one’s “performance” on a recording works in baseball, tennis, golf, and, guess what, the anesthesia simulator.

“Damn,” O’Reilly says, “you’re good, you could do this for a living.”

“I do.”

“Oh, right.”

BOX 8-14 Meconium

• Suction
• Intubate
• Suction through ETT

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FIGURE 8-27 Meconium might be a little icky, but that shouldn’t scare you off. Get that kid intubated and suck that stuff out. If the meconium “takes root” in the lungs, that baby is in for short-term and long-term respiratory trouble. What you do in the crucial first minute or two may make all the difference in that kid’s life.

“So anyway, the thing to do is fight the urge to mask-ventilate the kid right away,” the peds resident says. “It is so tempting to just ‘mask him up a little’; and I’ll tell you, I’ve seen some anesthesia people succumb to that temptation.”

Blushing, the anesthesia resident conceded the point without saying a word.

“So you intubate, you get a suction mechanism right into those lungs, and you suction out that meconium first. You give those lungs a good bit of housecleaning. Then you proceed with resuscitation.”

“It’s a battle of nerves, isn’t it?” the instructor asks.

“That it is,” the peds resident says.

“How did it feel when you wanted to get the baby out, but the airway wasn’t yet secure?” the instructor asks the OB resident.

“Well, speaking of a war of nerves,” the OB says, “you want to swing that blade down and get baby out now but now. With a fetal heart rate of 40, you know you’re just moments away from a severely impaired child for life versus a normal kid who grows up, joins a rock band, and drives you crazy in a different way.”

“But you have to wait,” the instructor says.

“You have to hear the word from anesthesia. And the airway comes first, there’s just no way around it. That’s when knowing your anesthesia person and knowing what he or she can do really makes all the difference in the world.”

Turning to O’Reilly, the instructor says, “So how is it ‘taking orders’ from anesthesia? Don’t you guys usually fight with them?”

“Doctor first, specialist second,” O’Reilly says. “If I happen upon a car wreck, then I might have to be a kind of ‘anesthesia airway’ person. That’s no time to say, ‘I don’t do airways.’ And in this case, anesthesia needed me to hang blood because there was no one else around, and she was busy with the airway. So you do what it says in the Hippocratic Oath.”

Eyebrows up all around the debriefing table. O’Reilly had been so quiet before, and now this! Still waters do run deep.

“Can’t end on a better note than that,” the instructor concludes.

Summary. Bleeding, fetal instability, lost airway, meconium, all laid against a backdrop of a litigious patient. It just doesn’t get better than this.

The anesthesia resident could have paused to get all “legal eagle” about consent for a central line, but at a certain point you have to be a doctor and not a lawyer. She did the best she could, first explaining, then sedating, and then getting the line. Absent the line, the patient would bleed to death, and that the anesthesia resident was not willing to do, no matter how the brother-in-law would react.

BOX 8-15 Calling for Help

• Do it early, before it’s too late
• Extra “brain” more clear-headed
• Better swallow pride than hurt patient

Anesthesia induction in the now bleeding, now unstable patient is always a concern; and at the last minute, the resident opted for ketamine over propofol, hoping to avoid further hypotension. Then the toughest exercise in anesthesia—dealing with a lost airway in an obstetric patient, with the baby having sustained bradycardia at the same time. A perfectly secured airway is the ideal, but the anesthesia resident had to settle for second best, a route that worked here.

Purists could argue—wake the patient up, let the baby do whatever it does, and do the intubation awake. In this uncooperative patient? With bleeding and instability? And just ignore the shouts from the obstetrician? That’s a call most anesthesiologists just won’t make. But controversy is controversy because you can argue the point either way.

One genuine mistake did slip past everyone in the debriefing. After induction, the anesthesia resident went right to turning on the sevoflurane. This, in the face of hypotension and bleeding? She should have at least checked the blood pressure first. She already had 10 of morphine and 5 of midazolam (intramuscular) on board, so that might have blunted any memories.

And how about a BIS? Recall in the obstetric or the unstable patient is a real problem. Though no cure-all, a BIS helps. (Of note, Simulators don’t yet have a way to incorporate this important new technology.)

Peds handled and explained the management of meconium to a T. Keep cool, suction out that trachea, then go to the ABC. Takes nerves of steel, but that’s what neonatal medicine is all about.

OB has to bide its time ‘til the airway’s secured, so they too have to “check their nervousness at the door” and stay cool under fire.

And what a swan song for this scenario. A surgeon says, “Whatever it takes to save the patient, I’ll do it.”

Good medicine.

SCENARIO 9. Mediastinal mass

The patient is lying flat on the OR table, and the anesthesia resident is reading the preop.

A 43-year-old man with a large anterior mediastinal mass, previously healthy. Flow volume loops show signs of obstruction. CT scan (on the viewbox) shows tracheal deviation and narrowing. Surgeons plan to resect this mass.

A progress note from the chart shows that in the holding area another anesthesia resident placed a right radial arterial line and, anticipating possible big blood loss, a 9 Fr cordis in the right IJ. An arterial trace and CVP trace are on the monitors as well as the saturation—99% and the heart rate—90. The patient has the oxygen mask on, held in place by a black face strap. The surgeon is in the room, and everyone is ready to go.

After the resident finishes reading, the patient speaks up, “Hey, can you give me some pillows or something, I’m having a really hard time catching my breath!”

“Oh sure,” the anesthesia resident says, putting the bed in reverse Trendelenburg. “That help?”

“A little,” the patient has a gasping sound in his voice.

The surgeon taps his watch, “Tempus fugit” (Time flies—Latin).

“Right, right,” the anesthesia resident says, “well, looks like we’re ready.”

“Unless you have something else you’d rather be doing?” the surgeon snipes.

Reaching behind him, the anesthesia resident turns on the sevoflurane.

The surgeon’s eyes go up, “What the hell, you haven’t given him any ‘Milk of Anesthesia’! Don’t you give that white stuff to make them go to sleep? Did you forget?”

“No. Now doctor, I’m going to ask you this politely. I’d like you to place a 9 Fr introducer in the femoral vein for me,” the anesthesia resident says.

“What? You already have a big line!” the surgeon protests.

“Humor me,” the anesthesia resident says, focusing on the airway as the surgeon huffily heads to the groin to place the line.

1%, then 2%, then up to 4%, the anesthesia resident creeps the sevo up, always keeping the patient breathing spontaneously.

BOX 8-16 Mediastinal Mass

• Can squash stuff
• Consider femoral lines
• Don’t burn bridges

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FIGURE 8-28 The surgeon is an oft-overlooked resource when you’re stuck for lines. Granted, you might have to grovel a little, but better to swallow your pride and get the line. Don’t let your pride interfere with the patient’s needs.

“We got the gurney nearby, right?” the anesthesia resident asks the OR nurse.

“Sure, why?” the OR nurse asks. This isn’t a prone case.

“If this mass suddenly compresses the airways, and there is no way I can move any air, we may have to flip the patient prone to take the pressure off the airways and breathe for him.

“And do you have a rigid bronch in the room?” the anesthesia resident asks.

At this point, the surgeon has had it with the needy, high-maintenance anesthesia resident, “We’re not doing a rigid bronch, doctor.” The “doctor” carries the tone “stupid doctor.”

As he intubates, the anesthesia resident explains, “If this mass sinks down, a rigid bronch might be necessary to stent the airway open. I’m trying to avoid that by keeping him breathing spontaneously, keeping his muscles ‘pulling up’ when he inspires.”

Endotracheal intubation is successful, but inspiratory pressures are high and the saturation is only 95% on 100% oxygen. Placing his stethoscope on the right chest, the anesthesia resident says, “You do know how to put in a chest tube, don’t you, doctor?”

No response.

The room is charged with two doctors calling each other doctor.

“Don’t think I need it, just wanted to make sure my partner hadn’t dropped the lung with his right IJ stick. I think he’s just tight and I need to breathe him down more. How’s that femoral line?”

“Femoral line’s in,” the instructor says.

The drapes go up and the surgery starts, “He’s bucking, better paralyze him,” the surgeon says.

“You ready to go on fem-fem bypass if I need it?” the anesthesia resident asks.

“That’s it!” the surgeon snaps off his gloves. “What else do you want? Valet parking? Foot massage? What?”

“Simulation over,” the instructor says over the loudspeaker.

Clinical lessons learned from scenario 9

Interdisciplinary scenarios can have genuine participants, like scenario 8, where peds, OB, and anesthesia were all participating and didn’t know what was happening next. At other times, you can have an interdisciplinary “plant,” a confederate who is there to challenge, bait, aggravate, and bring out the learning points in a more … colorful (?) manner.

The surgeon functioned that way in this case, much as Dr. Kettle did in the aortic valve scenario.

Anterior mediastinal mass—a nightmare waiting to happen for anesthesiologists. Most catastrophes involve “collapse” of the anterior mediastinal mass after induction of anesthesia and muscle paralysis. With nothing “pulling up,” the mass “falls down,” squashing the airways and great vessels, leading to cardiac and respiratory failure. Even our vaunted endotracheal tube may be of no use, as the “squashing” occurs distal to the tip of the tube, and you can’t move air.

Such disasters are more common in children. Children are more cartilaginous than us ossified, calcified old folk. So the cartilaginous kiddies are more prone to the anterior mediastinal “squishage” than adults are.

But still, even if you have a 43-year-old patient, like here, you still have your antenna up for anterior mediastinal trouble, as the debriefing shows.

Debriefing. “What were your red flags in this case?” the instructor asks.

“There was clinical and lab evidence of big time obstruction with this mass,” the anesthesia resident explains. “He was short of breath lying flat, that’s not good, and the flow volume loops showed obstruction; so, again, you are seeing signs that this mass is a real problem.

BOX 8-17 Planted Allies in a Simulator

• Aggravate
• Sabotage
• Great fun

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FIGURE 8-29 A mediastinal mass can kill a patient. Remember this little trick—if the mass is squishing down, move the weight. Put the patient on the side or even prone. Then the mass (well, the soccer ball in this case) is off the mediastinal contents.

“Add to that a CT that shows narrowing and distortion of the airway. I would look for physical signs of superior vena cava syndrome in such a patient. A mass like this, obstructing airways, can just as easily obstruct vessels.”

“Any other options before you induce—any medical options?” the instructor asks.

“I’m not picking up your thread here,” the anesthesia resident says.

“Radiation.”

Smacking his forehead with the flat of his right palm, the anesthesia resident says, “Oh yeah, I forgot that one.”

The surgeon laughs, “Finally, one thing you did forget. Thank God for small favors. If someone is so symptomatic that any procedure would possibly kill him or her, this is one time the radiation oncology people would ‘treat before they see the meat,’ as they say.”

“Treat before they see the meat?” the OR nurse asks.

“Radiation oncology is hesitant to irradiate anything for which they don’t have a pathology tissue diagnosis—the somewhat irreverently labeled ‘meat’ in their motto, ‘No meat, no treat.’ But in a case of severe symptoms like this, they might actually irradiate first to get the tumor shrunk down enough so surgery can be done safely.”

“But you seemed to get all the other stuff down pretty good,” the surgeon says, “even though I tried to yank you every which way.”

Bowing, the anesthesia resident says, “Much appreciated. Nietzche said, ‘What doesn’t kill us, makes us stronger.’ So you were doing me a favor.”

“Why didn’t you induce like they usually do?” the OR nurse asks.

“It all goes back to the mediastinal mass,” the anesthesia resident explains. “If I do the usual slam-bang induction, I may take away the very compensatory mechanisms the patient has in place. Think of each inspiration—the anterior thoracic wall pulls up on the mass, pulling it away from the vessels and air passages. Just like a pulley with wires lifting up.

“If I take that away with apnea and paralysis, that mass falls down. My positive-pressure ventilation from the ventilator is just not the same force, it’s not the same ‘configuration,’ so I might lose it all.”

“And the other things?” the instructor asks.

“If you get in trouble, you want to ‘unload’ the mediastinum, get the weight off, just like you’d get a fallen tree limb off someone getting crushed underneath it. You can turn the patient on the side, or even move them prone, to get the weight off. That’s why I wanted the gurney nearby.”

“And the rigid bronch?” the instructor continues. “The femoral line?”

“That’s all anatomy, you need the bronch to get in there and ‘hold up the roof’ of the bronchus if it collapses,” the anesthesia resident explains. “And the femoral line is a question of ‘doorways into the heart.’

“Blood returns to the heart through the superior vena cava from above and the inferior vena cava from below. Dissection up around the mediastinum can end up poking a hole in the innominate vein, the superior vena cava itself—some big vessel that ends up feeding into the heart from above. Even if you have a central line ‘from above,’ it might not do you any good in this kind of emergency. You may end up pouring blood into the surgical field! So you need big access from below, even if the surgeon puts up a fuss.”

“Me?” the surgeon says, all innocence.

Summary. It is a danger in anesthesia that we sometimes “tee-up” a case for our partners in hopes of “getting going” a little faster. That is well and good, but when you walk into such a “teed-up” case, you have to remember to “tee-up” your thinking cap before you proceed.

You have a surgeon tapping his watch and lines that at first blush seem sufficient for any monstrosity that might occur, so let’s get a move on!

It always pays to take just that one crucial minute to do nothing but think! Consider the special aspects of this case and make sure you make the right plan. Here, the resident did just that.

Consider the pathophysiology of anterior mediastinal “squishage.”
Keep the patient’s compensatory mechanisms intact by breathing spontaneously.
Have backup plans in place—gurney to flip the patient, rigid bronch, fem-fem bypass as the ultimate maneuver.
Get the lines you need, no matter the cries of woe and anguish from your surgical confrere.
Let tempus fugit just a little while you prepare for, and avoid, the worst.

SCENARIO 10. No smooth sailing, triage after a disaster

“A what?” the anesthesia resident asks.

“A cruise ship, you know, one of those Carnival things,” the ER nurse explains. “The steam boiler blew up or something, anyway, we’ve got 15 admissions, all burned, all with C-collars on. None are intubated, but they all have burns around their face. We are totally maxed out and there are two in this room.”

Entering the treatment room, the anesthesia resident sees two victims, both with black soot around their faces, both with C-collars on. The far patient is gasping for air, the near patient is silent. Both have pulse oximeters and EKGs attached. Both have oxygen on.

The gasping patient has a saturation of 85% and a heart rate of 140.

The silent patient has a saturation of 0 and a heart rate of 0. Flat line, asystole.

“Are we it?” the resident says, “we’re going to….”

“This is it,” the ER nurse says, “everyone else is taking care of the other ones. We’ve instituted a disaster drill, but no one else has come in yet.” The ER nurse looks at the guy in asystole. “You want me to start CPR here?”

Feeling for a pulse, looking for chest rise, and lifting the eyelid of the asystolic victim, the resident says, “No, help me over here with this guy who’s gasping. Leave this one.”

The gasping is getting more high-pitched, the saturation is down to 80%.

BOX 8-18 Triage

• Save the save-able
• Put off minor injuries
• Let the dead go
• Pray you never have to

“Anyone here who can cut a neck if I can’t intubate this guy?” the anesthesia resident says, “He may be all burnt up in the airway, swollen up.”

“All the surgeons are in the other trauma bays, you’re it.”

“His C-spine cleared?” the resident asks, as he places an oxygen mask and Ambu-bag on the patient, starting to assist his ventilations.

“No,” the nurse says, “no one to take them, no one to read them.”

At the patient’s bedside is a Cook cricothyrotomy kit, as well as regular intubation equipment. There is also a long skinny looking thing with an eyepiece on the top.

“What’s that?” the anesthesia resident asks, pointing at the long skinny thing.

“Oh,” the ER nurse says, “that’s the Shikani optical system. You load the endotracheal tube on it, then you slip it in the mouth and look through the eyepiece. There’s a little fiberoptic device in it. It’s supposed to be great for someone like this, you don’t want to move their neck because the C-spine is uncertain. It lets you take a look without extending the neck.”

“Does it work?”

“How the hell should I know? They never let us intubate,” the ER nurse says.

Suddenly, the high-pitched gasping stops with one final squeak and the saturation starts to plummet.

Placing a regular laryngoscope in the mouth, the anesthesia resident encounters a massively swollen tongue and can’t see anything.

“Gimme the cric kit,” the anesthesia resident says.

“You don’t want to try the Shikani?” the ER nurse asks.

“No, the cric kit.”

The anesthesia resident undoes the collar, opening up the front of the neck. Using a syringe with a 16-gauge angiocath, he enters the cricothyroid membrane, aspirates air, and withdraws the needle. Then he introduces a wire, floppy end first, into the trachea. Once the wire is advanced, he cuts a hole next to the wire, just like placing a Swan introducer, and introduces the Cook cric device. Once placed, the resident pulls out the dilator, hooks up his Ambu-bag, and inflates oxygen. The saturation turns around and climbs back up to the high 80s.

“We better sedate this guy and sandbag his head, we don’t have the collar on anymore,” the resident says. “You happen to have an insufflator here, I’d like to insufflate air through this little opening.”

BOX 8-19 Surgical Airway

• Be decisive
• Trachea as “big vein with air”
• Go for it

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FIGURE 8-30 The surgical airway, demonstrated in a partial-task trainer. Sticking the trachea is just like sticking a “big vein that has air in it instead of blood.” Then it’s in with the wire, make a nick, and you’re there. Of course you pray you never have to do this. But if you do, you’ll need to do it quick and right. So practice it in the simulator first!

“What’s an insufflator?” the ER nurse asks, looking around.

“Forget it, if you don’t know, you don’t have it, this will have to do,” the anesthesia resident says. “Once the dust settles out there, we’ll have to have ENT take a look at this amateur airway we’ve got here.”

“Simulation’s done folks!” the instructor says.

Clinical lessons learned from scenario 10

Disaster hangs heavy in the air these days, what with terrorists lurking in every Middlesex village and town. But even without terrorists, we keep finding ways to create our own disasters, which can and do overwhelm the medical system. Refineries explode, planes crash, buildings burn, trains derail—and in the blink of an eye, doctors are practicing the age-old art of deciding who to treat and who to “let go.”

When there’s only so much of you, you can only do so much. The debriefing explores this, as well as some airway questions.

Debriefing. “Can you spell T-R-I-A-G-E?” the instructor asks.

“I can sure spell it better than I can spell ‘Shikani,’” the anesthesia resident quips.

The assembled team—anesthesia resident, ER nurse, and instructor—go over the DVD of the simulation scenario.

“What were you thinking when you first got this news in the hallway?” the instructor asks.

“I wanted to get my hands around just how many people were injured and how many people would be available if I got in a jam,” the anesthesia resident explains. “I hear ‘explosion, burns around the face, and C-collars,’ and I’m picturing a lot of airway trouble. The Maryland Shock Trauma guidelines for the ‘need to intubate but don’t have a cleared C-spine patient going down the tubes’ are pretty clear.

“You won’t have time to do an elegant awake intubation, and the patient thrashing around may worsen the cervical injury. So you induce, you give a paralytic, you look, then if you don’t see anything, you cut the neck—that’s it. Crystal clear. It takes a lot of the murk out of this difficult but common airway dilemma.”

“But before you even got there, you had to make another decision,” the instructor says.

They review the DVD of his quick exam on the asystolic patient.

“When the ER nurse made it clear that there was no one else around, I had to marshall the most good out of what we had available, namely, the ER nurse and me,” the anesthesia resident explained. “So we have one guy with burns to his face, a rapidly closing airway, and vital signs. This guy needs a lot of expert help right now.

“And we have another guy who is asystolic. Of course I don’t automatically believe the monitors, I make sure a lead isn’t off or something. But with no pulse, blown pupils, no breathing, no lead misplacement, I figure, this is the real deal. This is asystole. This isn’t even V-fib that maybe we can shock him out of.

“So hey, what do I do, expend a lot of energy on a rhythm that rarely comes back anyway? Asystole is the baddest of the bad. I mean, come on, King Tut, technically, is in asystole. You going to spend a lot of time resuscitating him?”

“No way I’m doing mouth to mouth on a mummy!” the ER nurse says.

“Right you are,” the anesthesia resident says. “So, I triaged him to the ‘nothing more to be done’ group and went to the fast-closing airway.”

“No regrets on that decision?” the instructor asks.

“Hard times require hard decisions,” the anesthesia resident says, “so, no. No regrets.”

“OK, let’s go to the airway,” the instructor says, “what are you thinking there?”

“Soot around the face, a report that steam was involved—it all points to an airway burn that could extend all the way down into the lungs,” the anesthesia resident says. “You have to intubate right away, before swelling makes intubation impossible. And this guy was already giving a high-pitched squeak, so my mind’s eye was seeing his airway close off from above.”

“Why not use the Shikani system,” the ER nurse says, “it’s made for just this kind of thing.”

“New gizmos for securing the airway are all well and good,” the anesthesia resident explains, “but you always want to use new stuff in a nonemergent setting. Visit the Shikani website, review some teaching tapes, use the Shikani on a nice easy airway that you can always do ‘the regular way’ if you goof up with the Shikani thing.

“Do it the first time here? In a 4+ emergency and airway closure happening right in front of me? No way. This is the very time that you want to use all the familiar things. We’re in enough trouble as it is, we don’t need to import any more trouble.”

“I liked your recitation of the Maryland Shock Trauma airway protocol,” the instructor says, “but I notice you didn’t give any drugs.”

“That protocol is for someone with enough time,” the anesthesia resident says, “but this guy had just closed off everything but everything. My quick look said, ‘No way anything is going through the mouth here, this airway is just too far gone’.”

On the DVD, the resident does a slick job getting in the cricothyrotomy.

“Why not a regular trach?” the ER nurse asks.

“Takes too long,” the anesthesia resident says. “A regular trach in the regular place is much lower than where I went. I went high, at the cricothyroid membrane, where the airway is closest to the surface. If you view the trachea as just a big IV that happens to have air in it rather than blood, placing the cric is just the same as placing a central line.

“Only this central line actually is central!”

“But you didn’t do insufflation through it,” the instructor says.

“Yes,” the anesthesia resident says, “this opening is so small that you can’t really ventilate very well through it, and insufflation would be preferable to my kind of half-assed bag ventilation through it. But hey, something is better than nothing. If they don’t have insufflation equipment in the ER, then they don’t have it. But this at least delivers some oxygen to the patient.”

“What would your next moves be?” the instructor asks.

“Well, this guy would probably start to move and thrash around so we’d need to protect his C-spine. We’d need to secure his head better. Then, once A and B are taken care of, we’d have to focus on C, his cardiac status. I’ll admit in all the excitement, I never did get a blood pressure.”

“But I’m sure you would have,” the instructor prompts.

“But of course, I’m the best of the best. If you don’t believe me, just ask me again and I’ll tell you again!”

Summary. In a mass casualty situation, you may have to “write off” some people to save others. No easy task, and something that might haunt you later on, but it is part of our job.

Not that you can’t bring people back from asystole, but it’s a rare save when you do it. If you must divert resources away from anyone, that is the person to “write off.”

Burn, upper airway, steam—secure that airway ASAP, even if the patient doesn’t seem that bad at the time. Once they start swelling up and losing their airway, you will be in a heap of trouble in no time flat.

Learn about new equipment when all the world is calm and sunny, not in the middle of a raging hurricane. Of note, the Shikani is an excellent system and well worth learning. The device allows you to sneak into the back of the throat and “look up from behind the tongue” so you get a pretty straight shot at the vocal cords. You don’t need a big mouth opening to get this view, and you don’t need to extend the neck. Perfect stuff for the trauma bay, where everyone has an uncleared C-spine.

Anesthesia residents tend to live in morbid fear of that awful time when they have to “take up the knife” to secure the airway. Current airway kits take the terror out of this procedure so long as you make that one little intellectual leap.

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FIGURE 8-31 The Shikani optical scope, a great gizmo for securing the airway. But, as with everything else, you don’t want to use a “new toy” for the first time in an emergency. Either practice it in a simulated setting, or do it on a patient with an easy airway in a nonemergent setting. That way, if you blow it you can always shift into intubate-them-the-regular-way mode.

I’m just putting a central line in the trachea.

Voila! Suddenly it’s not so frightening.

Find air.
Thread a wire.
Cut.
Place the line in the trachea.

There now, that wasn’t so bad, was it?

SCENARIO 11. The miracle of birth, stat C-section

The OB nurse grabs the anesthesia resident by the sleeve, “Time for the MOB.”

“MOB?” the resident asks.

“Miracle of birth,” the nurse explains.

Entering the labor suite, the anesthesia resident notices that the fetal heart rate monitor shows a whopping 60 heart rate. Just as the resident’s mouth drops open, footsteps come pounding up from behind him.

“STAT C-section!” the OB shouts, then turns around and runs out.

“Anything we can do to buy some time doctor?” the OB nurse asks.

“Uh,” the anesthesia resident stumbles, then the fog clears, “left uterine displacement, turn off the Pitocin if she has it on” (she does), “stop the epidural for a second while we check the blood pressure.”

“Oxygen,” the nurse suggests.

“Yes, no,” the anesthesia resident stops for a second, thinking of retrolental fibroplasia. “Wait, that would be bad for the baby’s eyes,”—wait, is that right, the resident wonders? No, wait a minute, no. No, it’s not bad for the eyes, you treat the mom first, oh yeah, oh yeah, the Po2 of the baby doesn’t even go up that much anyway, no way the oxygen can cause retrolental fibroplasia when you give the mom some supplemental oxygen. What was I thinking?

“Yes, oxygen, definitely. And some terbutaline, yeah, some terbutaline, let’s slow those contractions.” God, did I think of everything? It’s so hard to remember stuff when everyone’s yelling.

The scenario does a technical time out, as the team goes from the labor suite to the OR suite.

In the OR suite, the patient is being preoxygenated. The patient is flat on her back.

The blood pressure shows 80/50, from the speakers in the mannequin, a voice says, “I feel rrrrrrrrrrrrruuuuuuuuuuullllggghhhhhh!”

“Suction!” the anesthesia resident shouts, looking around. Damn, where is the suction—oh, here.

“Heart rate is still 60, we have to go!” the OB resident shouts. The patient is draped, and they are ready.

“OK,” the anesthesia resident says, “just a second.” The resident places the suction catheter in the mannequin’s mouth. “I need some cricoid.”

The circulator is not even up at the head of the bed, the circulator is under the sheets at the foot of the bed!

“Um, I need someone up here,” the resident says, “right now.”

“Heart rate 50, come on!” the OB is apoplectic.

“OK,” the anesthesia resident gives a syringe of Pentothal, then Sux, then tries to hold the cricoid pressure himself, the arms getting tangled up.

“Wait!” the OB nurse at the foot of the bed yells, “the head’s out! The baby’s head’s out! Don’t put her to sleep!”

“Oh shit!” the anesthesia resident says.

“Oh shit!” the OB resident says.

“My arm hurts!” the patient yells. “I feel weak.”

Looking down, the anesthesia resident sees that the IV site is red and infiltrated.

“I … can’t … breathe,” the patient’s voice falls off. “My … arm …” then she falls silent.

Behind the anesthesia resident, the blood pressure cuff alarms, error—error—low BP reading.

The OB resident looks up, “You didn’t put her to sleep, did you? She’ll need to push now.”

“Um …”

Reaching for ephedrine, the anesthesia resident realizes that the IV is infiltrated, that there is subq Pentothal and succinylcholine on board, the patient has stopped breathing, the blood pressure is too low to read, the baby’s head is out, and, oh, he took the cricoid pressure off just now, and everyone is looking at him. The pulse oximeter stops reading, and ectopy starts on the EKG.

The door to the OR opens.

“Everything going OK in here? I was just about to go home and wanted to see if you needed a hand before I left,” another anesthesia resident says. “Hey, shouldn’t she be in left uterine displacement?”

BOX 8-20 IV Infiltrated

• Get new one
• Get help
• Breathe down or
• Wake up

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FIGURE 8-32 A. The miracle of birth awaits this lovely young mother-to-be. B, C. But wait, there’s trouble in maternity-ville. Quick, put Mom in left uterine displacement to increase venous return and restore uteroplacental sufficiency. D. Don’t push too hard, though.

His hair attempting to stand on end through his OR cap, the anesthesia resident says in a voice an octave higher than usual, “I could use a hand.”

Pushing a wedge underneath the patient’s right hip, the second anesthesia resident asks, “What can I do you for?”

The first anesthesia resident literally shakes his head, trying to clear away the cobwebs and short circuits, “Lost IV, she’s not breathing, head’s out, and….”

“OK,” the second anesthesia resident says, “ABC, chill, just do the ABC and we’ll be OK. You mask, get that sat up. I’ll get an IV. You, Dr. OB, can you get the baby out with salad spoons (forceps) if I give you a little fundal pressure?”

“Don’t really need the forceps, the head’s out,” the OB says, “but a little push and I should be able to get it.”

“Good,” the first anesthesia resident says, “and I’ll need cricoid up here. Don’t think she’s weak enough to instrument her airway.”

The circulator comes out from under the drapes, goes to the head of the bed, and gives cricoid.

“All right,” the first anesthesia resident says, “you’re getting the IV, leaning on the uterus, and helping get the baby out. You’re going for it to get the baby out.”

The pulse oximeter comes back.

Again, the OR door opens.

“It’s a wrap! Simulation’s done!”

Clinical lessons learned from scenario 11

When things go sour on OB, they can go sour fast, testing your ability to adapt and change as the situation evolves. A lot of players were involved in this not-terribly-far-fetched sequence. The debriefing allows us to play it all again in slow motion, see what went right, what went wrong, and the all-important what to do better next time.

Debriefing. “Some miracle of birth,” the instructor says.

“Call it the ‘madness of birth,’” the first anesthesia resident retorts.

That loosens up the whole debriefing table.

The instructor goes to the white board and says, “Let’s debrief this by laying out a time line so we can see what’s going on at each time point and what everyone’s thinking.”

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“What happened in between point A and point B?” the instructor asks.

Starting out, the OB nurse says, “We got a real bad deceleration, and we had to get going.”

“What’s the big rush?” the instructor asks the OB resident. “There are marathon runners who have heart rates of 35. What’s the big deal if the kid is clipping along at 60?”

“Babies have stiff hearts, incapable of stretching and increasing their cardiac output like an adult. Kids are heart rate-dependent. And if they drop their heart rate, that is actually a maladaptive response. So, in a kind of double-whammy, a kid who is in trouble—uteroplacental insufficiency from any cause—responds by doing the worst thing! Slowing their heart rate,” the OB explains. “The only good thing about that, if you are looking for silver linings, is that fetal bradycardia is the red flag that tells us we have to move.”

“God is sending you an urgent e-mail,” the instructor says.

“Exactly.”

“And what do you do when you see this red flag?” the instructor asks the anesthesia resident.

“Well,” the anesthesia resident says, “as was evident here, I got flustered and mixed up. God may be sending me an urgent e-mail, but my mailbox got so full I couldn’t read it.”

“OK,” the instructor says, “let’s put that on the time line.”

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BOX 8-21 Panic

• We all do it
• Reduces brain to oatmeal
• Extra person—a Godsend

“Don’t dismiss the human tendency to panic,” the instructor says. “There’s a lot of input, you don’t have all the information you want, and the pressure’s on to do something instantaneously. This isn’t grand rounds where you sit in your chair and sort of weigh the options, discuss what’s best, and come up with a consensus after a review of the literature. This is now, now, now.”

Nods all around the table.

“This is similar to learning a foreign language,” the instructor says. “You study for years, have a wealth of verbs, conjugations, and sayings in your head, but when you go out on the street and the first person says something to you, your knowledge base shrinks to the smallest possible unit. You may have studied Spanish for 4 years, but all you can remember is ‘Hola’.”

“So,” the instructor continues, “what is a good antidote to panic?”

“Go back to ABC,” the first anesthesia resident says, “and call for help.”

“Right, you never go wrong going ABC,” the instructor says, “don’t hesitate to even say it out loud. It’ll focus you.”

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“What’s the big deal about help?” the OB nurse asks.

The second anesthesia resident answers, “When you’re the first one, you get a little too close to the action, plus it’s easier to get your ego wrapped up in the proceedings. ‘Oh man, this is my case, and things are going to hell!’ That second person has the advantage of objectivity ‘Well at least I didn’t get us into this jam,’ so the second person can look at things in a much cooler, ‘Well, let’s just go down the list and see what needs to be done’ manner.”

“Let’s look at things from the obstetric angle, since we are married together in these kinds of cases,” the instructor continues, “What was the deal with the head coming out.”

Rolling her eyes, the OB resident says, “Gotta always take a peak between the legs and see if Baby Dumpling has made a surprise arrival. In my rush to cut, I forgot an important lesson of delivery—kids have their own agenda and sometimes deliver from below while we’re going at them from above.”

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FIGURE 8-33 A, B, C. Off to do a C-section? Never forget to take one last little peek. Every now and then the baby beats the odds and shows up. D. Well, what do you know?

“So,” the instructor explains, “what exactly was the dilemma at the, shall we call it, high point, or maybe, low point, of the case.”

“The OB was surprised by a baby halfway out,” the first anesthesia resident says, “I was surprised by a, well, IV halfway out, you could say. And I forgot the ABC, forgetting to wait for someone to give me cricoid and forgetting about the basic left uterine displacement needed to keep adequate venous return and keep her blood pressure up.”

“Sort of a Grand Slam of trouble,” the instructor offers.

“Then I arrived to save the day!” the second anesthesia resident trumpets.

“Your day will come,” the OB pokes a hole in the resident’s balloon.

“Humph,” the second anesthesia resident shrugs it off. “I just focused everyone on what we could do, and what needed doing. I work on getting an IV, my anesthetic confrere keeps oxygenation going in this less-than-perfect world of a half-anesthetized, half-paralyzed patient, and the OB gets the baby out in the less-than-perfect world of a baby with the head out but a mom unable to push.”

“You could argue different options,” the OB says.

“Sure, you could say, ‘Wait until I get an IV, then induce the rest of the way, secure the airway, then cut.’ You could also say, ‘Let the anesthetic drugs wear off, then let her push.’ There are always different options. But right then, with things the way they were, I read this as the best way to go. We pick the plan, we go for it.”

“Wrong, yes. Uncertain, never!”

Summary. Anesthesia is a field of “remember the basics.” What gets us in the most trouble is the basic stuff, hardly ever the exotic, bizarre stuff.

IV infiltrated, forget to inspect it? Now you can’t induce, can’t give fluids, can’t give resuscitative drugs such as ephedrine, and you can end up with subcutaneous drugs that hurt you. Pentothal can cause tissue damage, succinylcholine can cause partial paralysis as it’s slowly absorbed.

Forget left uterine displacement? This—beaten into us over and over again—is easy to forget in the panic of an emergency. And if you forget this basic maneuver, you drop your blood pressure, can induce nausea and vomiting, and get yourself into all kinds of trouble.

Forget to do the OB exam? Though not exactly our bailiwick, we do need to know “the other doctor’s job” almost as well as our own. The ultimate goal here is taking good care of the patient, after all, not drawing lines of responsibility and saying, “Well, that’s not my job so it’s not my fault.” You, as anesthesiologist, should have a good grip on how far along the baby is, how likely the baby is to “deliver from below,” and whether any surprises are in store, “Oh, look, the baby’s already here!”

And finally, you need to know when to ask for help, and you need to know the tremendous value that help can be. Right when your mind is amped out with too much bad news coming in too fast, you can get a second assessment, a second pair of eyes, a second brain. That may save your butt.

And may save your patient’s life.

SCENARIO 12. Keeping an eye out, agitation in an opththalmic case

“Hate to do this to you,” the attending says, “but you’re in the eye room today. Need a magazine? Don’t think much is going to grab your attention in there.”

The resident shrugs, “Whatever, so long as you sign the check at the end of the month.”

“Look,” the attending (instructor) says, “the retrobulbar block is already in, the bed is turned around, just keep your eyes peeled, no pun intended, in case there’s an oculocardiac reflex or something.”

Entering the OR, the anesthesia resident sees the bed reversed, the surgeon by the head of the bed, the patient’s feet toward the anesthesia machine, with the patient’s feet sticking out from underneath the sheets. All the vital signs are OK, oxygen tubing is snaking underneath the drapes, and the CD player has Figaro’s aria from the Barber of Seville playing.

“Figaro, Figaro, Figaro, Figaro!”

God, how can people listen to this stuff.

“Figaro, Figaro!”

“Hey, hold still!” the eye surgeon says, “hey, anesthesia, he’s wiggling, can you give him something?”

At first the anesthesia resident doesn’t even hear the surgeon, his complaint drowned out by the wailing operatic music.

“Hey, anesthesia!”

“Oh, yeah,” the anesthesia resident looks around, there’s some Versed.

“OK, sir?” she says to the patient, then lifts the drapes a little to look at the patient’s face, “are you OK? I’m going to give you something to help you relax a little, OK?”

The anesthesia resident gives 1 mg of Versed, waits a minute or two, then gives 1 mg more.

“Better,” the surgeon says.

“Figaro la! Figaro cua! Figaro la! Figaro cua! Figaro, Figaro, Figaro, Figaro!”

The anesthesia resident rolls her eyes. Opera, who the hell goes to the opera, who the hell listens to opera? Of the 5000+ songs she’s pirated and loaded on her iPod, not one, not one single opera. And there will never be one either!

“Hey,” the opththalmologist says, even more irritation in his voice than the stupid guy singing opera, “he’s still moving, can’t you give him some of that white stuff?”

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FIGURE 8-34 “Hey, he moved!” Sedating a patient during an eye case can set up a really vicious cycle. They move, you sedate, they weird out on you, then you give more, and round and round you go.

Related posts:

How Anesthesia Simulation Is Done Bibliography What Is a Simulator–a Clinical Checklist or a Theater? With What Other Disciplines Should We Work? The Great Debate Simulation Equipment