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Tuesday, July 8, 2008

In the Bag

First day of clinicals is behind me! I was very nervous. It might not make that much sense to people who know me and know that I have a lot of experience with very sick ICU patients. In my previous life, I was a trauma ICU nurse with 11 years of experience. I worked in highly-regarded academic Level I trauma centers, and was very competent. I could resuscitate a critically ill patient, and recognize signs of danger before it happened so I could prevent it. I was responsible for trauma patients both in their initial resuscitation phase in the ER and when they were admitted to the ICU. I could run a code, and direct new residents when needed to get what a patient needed done. I was trusted by all of my coworkers and known as level-headed and highly competent.

But now I am in an entirely new environment. There are a lot of new rules in surgical areas--about how to maintain the sterile field and not contaminate it, which means you have to learn where you can and cannot walk, and learn subtle cues about what the surgeon and other OR staff are doing so you know what you can do (or should do) at that time. There is, of course, an entirely new staff of people to learn, and a lot of these people feel it is their duty to administer a trial by fire to every student. Plus, there are very high expectations of what we should come to the OR knowing ahead of time--every drug we give, every procedure we do, every aspect of managing an airway--making sure we can adequately breathe for the patient, making sure any breathing tubes are correctly placed so we know the patient is really getting oxygen (it's easy to place a breathing tube in the esophagus because the anatomy is very close togther, and of course a patient can die if that happens). So many things to know. Plus, nearly every drug we give in the course of an anesthetic has the potential to kill someone. So it starts to make more sense why learning how to administer anesthesia is nerve-wracking.

Today, my first day of clinicals took place in the ECT lab. I think I blogged about ECT before, when I was there for airway management a few months ago. ECT is electroconvulsive therapy, which is used to treat depression that doesn't respond to antidepressant medication. It sounds archaic and brutal, but it is very helpful to patients who can't get relief otherwise. It is always voluntary, and the patients are anethetized for the treatment so they don't have any memory of it, and aren't hurt. That's why I was there, to learn how to do this anesthetic.

ECT is very fast and short. Each case takes 30 minutes or less from start to finish. We had 7 patients today and were done by 11am. That makes it sound easy, but short cases are difficult in a lot of ways for the anesthetist. A lot of things need to happen in that short amount of time. It's a good place to be a student, though, because you are doing basically the same thing for each patient, and because we don't use a breathing tube, but we do give a muscle relaxant (aka paralytic medication, which temporarily paralyzes all the muscles), we have to learn how to properly ventilate the patients since they can't breathe. There are a lot of medications given for this short treatment--one to prevent the heart rate from dropping too low, one to sedate the patient, one to paralyze, and we usually have to treat high blood pressure with at least one IV drug, often 2 or 3. In addition, patients often get an anti-inflammatory drug to prevent sore muscles after the treatment, an anti-nausea medication, and more sedation at the end if they have woken up combative in the past. Some patients receive IV caffeine to induce a better seizure--it is actually a seizure that is induced by the electrical impulse, and the goal is a seizure that lasts about 30-60 seconds, for the maximum benefit to the patient. In addition to all of this, many patients are on a lot of other medications which can interact with the medications we give for this treatment, so you have to be very careful to check everything against each other and make sure the patient will be safe. After it is all over, the patient slowly wakes up and has no memory of the treatment. They often go home that day, but patients typically have about 8 treatments, 3 per week, before they are done, and then often will come back every month or two for maintenance treatment.

I was working with a really nice CRNA named Marcus today. He was very understanding that I was nervous and new and didn't really know how to do any of this yet. He did the first case and let me watch, and ventilate the patient after she was induced, then I gradually did more of each case until I did the last one from start to finish myself. Having a kind CRNA makes all the difference--I was less nervous, and able to actually learn. By the last few cases I felt like I was actually getting the hang of properly ventilating a patient with a mask, which is often a difficult skill to gain. It will take a lot more practice, but I did start to notice a difference.

Setting up the room was very hard for me this morning because it's been so long since I was in ECT last time, and I wasn't certain of which drugs to draw up. Checking the anesthesia machine also takes me a long time, since I've just learned how to do this. We get to the hospital about 45 minutes to an hour early, to set up the room and check the machine before we see our first patient. This meant 0545 this morning, to be ready to see the first patient at 0630. (Tomorrow I will actually get there at 0530, because I felt a little rushed this morning.) I had my careplan ready, for the most part, but Marcus didn't ask to see it and we didn't really have time to go over it at all--which was fine with me.

Someday, I'll feel like I know something about this whole business. Not yet, though.

Now, I am off for a run before it gets too warm. I have to go back to the hospital at 2:30 to check tomorrow's assignment, and then make a care plan for that. I also have to study pharm today--but once my run is done, I'll be a little more relaxed and better able to focus, I think. I'm glad this first day is behind me, though, and that it went well.

1 comment:

PennyLane said...

Hi Gwen, I've been reading your blog and it is such a help and inspiration! I have a surgery date coming up in less than two weeks (yikes!) and I am getting very nervous about many things specific and general...I'm a mess.

One of my specific concerns is about anesthesia, which you know a lot about! My first main issue is that I've never had it before and I'm worried I might have a reaction--how common is this and how easy/hard is it to notice and how dangerous is it?

I'm also concerned because right now I have a terrible cold, it might be bronchitis and this doesn't seem like something that is really good for anesthesia. I know they won't operate if I'm still sick, but does a recent illness/inflammation of the airways effect the likelihood of complications?

Also, those horror stories of people waking up during a surgery or not being fully out....that's really rare and is a huge human error problem, right?

Finally, just because it's on my mind and because I've gotten sick a lot this year, have you ever had a bad cough with the band? Would that effect it in any way...making it slip or the stomach prolapse or anything? Weird question I know but my stomach muscles are SO sore from all this coughing I can't help but imagine what it would be like to have a band in there.

Any help would be so greatly appreciated!

(doing it anon for now...just protecting online privacy but i use the same name on lbt, and i'll check back here for a response)