Dr. Eric Freeman writes from China
Pictures from China by Dr. Eric Freeman
5/7/08 935pm
OR Efficiency
Today our first case was a 56 year old male for a hepatectomy. I was working with Dr. Rong (a resident). Her english was not as good as Dr. Xieke's so I had to speak extra slowly and repeat myself often. I'm not quite in my rhythm as I am back home drawing up medications. The syringes and needles are combined and the package is a little annoying to open. All medications are in glass vials. Must be more inexpensive to manufacture them like that. I just need to open them slowly or else I will be on the receiving end of a axillary block for tendon repair surgery. After a straightforward induction and intubation, I put in an arterial line. There is no room full of hanging A-line and CVP pressure bags here. I grabbed a heparin vial and prepared one myself. Getting a little stool to make myself comfortable I was ready. Looking up I realized that an anesthesia cart chock full of supplies was not in front of me. No gauze, no little alcohol pads, and certainly no wire should I screw up. I had a 20 gauge catheter, tegaderm and cotton balls with antiseptic all lined up. Unfortunately I made a mess cleaning the patients forearm as I forgot to compress the heavily soaked cotton balls. I felt a bounding radial pulse and nailed it. Dr. Cui asked if it would be ok for Dr. Rong to put the central line in. Of course I had no problem as I have done at least 75 of them during residency, if not more.
No triple-lumen catheter here; its too expensive. Just a single lumen, 16 gauge CVP. We induced with midaz, fent, propofol, and vecuronium, then set up our standard infusions of prop, vec, and 0.5 MAC sevo. I wanted to use remifentanyl since I have limited experience with this drug. So we ran an infusion of 0.2 ug/kg/min since we already gave 200 ug fentanyl. The case took about 2 hours. The patient lost about 1 liter of blood. The hematocrit came back at 25%. The patient had no significant cardiac history. We just gave more colloid. Dr. Cui said that he is quite conservative with transfusing. Seems like the Chinese are not as gung-ho in giving blood as in the USA. As the case had about 1/2 hour left I turned off the vecuronium and we later stopped the remi and gave a bolus of sufentanyl. An IV PCA of sufent would be started in the PACU. Again, another intubated patient to the PACU as I bagged with room air O2. After connecting the monitors, I left to wash my hands as I knew our next case would start in about 10 minutes.
As I mentioned, this hospital has 10 operating rooms, and performs about 30-40 cases per day. To have all cases done by 4-5pm and be efficient, very rarely are any of the patients extubated immediately after surgery. They are brought to the PACU and within the hour extubated. The PACU can hold up to 5 patients. There are no day surgeries. The patients are either admitted the day prior or are in-house.
The nurses put the IV's in. As one case is in progress, the next patient is in a stretcher waiting outside the OR. The rooms are cleaned immediately. Very shortly after extubating, the patient is sent back to the floors. Should there be no room in the PACU, then the patient has to wait in the OR, but this rarely happens. If a spinal or epidural anestehsia is administered, it is not uncommon for a patient to be discharged to the floors with a dense motor block. Quite different management here. Dr. Cui seems to think highly of this model. Neostigmine is rarely given as Dr. Cui does not like to give too many medications.
I eat dinner for the most part in the same restaurant. The department gave me a debit card and I just present it to the waiter after stuffing my face. I try different foods every nite. I feel like a little kid pointing at pictures on the menu. I'm averaging about 50% in terms of ordering very spicy foods. Thats the next phrase I need to learn in Chinese: "not spicy." I got a little reading done and am working on my lecture for this weekend meeting in Lian Yun Gang in Jiangsu Province. I will give an abridged version of my grand rounds talk on "Non-obstetrical Anestehsia for the Pregnant Patient." That should be a trip since I have to obviously have it translated.
I have noticed that card playing, drinking tea, and ping-pong are quite popular here in China. A bunch of us are going to go out next week after work and hit the ping-pong ball around.....