Dr. Eric Freeman writes from China
Pictures from China by Dr. Eric Freeman
5/16/08 9:50pm
Watch one, do one, teach one
I am getting a bit tired of eating the same breakfast; fried eggs, a roll with apple jelly, and some heated milk. Of course I use chopsticks. I will have to check my cholesterol when I return home. I am sure it is through the roof; I might have to start Lipitor. It was a nice gesture when Dr. Wong, one of the attendings brought me breakfast today. She handed me this triangular shaped object. I forget what it was called, but it was hot to the touch and wrapped in a bamboo leaf. I eagerly opened it and cracked a smile. Of course…RICE. This was brown rice and rather gooey. Not sure if I was supposed to eat it with chopsticks but I was so hungry that I did not care. I made a bit of a mess at my desk . Washed it down with some coffee. Pretty tasty. There was some meat when you got to the middle of it. Hopefully it was not pork.
As physicians, specifically anesthesiologists, we are constantly learning. Learning from our patients, our colleagues, our textbooks, conferences, whatever. I have noticed that there is not that much diversity amongst attendings in terms of the administration of a general anesthetic. The majority of patients will have their endotracheal tube supplemented with 0.5 MAC of sevoflurane, with an infusion of propofol and vecuronium added to the mix. Of course all received fentanyl, usually 200ug and some midazolam on induction. The usual cocktail for a combined spinal-epidural is 2cc of .75% ropi with 1cc 10% dextrose for the spinal, and then 1% lido with 0.375% ropi for the epidural infusion. I am learning and being exposed to so much here that I asked myself what could I do differently and teach them that maybe, they have not seen.
I have been working quite a bit with Dr. Xieke, since his English is the best among all the residents. For the most part, the patients will either come down to the OR with an IV in place from the floors or the OR nurse will place it in the room. I asked Dr. Xieke how many IV’s he has placed. He answered, “I think maybe five.” He told me on the Operation Smile trip he participated in he had to ask for assistance with IV’s. To me, this was totally unacceptable as he was a third year resident. I said to him, “ Every case we work together and the patient has no IV, you will place it, not the nurse.” I am teaching him and he is improving.
72 year old patient for ORIF of the femur. History of HTN, but otherwise in pretty good health, unlike the usual ASA 4’s we are accustomed to in the Bronx. Dr. Cui knew that I was eager to perform a continuous spinal anesthetic last week but he would not let me because of the catheter size in the kit. I was shocked when he handed me a special continuous kit that he ordered. So nice of him; he bought a few of them just for me. I had a little bit of an audience for this one as some of the attendings had never seen this anesthetic done before. Patient in the usual lateral decub/fetal position. A clean scrub of the back, a little local, and away I plunged with the tuohy needle. The CSF was flowing like Niagara Falls. Catheter threaded, taped well, aspirated back for CSF confirmation. Patient repositioned, BP cycled to every minute. I gave the patient a total of 9cc, 0.1% isobaric bupivicaine. T10 level confirmed. The blood pressure did not budge. Case lasted about 2 hours. Rock stable hemodynamics. Catheter then pulled. I think Dr. Jackson and Dr. Muger would both be proud of me if they were here. As usual, patients are sent back to the floors after neuraxial anesthesia with a dense motor block. I will check on the patient later.
It was starting to bother me a bit that every patient left the OR intubated. I understood about OR turnover time and efficiency but I knew there could be another answer to this. Ahh… the deep extubation! That’s it. I told Dr. Cui my plan and he told me to proceed. Dr. Xieke was eager to watch and learn. Another drug I have yet to see is glycopyrolate. Hmm. Potential problem. Neostigmine is everywhere here, just never used. Atropine is also floating around. Jogging my brain a bit. Neo and glyco, edrophonium and atropine. Kinda like Sonny and Cher, or Mork and Mindy. The two are not supposed to be separated or problems might occur. Onset time, duration of action. I saw an old version of Barash lying around so I ran to double-check something about the pharmacology of these drugs, but remembered the book was in Mandarin Chinese. The 2 hour case was coming to an end. A half hour until we were to depart to the PACU. I scrambled into 3 different OR’s before finding an oral airway. I like playing with their fancy twitch monitor with the force transducer. T4/T1>0.9. Sevo to 8% . Deep suction, airway placed. The reversal issue awaited me. Give a little neo now and then a small dose of atropine later.? Or maybe just a few small boluses of neo while being vigilant to the HR and BP. I ended up giving 1.5 mg neostigmine and 0.2 mg atropine. Patient extubated, face mask on. Spontaneouly breathing. Tidal volumes picked up and the gas turned off. After the last stitch, I told the patient to “open his eyes” in Chinese with my mild Bostonian accent. 30 seconds later he reached to take the oral airway out himself. Off to the PACU. The nurses were taken aback not seeing an intubated patient being wheeled in. I told them it was to make their work easier. I don’t think they understood me.
Today was a very good day. I feel that the residents got something out of it and I hope they will maybe use these techniques in the future. For myself, I was estatic. My confidence went to a new level; no attending looking over my shoulder. I walked out of the hospital with a large smile on my face.