Dr. Eric Freeman writes from China
Pictures from China by Dr. Eric Freeman
5/13/08 10:45pm
A day with the bone docs
A day with the bone docs
The weather walking to the hospital was quite pleasant this morning. Unfortunately, devastation hit central China yesterday around 230pm in city called Chengdu. An earthquake measuring 7.8 on the Richter Scale caused massive destruction with a death count of 10,000 as of today. I was hard at work in the OR at that time and did not feel a thing, even though its effects were felt as far away as Thailand. I was on the internet late last night and received numerous e-mails from my mother making sure I was ok. I emailed a good friend of mine in the residency program who called her to say I was doing just fine. The chairman of my department also called my mother to reassure her that I was doing well.
Today was ortho day. It is really my favorite subspecialty of anesthesia I think mainly due to the fact that my best friend from medical school is an orthopod and if I were to be a surgeon in my afterlife, orthopedics would definitely be it. Our first case was a 77 year old woman with coronary artery disease and hypertension and normal ejection fraction of 67% for an ORIF of the hip. I asked Dr. Cui last night if I could do a continuous spinal as my anesthetic plan. I have done a few of these back home on very sick patients for lower extremity bypass surgeon with great success, specifically stable hemodynamics. Dr. Cui was not keen on my doing it after much convnicing. He sited postdural puncture headache and cauda equina syndrome as main complications. Of course I could not argue, but I tried to make my points, especially after yesterdays combined spinal-epidural in an 11 year old. The patient was on the table and I hooked up the monitored and but an arterial line pre-induction. HR 110, BP 190/97. The resident told me the HCT was 22%. Great. Guess somethings just do not change no matter what part of the world you are in. Another optimized patient from the orthopedic service, just like in our hospital where some orthopods think that 1 gram of cefazolin will increase cardiac output. After pushing some anti-hypertensive medications, we proceeded with a narcotic based induction. As expected, quite a few blood pressure swings was seen. I transfused 3 units of packed cells thru a central line. After the two hour case, we transferred the patient to the ICU without monitors, but with O2 this time. The ICU was pretty standard and I was a bit surprised to see a bunch of Baxter pumps by each patient’s bedside. Hopefully this patient will not develop a post-op MI.
A quick lunch of delicious duck and some green vegetables followed. I decided to hold on the rice again. The Chinese really love their rice. Lunch and dinner. I asked if they had it for breakfast also. Sometimes they will, if not in a rush. I heard on CNN the other day that the price of rice is at an all time-high. I certainly am not contributing to that…
Next case was a 50 year old for ORIF of tibia. I was excited as I would get to redeem myself from my pathetic performance yesterday with an epidural. 2mg of midazolam in. I got the kit ready and positioned the patient right-lateral decubitus. I had to grab a sterile set of 7.5 gloves. It was still a tight fit. I am normally a 7.0. The Chinese have small hands. An 8.0 is the largest size they have here in limited supply. I just can not deplete their stock. After prepping the patient, I drew up 2% lido for local and the spinal would be ropivicaine. I’m used to the fancy all in one combo of bupi plus dextrose for out hyperbaric spinal. I had to take 2cc of 0.75% ropi and add 1cc of 10% dextrose. Getting into position I was ready. Looking at the tuohy needle, I counted 8 lines. We have 9. The resident said, “American’s big, Chinese little.” I added a little saline into the glass syringe to decrease any friction. After a few minutes of poking around I felt a loss. Hard to describe using the glass syringe, but it just felt different. Pushed the spinal needle thru and out spurted the CSF. Medications injected, catheter threaded, and patient repositioned. Now I do feel pretty knowlegable with local anesthetics. Ropi and bupi are pretty similar with the main differences being less cardiotoxicity and motor block with ropivicaine. I was quite surprised to see the motor block from an intrathecal injection take about 7 minutes onset time. We’ll see what I observe the next time…. I wanted to snow the patient with propofol. I am told the Chinese do not like to be heavily sedated during surgery; they like to know what is going on. So 2 mg of midazolam. That’s it.
Of note, it was really nice not to see or hear any of those annoying orthopedic reps that are always floating around during cases…
Last case of the day, axillary nerve block. 19 year old female for an ORIF of the proximal 5th digit. I decided to grab a seat and see how they do it here in China. 2mg of midazolam in. The resident prepped the axilla then injected a little lidocaine. Now I did not expect to see some big 80,000$ ultrasound machine with multiple knobs and all the bells and whistles one could ask for., but what I saw next definitely raised an eyebrow. After palpating the axillary artery, the resident took a syringe which contained the local anesthetic and a regular sharp 22 gauge needle. I am used to performing blocks with a nerve stimulator. Of course before this invention, the old paresthesia approach was used. I am pretty sure that blunt bevel needles were used to reduce the incidence of nerve trauma. The resident was not trying to elicit a paresthesia, just positioning based on anatomy. After aspiration, incremental injections of local anesthetic was given. The local was 15cc 1% lido and 15 cc 0.2% ropvicaine. I double checked this later. Of course the 1% lidocaine is analgesic. I was not quite sure about the ropivicaine. I read that concentrations greater than .375% ropivicaine can give a moderate block. So this really did not seem to make sense as this would be our primary anesthetic. Incision made 15 minutes later. The patient moved around quite a bit and said a bunch of words that sounded like curse words… I grabbed a syringe of propofol, bolused it, and cranked up the sevoflurane to 8% and threw a mask over her face. A failed block. I can’t say that I was surprised. I asked Dr. Cui the failure rate of blocks performed this way. He quoted around 20%. As Dr. Cui told me, “The USA is a developed country, China is a developing country.” The department just purchased a nerve stimulator monitor about 2 months ago, yet the needles are quite expensive, about 20 USD a pop. He said the next case requiring a block I can use it. The residents there have yet to use it. If I performed this type of anesthetic back home I am certain I would be at center-stage during one of Dr. Lagasse’s QA conferences.
After work I joined Dr. Xieke, one of the residents and his wife for dinner. They both speak the best English I have heard here in China. His wife is a microbiologist and has been speaking English for quite some time. I think maybe ten years. I think that Chinese is probably one of the most difficult languages to learn. I have heard that a good 3 to 4 years is required. I have a few phrases under my belt. God knows how to write them in Chinese symbols. It was nice not having to point at pictures and guess what I would be eating for dinner. I stuffed my face with oysters, mutton, frog, and bamboo shoots. Dr. Xieke told me he has been on 2 Operation Smile trips during his residency and that each year a group from the department go to an underserved area of China and provide anesthesia. I thought that was awesome and said how I planned to do that in the near future. We talked some more about anesthesia and how I intubate difficult airways and the types of anesthetics I adminster for certain procedures. I hope to teach him some different techniques during my time here, after all, we can learn from each other….