When the bark is louder than the bite

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In residency, you learn to deal with many different personalities.  This ranges from super sweet and helpful to utterly cruel and egotistical.  At MGH, our CA-3 year was spent running the call schedule on night call (the first-call experience).  It’s a terrific experience in prioritizing as well as organizing your team to prepare for what rolls through the OR doors.  Fast forward 4 years and now I’m in private practice.

While running the schedule on call, I get a call from the trauma surgeon saying a patient with an epidural hematoma needs to come to the OR emergently and couldn’t wait for another anesthesiologist to be called in from home (home call gives an anesthesiologist 30 minutes to come into the hospital for an emergency).  So, I made the executive decision to pull the anesthesiologist from the elective suboccipital craniotomy case to do the emergency.  It was a crani to crani and neuro to neuro switch… meaning the neuro team and crani trays were already open and ready to go.  It made the most sense in my mind.  Of course, without missing a beat, the “elective” neurosurgeon showed complete disdain of my decision.  To add fuel to the fire, he proceeded to berate the OR nurses, myself, and staff to make sure his displeasure was known.  I stood by my decision because it was the best decision for the emergency craniotomy patient who could have potentially died.  Secondly, I chose not to call in my final anesthesiologist for an elective case as we would have gone on “trauma bypass”.  This means that no traumas or emergencies could come to our hospital.  The “elective” neurosurgeon became more livid by the minute.  2.5 hours after he was supposed to start his case, I finished my first case and was able to get his case started.

Now, who does an elective suboccipital craniotomy for tumor case on a Saturday?  Secondly, he decides to do this in a sitting position — this has it’s own sets of risks.  He needed a precordial doppler, which our hospital did not have, so we called for it from our neighboring sister hospital.  In the meantime, I had another plan…that was to put down a TEE probe to monitor for venous air embolism (VAE).  After speaking to the patient and family, I proceeded to explain the risks/benefits of arterial line, central venous line, transesophageal echo, mechanical ventilation, blood transfusion, and intensive care unit stay.  It’s always a lot for the family to comprehend, especially while meeting them for the first time.  However, it is our job as anesthesiologists to make them comfortable and calm their fears.

**This picture taken from a google search for “precordial doppler”.  It is not my own.**

IndianJAnaesth_2012_56_5_502_103979_u2

**This picture taken from a google search for “precordial doppler”.  It is not my own.**

We get to the room and proceed with vital signs monitoring.  Uneventful induction and intubation.  A right internal jugular vein central venous line is placed (mainly to use as a Bunegin-Albin catheter).   TEE probe placed to look for air in RV and possibly air lock and RV failure –> VAE.  Radial arterial line placed and transduced at the level of the head.  Pt was placed in Mayfield pins and positioned in steep sitting position with reverse Trendelenberg and flexing the legs up.  Neuromonitoring commenced looking for changes in sensory and motor signaling.

All throughout the case, the TEE showed various amounts of air coming through the right side of the heart:

IMG_6787.PNGWith greater amounts of air, there would be a detectable decrease in blood pressure as well as end-tidal CO2.  While the right ventricle was still capable of pushing blood forward, I simply increased the blood pressure pharmacologically and increased the patient’s volume with normal saline from the IV.  Rarely does one get to see this TEE view as most of these cases are monitored non-invasively via pre-cordial doppler or ETCO2 and BP.

Lastly, this patient had a great outcome.  A 2cm x 2 cm hemangioma was resected with minimal disruption or trauma to surrounding tissue.  2 hours after a lengthy 4 hour surgery, the patient was sitting with their family… communicating and interacting with them.  All motor and sensory intact.

Pearls from this case:

1) Always do what is best for the patient.  When a life-and-death situation presents itself, it gets priority.  Period.  It doesn’t matter what pressure or temper tantrums you get from outside parties.  Make the best clinical decision. Organize a plan.  Stick with it.

2) Find out the surgeon’s plan.  This case was not booked in sitting position.  Some of these cases are done in prone position, which makes the likelihood of VAE significantly lower than in sitting position.  Knowing the surgeon’s plan of attack is critical to an anesthetic plan.

3) Read. Read. And read more.  Although I’ve been out of residency and fellowship for 4 years, cases will always test your knowledge as well as make you learn new skills/techniques to better your plan.  Take the time to do your best.  Always review.  Medicine is a lifelong learning career.

4) Don’t sweat the small stuff.  The “elective” neurosurgeon who raised such hell at the beginning of the case was thanking me for my help and expertise by the end of the case.  Learn as much as you can from your residency.  Take the knowledge gained and let your clinical acumen do the talking.  There is no room for ego when taking care of a patient.  Your ability to be well-read, well-trained, and well-respected will dictate the tone.  No fluff is needed when you bring 100% to the table.  Don’t be intimidated by the loud bark.

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1 comments on “When the bark is louder than the bite”

  1. Just postop-ed my suboccipital sitting crani patient from yesterday. He’s sitting up in chair eating breakfast w his mom. He’s so incredibly thankful. Not gonna lie… Shared a tear and a smile with him and his mom. The patient is just a kid and I’m so impressed w his genuine kindness and outlook on life. All sensory and motor intact. He just has a headache (not unusual after brain surgery). 😊 He completely made my day. Healthcare isn’t for a hardened soul. Medicine encompasses compassion. It embraces the ability to relate to other human beings and create a connection. As grueling as my job can be, I’m grateful to be able to connect with others and truly make a difference in their lives.

    Like

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