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Wednesday, April 9, 2008

Out of Gas

My classmates have been talking about the same thing that I've been thinking: our brains are tired. We're not as fired up about 5 hour study sessions as we were a couple of months ago. It's almost like that brief little spring break just sapped away our remaining energy for studying. But I doubt it's spring break that did it. I think we've done a lot in the last 3 months and we need to assimilate it for a little bit. Unfortunately, we don't really have time for that.

This morning we were in the OR for airway management. From now until we start clinicals in the fall, we will have airway management in the OR every Weds morning. These mornings are a little chaotic. They start out at 0630 in the CRNA office which is located in the OR. So we have to get there early enough to change into scrubs and hats and be ready to get our assignments. The practice is large and busy; there are 28 ORs in the main hospital, 6 more in the outpatient building, and not all of them run, but almost all have a case starting at 7am. There are 8 senior students already assigned to rooms (on Wednesdays the juniors don't have clinical, which is why it works for us to go do airways that day) plus the 8 of us freshmen. This morning was a good example of what happens: about half of us had our assignments changed at least once, which isn't terrible, but a little hard to sort out in the morning. My assignment was changed once before I even arrived, then was changed again because they put me in with John, our clinical instructor, who was doing a "request" case (someone he knew requested him to do the anesthesia for a case; those cases don't have students in them). So I was changed again, to work with one of the senior students, which was great. We were in a room where a surgeon known for very VERY speedy cases was working. Our first case was an ileostomy take down, a fairly quick procedure in general, but the surgeon was completely done 17 minutes after I had intubated the patient. That is FAST. The paralyzing drugs haven't worn off by then, and any other drugs you've given are still working enough that the patient doesn't want to breathe when you need them to breathe, so you can get them to PACU and start the next case. We waited in the OR for about 15 minutes with the patient, after the case was over, until she was breathing and responsive enough to extubate her. The intubation (only my 2nd) was quite easy, but she had prominent front teeth and I was very afraid I would chip one of her teeth with my laryngoscope...but I didn't, yay for both of us!

My second patient was pretty interesting...an older (60s) man who was developmentally delayed and nonverbal, nonambulatory, obviously full time care when he wasn't in the hospital. He was having another GI procedure (one slated to take a little longer than the first one). He had no teeth--for the anesthetist, this is good because you can't chip any teeth with the metal laryngoscope blade, but bad because it is a little harder to breathe for the patient using a mask and bag, because you can't get a very good seal on the face. He looked like we might not be able to move his head very much, which makes intubation much harder. So we had some helpful tools available "just in case", but as it turned out I didn't need them, because his neck and head were much more mobile than it appeared at first. His airway anatomy was fairly unusual, but obvious enough that I could intubate him pretty easily. Woo hoo, my third intubation! Someday it won't be as nerve-wracking as it is right now, but I can't forsee that being anytime soon. Still, that is why we have these airway days for weeks before we are expected to do everything else.

We don't only perform endotracheal intubation on the airway management days. Some cases use a laryngeal mask airway, which is a slightly less invasive and simpler device (there are pros and cons for using them and it's decided which to use based on what the requirements of the patient and the procedure are). Other cases we don't "secure" the airway at all, but just mask (bag) the patient for the whole case. Nowadays that is just for very short cases, like ECTs (electroconvulsive therapy), but they used to mask patients for hours during surgery. Now there are so many ways to do anesthesia, and so much to do while the case goes on, they rarely mask for that long anymore. It's hard on your hands. Naturally, some cases are done with spinal blocks or epidurals, or even just deep sedation and local anesthetic, or peripheral nerve blocks and sedation, for certain cases, but at this point they want us focusing on managing airways, so we are doing general anesthesia cases where we have to do something with the patient's airway.

These airway days are nerve-wracking, but fun. It's so nice to actually work with patients and do what it is we came to school to learn. It's hard in a lot of ways to be a student again and a complete beginner when we are all used to being experts in our previous environment, critical care nursing. But when you learn how to stow away your ego for a while and learn from all the people who are experienced and knowledgable and willing to teach, it's a great experience. Of course, we know all of the things that can go wrong when trying to manage an airway, even one that no one expects might be difficult (when they turn out to be difficult, that can be the hardest, because you aren't as prepared mentally), and knowing those things makes us all scared witless at this point. But we always have a CRNA on one elbow and an MD anesthesiologist on the other one, making sure the patient is safe and we are doing the right things. If something goes seriously wrong, we bail and let the experts handle the situation. They will let us learn how to get out of a bad situation as long as the patient isn't in danger, but if things get out of hand they are right there to make sure things are done right. It's a good learning environment.

I still have so much to learn in my other classes before we start clinicals this summer, though, so I've gotta get my mojo back.

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