It was proceeding like any other case. Sure, it was billed to be “technically difficult,” but that didn’t mean too much more to us, the anesthesia team, other than to prepare for “surgical difficulties” along the way.My team is composed of myself (a cardiac anesthesia fellow), an apt but fresh CA-1 anesthesia resident, and a senior attending who has been in practice for over a decade.
The beauty of anesthesia is the extreme amount of planning that goes into everything we do. We make contingency upon contingency to ensure that no matter what happens, we will be prepared to handle it. Handling emergencies won’t necessarily be easy, but at least we will have a plan laid out should they find their way to our doorstep.
A few changes of plan are made out of the gates in this COVID era. We plan to begin the procedure like we often do, when the surgeon “arrives” to the hospital. Now, hospital arrival might be walking in the building, but in today’s hurry up and go world, sometimes it’s when the surgeon pulls into the parking deck, or some similar surrogate of having made it safely to the campus.
But my attending reminds us of a worst case scenario: What if the surgeon, who feels fine, has a 100.3 fever, and gets turned away by the COVID temperature screeners at the door? We would have relegated our patient to general anesthesia and all of its risks, and the only person who could perform the operation is stuck outside, unable to enter the building - quite a conundrum.
The surgeon arrives, and the case begins. Special lines are placed in the femoral vessels, just in case we get into trouble. Not the kind of trouble one gets in from staining the carpet, but the kind one finds themselves in from accidentally making a hole in someone’s heart. These lines can be used to initiate cardiopulmonary bypass expeditiously if we are in a real jam. The patient had had a cardiac surgery as a child, which makes re-entry into the chest fraught with more difficulty, because of decades-old scar tissue and adhesions. In these scenarios, we make sure to have cross-matched blood IN THE OR, rather than the usual standard of ensuring its mere availability at the blood bank.
The chief cardiac surgical resident looks me in the eye over the drape, and says, “We are going to have an issue here.” While it’s a welcome departure from the usual lowballing of estimated blood loss, the red pool atop the patient’s chest grows larger, and I see the gravity of the situation.
Despite knowing how to handle such an event, I make the call for help, as at the very least, we will need extra sets of hands for pumping in blood. We are eventually able to resuscitate the patient using the blood that we had brought to the room, crash onto emergency cardiopulmonary bypass, and get the patient through the surgery.
In this case, there were so many opportunities for us to be caught with our proverbial pants down. What if we started the surgery and the surgeon couldn’t get into the building? What if we didn’t have blood at the ready when necessary? What if preparations had not been made for getting onto the heart-lung machine emergently?
Every preparation had been made, and we were able to safely navigate through the ordeals. In my “in-between” supervisory role as a fellow, I am responsible for resident oversight, but still have an experienced attending to report to. It is my job to walk the fine line of bringing out the best in the resident, making sure he is performing at the top of his training, but not asking too many questions and double-checking so many things that his intelligence is insulted.
At the resident level, the expectation is not to make esoteric management decisions based upon the 50+ pieces of data being fed to you in the cardiac OR at any given moment. It is his job to merely be prepared with a proper set-up, have blood, emergency drugs and equipment available, and pick up what he can along the way.
My job as fellow is to anticipate emergencies, provide a higher level of care to the patient, and help the resident to learn and assimilate all of the information constantly being thrown at us. On top of that, I can instruct him through example or verbiage on how to be a good steward of the department, and work with the surgeons in a professional and respectful way. Easier said than done.
The attending keeps a 30,000-foot view of the entirety of the OR. He’s the one who knows when visitors in the corner are speaking too loudly. He knows to delay the case until the surgeon is physically confirmed to be inside the building. He knows to pull himself out of the emergency for a moment to cancel the massive exsanguination protocol after it’s clear that we have obtained control, an especially important step during our current COVID-induced blood shortage.
As the years of training and career go by, we continue to expand our worldviews. As M1 and M2 students, we learn the background material. As M3 and M4 students, we begin applying that information to guide some basic decision making. As we progress towards internship, real responsibility finds us, and our patient list explodes from the 2-3 in medical school to a 50-patient cross-cover night census. By the end of residency, we can manage patients, manage teams, and look for ways to improve our own efficiency, patient safety, and lift up those around us.
It’s important to remember that the expectations placed on us should be congruent with our level of training. As a green CA-1, I remember the frustrations of putting the ET tube in the esophagus and blowing IV after IV in patients with giant veins. My attendings lifted me up: ”Hey man, you’ve got three years.”
Much like our worldview expands as we travel and see and experience more of the world, our own consciousness and understanding of “how it all works” grows with each passing year. Be patient, aim to exceed the expectations that are placed on you, and pick up everything you can along the way. The path is long, and therefore can be daunting. But every day, every patient is a learning experience. When you compile them, over the course of years, you will have it all figured out
Photo by Sharon McCutcheon on Unsplash