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Awareness under anesthesia

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In my previous life, before I became an anesthetist, I had worked for years in critical care and PACU. I became quite familiar with the care of post-operative patients and the issues that surround operative care.

When I decided to start my family, I carefully read every book I could lay my hands on about a natural, well-planned and thought-out labor and childbirth. I attended my prenatal classes, practiced my breathing, and, when I went into labor, already had my overnight case packed, with books to read, music to listen, phone numbers ready.

Life doesn’t always go like you plan it. It took me many painful hours (more than 24) just to dilate to 5 centimeters (in those days that was the magic number to receive an epidural). I actually hadn’t even planned on getting an epidural. Nope, didn’t want one. I quickly changed my tune after the first 24 hours of contractions. Epidural went in fine, pain relieved, but for the next 24 hours, I would not finish dilating. Got to 9 cm, but could not progress any further, despite everyone’s best efforts. My baby was starting to show non-reassuring signs on the fetal monitor, and it was decided that I would need a Caesarian section. So much for my plans.

But, to make matters worse, my epidural was deemed non-suitable for delivery – apparently it had dislodged. Suddenly, my baby’s heartrate dropped precipitously, and I was rushed off to the Operating Room. They had to put me to sleep with general anesthesia to get the baby out as quickly as possible. Now I realized I would miss my baby’s birth. But his safety was paramount to me, and I gazed into my husband’s eyes as I drifted off to sleep.

It is not as hard for me now to talk about what happened next as it was at earlier times in my life. I used to not be able to even think about it without getting a hard pit in my stomach and a well of tears.

In the middle of the operation, while I was still being cut and before the baby was out, I woke up. Yes, I felt the sharpness of the knife and the tearing of my tissues, the pushing on my belly, and indescribable, unspeakable pain. I tried screaming and screaming (in vain), and then realized that I had the breathing tube in my throat, plus I was still paralyzed from my anesthesia drugs and could not even move a finger or open my eyes. How many patients had I cared for, how many patients waking up from anesthesia, how many incisions and how many pain medications? Why was this happening to me?

This was beyond a nightmare; it was some kind of cruel joke. No one could hear me (I WAS SCREAMING), and I was totally awake and could not communicate to anyone what was happening to me! What seemed like hours but may have only been a few minutes, I was in some different parallel universe of torture and agony. And then, that’s all I remember. Everything went blank after that; next thing I knew, I woke up (again in a lot of pain) in the PACU, and it was over. The psychic pain, though, remained for a long time.

When a mother must undergo general anesthesia for a C-section, she is traditionally kept “light” – a term that means that “not too much but just enough” anesthesia is given. Mothers under general anesthesia are kept light until after the baby is delivered, because of the real concern about anesthesia drugs crossing the placenta into the fetus and possibly causing an unsafe situation for the newborn. This is exactly what happened to me; sadly, I was a little too light. When I “blanked out” during the C-section, I had probably just been “deepened” with anesthesia because my baby was being delivered.

This experience was life-changing on many levels, but I will speak here about how it has informed the way I practice. I fulfilled a career-long dream to become a nurse anesthetist about 10 years after the delivery of my son. I love everything about giving anesthesia – it is clinically stimulating, intellectually challenging; it’s about making a sound differential diagnosis, navigating the decision tree, and problem-solving. But what it’s really all about is the patients.

Patients’ fears and concerns are real, all of them. None of them are silly, neurotic, or whimsical. I take them all seriously, and I allow my patients to talk freely about what is worrying them about their upcoming surgery. Often their biggest trepidation is the anesthesia – dying, brain damage, loss of control, throwing up, feeling pain, waking up in the middle of the operation . . . .

My horrific experience under anesthesia has empowered me to become a strong listener, a better CRNA, a more genuine patient advocate, and a more caring person. I try to tune in to my patients’ preoperative anxieties, and I pay particular care and diligence to ensuring that their anesthetic experience is optimized to their comfort, well-being, and safety. To do anything less for my patients would be diminishing to the standards of my profession, to what I’ve lived through, and to who I am.

For more information about awareness under anesthesia, I would refer you to this outstanding book, Silenced Screams, and to this information released by the American Association of Nurse Anesthetists. As a postscript, I would like to assure my readers that the frequency of awareness under anesthesia is quite low and uncommon today, ranging between 0 .1- 0.2% of the adult population.

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If there is one drug which truly enhances the arsenal of an anesthesia provider, that drug would be Propofol.

What is Propofol? Chemically described as diisopropylphenol, it is an emulsion; it is white, it contains soybean oil. It is a sedative-hypnotic agent that is used for the induction and maintenance of both general and sedation anesthesia.

Propofol is my friend. And Yours.

It has a very quick onset and short duration. When You need a colonoscopy, I can deliver squirts of this milk of amnesia in just the right amounts to keep you sleepy enough to not feel or remember a thing. You will wake up almost immediately after the procedure and just look at me incredulously when I tell you that it’s over and done.

It is also quite useful for cases where your surgeon can work on You using local anesthetic. As anyone knows who has been to the dentist, sometimes the administration of local anesthesia can burn and hurt. A couple of squirts of Propofol by me will help you nap through the numbing process, and never even feel the needle, let alone the actual surgery.

Let’s say You are having a minor procedure but you are just plain scared or uncomfortable about being in the operating room setting (I’m thinking podiatry, minor hemorrhoids, cataracts, breast biopsy for a small lump, and the like). *[ Note – most folks having these procedures get some type of sedation. There are an occasional few people who prefer NOT to be sedated at all, and that’s perfectly alright, too.] Propofol to the rescue after you’ve been numbed up, to give you that cat nap that you crave and need. It can easily be delivered as a “drip” and titrated to the desired effect. Combined with other IV drugs like benzodiazepines (think Versed – sedative) and narcotics (think Fentanyl – pain-killer), it creates an ideal sleep, where You can maintain your own airway and breathing, and I can watch over you and monitor your depth and adequacy of “LaLa-Land.”

For patients getting spinal or epidural anesthetics for their surgery (lower extremities and sometimes lower abdomen), a Propofol infusion will allow You to zone out for the duration of the operation. When a general anesthetic is required, where I will need to secure your airway with some type of breathing device, I administer Propofol in much much larger doses, as this will produce not only unconsciousness but also apnea (stop breathing) and a blunting of your gag reflex. Maybe more information there than you cared to know (sorry), but it definitely makes my job much easier, which ultimately makes taking care of You a much safer experience. After this “mega” dose of Propofol wears off (remember, I said it was short-acting), I can keep you asleep with either more Propofol, or other intravenous or inhalation agents, and assist your breathing as required.

I also use Propofol in “remote” settings throughout the hospital (any place away from the OR) – for cardioversions, where You need to be a little dazed for the jolt you will receive; same holds true for ECT – electroconvulsive therapy; and it is a lifesaver on any patient unit when someone needs to have a breathing tube placed – smaller or larger doses, it provides a short and quick solution to sedating a distressed patient.

So, say hello to my little friend…

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Behind the mask

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Imagine going to work everyday and the only thing you can see on your co-workers’ faces is their eyes. Such is the parallel universe that is the Operating Room.

We all wear masks in the OR. It is for our protection, and yours. Surgery can be messy; “things” can splatter. And our germs are nasty; all of them. You certainly don’t need us blowing them all over your open wounds. Actually, everyone wears a mask except you – we don’t need to protect you from  your own germs – they’re already yours!

So up go the masks, as soon as we enter the Operating Room. Some masks even have built-in face shields, which come in really handy for those of us who don’t wear any sort of glasses or eye protection.

It’s different when you are communicating from behind a mask.

First of all, you cannot rely on lip-reading. You and your coworkers learn quickly to e-n-u-n-c-i-a-t-e your words, that and meticulously clean your ears before leaving for work. It is not unusual to hear yourself repeating “Huh, what did you say?” innumerable times during the work day.

You learn to read peoples’ cues, and we all send them. Starting with our eyes, of course, which speak volumes – the knowing glance, the darting glance, that desperate look, the tears, the glare, the eyes popping out of the head, the warmth of smiling eyes, and reassurance  – yep, we’ve seen all that! We communicate so much to each other through our two little orbs that peep up above the mask!

And there are more subtler nuances, too. A bead of sweat, a shrug, a sigh, speed of movements, deliberation of movements – we watch each other, and watch out for each other, and feel the pulse of the room in a whole other language. We rely on all of our senses.

At the end of the day, when the masks come off and the OR hats are removed, we frequently don’t recognize some of the very people we worked beside just earlier. Civilian clothes! a real face! and a hair style! (albeit a little scrunched from being under a hat all day)

“So that’s what you look like!”

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What really goes on in the Operating Room while you are asleep?

I get asked this question by friends and family all of the time. “Are they talking about me?” “Laughing at me?” “Commenting about my thighs?”

None of the above, really.

Conversations in the OR can range from sports to politics to gossip, or, no conversation at all.

Take the room I worked in today. We did 2 spine cases, with a different surgeon for each case.

Surgeon #1 insists upon total silence in the room, no phone conversations; in fact, all cell phones must be turned off. NO MUSIC. All energy and activity during the case must pass THROUGH the surgeon. “Independent thinking hurts the team” he has been known to say. He wants to know what’s going on at all times in all spheres. Control freak, yes, but in the very best sense of the words.

Surgeon #2 brings into the OR his iPOD and Bose speakers; in fact, they’re the first things he sets up. The music is always LOUD, and the mood is upbeat. The atmosphere is what I’d call “loose,” and laughter frequently flies.

So, who’s harder to work with, and who’s easier? Tough question, surprisingly! With Dr. Laidback, you actually must pay closer attention to your work; between the music and the conversations, these can be major distractions. With Dr. Serious, the mood is so somber (and spine cases can be so long) that it can be easy to get a little bleary-eyed and zoned out by mid-way through the case.

These are two outstanding surgeons, by the way. I would let either one operate on me. Both handle routine and emergent situations with clinical acumen and astute decision-making. So, who would you go to for your spine surgery? Dr. Serious, or Dr. Laidback?

We all hope to never have to make that kind of decision….

Amazing grace

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The pre-op holding area is a busy place.

Patients scheduled for surgery begin filing in on their stretchers at the crack of dawn. Each patient gets parked at a separate bay; the room fills quickly, empty slots being filled faster than a train station parking lot during rush hour.

Hustle and bustle, checking names and ID bracelets, charts and allergies, consents and orders. It’s a whirlwind of activity, and an exercise in efficiency, when done right. Each patient and their chart must meet the rigid standards of the profession before they can pass the doors into the OR suites.

In the midst of this beehive of a place, a lovely old woman I’ll call Sadie was parked on her stretcher in its bay the other day. She was blind, toothless too, withered with age, and slight of build. Sadie was in her early 90s, and I cannot remember what procedure she was there for; but I do know that in the midst of all the scampering and shuffling that was going on all around her, Sadie began to sing.

She started off softly and quietly, humming so that only those next to her could hear. Smiles lit up their faces. Then Sadie began to slowly crescendo; one by one, work began to slow down as people took pause. That’s when Sadie really began to belt them out – a few by Billie Holiday, a few gospels, and finally Amazing Grace. Any semblance of work came to a complete halt. What was this beautiful sound coming from this wisp of a woman? Was Sadie at one time in her life a singer on stage? Perhaps in her church? Her voice was so smooth and sweet; she sang with an effortless elegance. It almost seemed incongruous to hear such a voice coming from such an invalid person. There she laid on her stretcher, like the other patients, a disease and a diagnosis, but she had the style and temerity to truly rock the world around her.

Nothing short of an atomic bomb could have brought all of the activity in that holding area to a complete halt that day, or any day, but mighty Sadie did. By just singing those bars, one by one, Sadie stopped everyone in their tracks. Workers came up to Sadie and hugged her and thanked her.

I never leave work without realizing that I learn something new each and everyday. We all brought a little of Sadie with us for the rest of our day, and days to come.

Giving anesthesia is an interesting calling.

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It requires careful, dilligent planning and analysis to be able to sit back for a few hours in your chair at the head of the bed and appear to be doing nothing.

Anesthesia providers are the brunt of many jokes   – about how we read the newpaper, do crosswords, or basically sit down and relax for the duration of the operation. Piece of cake, huh?

It’s a tough job but somebody’s gotta do it. Someone who has highly-trained hearing and vision, and a sixth or even seventh sense to pick up nuances in the rate and tone of the monitors while constantly evaluating the depth and adequacy of anesthesia and hemodynamic stability.  Someone who can work calmly, methodically, and act upon an informed, comprehensive, and sometimes near-instantaneous differential diagnosis. An anesthetized patient speaks to you in an entirely different language; are you skilled enough to read it?

Giving anesthesia takes more than good training and the ability to spout off formulas and book chapters. It takes hours and days and weeks and months of seeing how patients behave and misbehave under the effects of anesthesia and surgery. How life (and death) are incremental events, and can change from one moment to the next. How being forewarned is truly being forearmed.

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Speaking of forearmed, giving anesthesia is like going off to battle. You must be well fortified, equipped, and prepared; ever ready and ever watchful. The soldier who is crouched in the field, or beside a rock, may appear to be doing nothing; but he is forever assessing his situation and his options, knowing that he may spend hours in idleness or moments in terror. But his vigilance never falters. Someone’s life depends on him.

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Sometimes, You need anesthesia. It happens to the best of us. Healthy lifestyler or living on the edge. Vice-free or poly-substance abuser. Female or male. Thin or fat. Young or old.  And everything in-between. Sometimes You need to have an “intervention” done – surgery, special study, endoscopy – and You will need anesthesia.

Although the prospects of having to undergo some type of anesthesia are never “pleasant,” usually the anticipation and fear are much worse than the actual experience. Our minds have a way of playing with us like that.

But there are some steps that You can take to make your anesthesia encounter an optimized one, and quite possibly, surprisingly stress-free.

  1. When you are instructed to have nothing to eat or drink after midnight, that means nothing. No food and no drinks. It also covers gums, lozenges, candy, coffee, juice, and anything else you think is okay. It’s not. Don’t place yourself at high risk – get your procedure over with, and then you can eat and drink and be merry. Of course, if you are instructed to continue taking specific medications, please do with a minimal (like, as little as it takes) amount of water to get the pills down.
  2. Please leave all of your jewelry at home. If you have a tongue ring, be prepared to remove it for your procedure. As these holes have a tendency to close quite quickly, we can place some surgical thread through the hole to keep it patent till your procedure is over. The same holds true for makeup – less is more. It’s only going to get all smudged while you are under the influence, and you will look much worse with smudged makeup than none at all, believe me when I say that.
  3. Try to familiarize yourself with your medications. If you cannot, then either bring a list of your meds with you, including dosages, or just bring in your medications in a brown paper bag with your name on it. This is an enormous service to your caregivers, to know exactly what prescriptions you are taking.
  4. At your pre-operative anesthesia interview, please answer all questions honestly. Nobody is interested in outing You about ANYTHING in your life; you will not get busted. But the more we know about you, the better we can take care of you and do what is right by you. We are not here to pass judgment – but after you are asleep, You can’t talk to us anymore about something we may really need to know.
  5. We appreciate your help, REALLY WE DO, but sometimes that one vein that they always get blood from is not the right vein for an IV. Have some confidence in our skills and acumen, and allow us to try to find your best vein for an intravenous. We are pretty good at what we do.
  6. Number 6 is just some bonus pointers – get a good night’s rest (if possible) the night before your procedure. If you are a smoker, even cutting out that morning’s cigarette is helpful, but the more smokes you cut out before anesthesia the better. Ignore all hearsay – most of it is viscious gossip, meant to scare you and fill you with doubt. We are professionals, and give anesthesia 24/7/365 – come for your procedure with a written list of any questions you may have (we encourage it!) and know that the people behind the hats and masks are folks with hopes, dreams, and loved ones, just like you, and we are here for You.

The “it” girl

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Having surgery can be scary. Having to have anesthesia can be even scarier. Fears of pain, waking up in the middle of the operation, suffocation, loss of control, bleeding, brain damage, death. All of these thoughts, individually or collectively, have raced through patients’ minds as their impending surgeries loom.

I feel that part of my job is to acknowledge the fears that all patients experience, and do whatever I can to help quell them. A little (or a lot of) reassurance (and drugs) can go a long way.

Last week, as I was putting a gentleman to sleep, I was talking calmly and soothingly to him in his ear, as I usually do with my patients while their sleep-inducing drugs are being administered. There was a lull in the busy activity in our OR suite, and everyone in the room sort of stopped what they were doing, and for some unexplained reason, I had a captive audience.

Me: “Take a slow deep breath, and slowly let it out.”

Mr. Patient: …Inhale….Exhale.

Me: “We are starting to give you your sleep medications, and you will begin to feel more and more relaxed. More and more peaceful and serene.”

Mr. Patient: …Inhale….Exhale.

Me: “We will watch over you every second, making sure you feel nothing, you remember nothing, and you are safe.”

Mr. Patient: “Thank you, oh thank you.” …Inhale…Exhale.

Me: “Pick out a sweet dream, your favorite vacation spot, or your most pleasantest of thoughts, and feel all your cares slowly drift away.”

Mr. Patient announced: “I’m going to sleep thinking of you. I’m going to dream of you.”

And with those words, he was asleep.  There was a collective “awwwww” heard in the room as this gentleman uttered those words, and I detected a mild blush on my face.

Which quickly turned to flaming beet red when Mr. Patient’s blankets and gown were pulled back in order to insert a catheter into his bladder. There, standing at attention, was Mr. Patient’s erection, and it was pointing at me. For the second time in as many minutes, another collective “awwww” and a few snickers could be heard in the room.

I was dubbed the “it” girl for the rest of the case, and for cases to follow…..

Change of Shift will be held at Someday Nurse on September 8, and the theme will be nursing students. Nursing school was an eye-opening experience for me.

 I was a nursing student about the time that dinosaurs were roaming the earth, although it really doesn’t seem like that long ago. But when I look at my 22 year old son, I realize that when I was his age, I had already been a nurse for a year and running! Yikes.

Anyway, one of my favorite stories from my training carries me back to my OB rotation. I was a real softie there from the get-go. It seemed like at every delivery, the mother and father would be crying tears of joy, and I would be blubbering too. I don’t know why, but I would just get sooo emotional when these kids were born, and I could not for the life of me hold back the waterworks. So I think I made myself a marked woman while I did my training in the delivery room.

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Back then, mothers stayed in the hospital for about 4-5 days post-partum (let’s not even talk about how times have changed!), and if they desired for their male newborns to be circumcised before discharge, the procedure would be done in the DR. Don’t ask me why, but that’s just the way they did things at that hospital.

So, anyway, here I was, eager and willing student nurse, about to witness and learn about my first baby circumcision. One, two, snip – it was done and over that quick. The obstetrician handed me the foreskin at the end of a forcep, and asked me to go out to the front desk and tell them that the “specimen” needed to go to pathology, stat. Nursey-on-the-spot, I gleefully took the specimen out to the front desk, and was feeling so proud to be an integral part of the team. The nurses at the desk took one look at that foreskin and burst into laughter. They informed me that what I was carrying was considered, er, um,  “disposable” and that I had just been victim to one of this obstetrician’s pranks. I went back to that DR suite, where I found the doctor being propped up by a couple of nurses, because he was laughing so hard. Joke on me, but even I broke out into laughter.

Starry-eyed, eager, and the perfect straight-woman for a longstanding practical joke performed on all students like myself who were ready to save the world! I learned how to laugh at myself that day.

Can I put the tube in?

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I get called to do intubations all over XYZ Hospital. Impending respiratory failure and airway protection are usually the two biggest reasons for inserting endotracheal tubes in patients. Very often, when I arrive at the patient’s bedside, I am met by:

  1. a first year intern
  2. a fourth year medical student
  3. an ER or ICU resident
  4. an EMS student

with an eager, wide-eyed, hungry look on their face. I’m familiar with the look; it’s the first eye contact that is made with me as I arrive carrying my code box, and the greeting and exchange of information is always the same….Hi, are you anesthesia? I’m ….. and this patient is not doing well and will need an endotracheal intubation. (here it comes….)  Would it be alright if I put the tube in?  

Therein lies the quandary. So Let’s Talk a Little Bit about the surrounding conditions that anesthesia providers find themselves in when intubating the trachea.

In the OR, for all elective cases, the patient is NPO. Bed height is easily adjustable; working suction within arm’s reach; and every intubating tool, device, and medication, in addition to extra anesthesia personnel, is at hand. There are different sized masks and types of airways, and the anesthesia ventilator is at the patient’s side. This is a controlled environment, which is always optimal for successful intubations.

Contrast this with an emergent, urgent, or semi-urgent intubation elsewhere in the hospital. PO intake status is unknown or questionable; suction may either be not ready or of dubious strength; all tools, devices, and personnel to assist with intubation are not always present and accounted for, properly functioning, or adequately experienced. It’s a jungle out there!

Add to this mix the ubiquitous unknown factors – how difficult will this patient’s airway be, and how will this patient respond to manipulation of the airway? Taking in the big picture, these are all less than optimal conditions for intubation. But intubation has determined to be necessary, and so we must act in the patient’s best interests.

The approach taken to any intubation must always be carefully thought out and well planned, and must always include a weighted strategy, not just forging ahead and trying to put the tube in…… what to do if it looks like a difficult intubation?…what to do if you cannot intubate?…cannot ventilate?

The responsibility for the patient’s airway rests with the anesthesia provider who has been called to the bedside. This is why the intubation is not always so readily handed over to an apprentice or even someone with a little more experience. I may be meeting you at the bedside for the very first time, and I have no idea what your training, skills, and comfort level with intubating may be. How adept and careful are you? If you should knock out a tooth or injure the cords while intubating, that is my fault. If you goose the patient (anesthesia lingo for intubating the esophagus), then every subsequent laryngoscopy will view a slightly more edematous or quite possibly even bloody airway as a result of repeat manipulations. Do you think that could be risky?

I enjoy teaching and mentoring, don’t get me wrong. Some patients have great airways to learn on; others have great airways to learn from. But I believe that all patients needing intubation must be approached from a safety first standpoint.

If you are turned down for the chance at an intubation at the bedside, please don’t take it personally or get mad at the anesthesia provider. Understand that it can be a multi-faceted situation in a multi-factorial decision tree. Not all intubations are created equal.

If you are interested in honing your intubation skills, why not consider a rotation in the OR, shadowing an anesthesia practitioner, for a week or more? We love to instruct, and you’ll get much more optimal exposure to putting the tube in, too.

Thanks for reading.

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