Clinical Case: The Emergency Room physician calls you to see a 70-year-old man with severe abdominal pain and a known abdominal aortic aneurysm. The patient’s BP is 80/40, and his heart rate is 120. What do you do?
Discussion: Prior to my anesthesia residency I was an Emergency Room attending at Stanford University Hospital. I witnessed patients such as this one managed well, and mismanaged. Difficulties were system problems coordinating the ER, the OR, patient transport, the surgical team, and the anesthesia team.
Let’s look at this case. Assume it is 10:00 p.m., and the patient is in a private hospital setting. When you get the call from the ER, you are at home, 20 minutes from the hospital. You jump into your car and streak toward the hospital. You telephone the OR from your car, to make sure the room is ready, and the anesthesia techs (or nurses, as some hospitals do not employ anesthesia techs) have the equipment that you want ready in the OR. You request two Level 1’s, IV lines, an arterial line and pulmonary artery catheter, 3 transducers, a four-channel drug infusion pump, a TE echo, and a tray of syringes. Next you call any other anesthesiologist who is already in the hospital. This will usually be your colleague or partner in OB anesthesia. You present the case to him or her, and make a plan. Your colleague will go to the ER, and transport the patient to the OR. You also re-telephone the ER to make certain that a surgeon is there, or en route. You instruct the ER physician to put the patient on oxygen, to attempt 2 large bore peripheral IV’s, to get blood stat from the blood bank (probably O negative given the acute nature of the bleeding), and to attach a portable monitor. You instruct both your partner and the ER staff to not waste time on arterial line attempts or CVP attempts. They need to transport the patient to the OR as soon as possible.
When you arrive at the hospital, the patient is rolling into the OR, stuporous and moaning. Your partner helps you attach routine monitors. The blood pressure and heart rate are the same as they were minutes ago when the ER physician called you. The surgeon scrubs and gowns, and the nurses prep as they would for a stat cesarean section. You leave both arms out for line access. You do a rapid sequence induction with etomidate and succinylcholine, and intubate the trachea. You also give .4 mg scopolamine IV for amnesia. The surgeon makes the incision and clamps the aorta in minutes. The bleeding is retroperitoneal. There is no blood in the abdomen. After aortic clamping, the BP rises to 100 systolic. You continue volume resuscitation with O-negative blood. Your partner places a radial arterial line and sends a blood gas, while you place a TE echo to monitor left ventricular volume. You consider adding a pulmonary artery catheter as quickly as possible, to give cardiac output and systemic vascular resistance data. Maintenance anesthesia may be either inhalation or narcotic, if the patient’s BP will tolerate any anesthetic.
For patients with ruptured abdominal aortic aneurysm, the overall mortality rate is up to 90%, with the time from onset of symptoms to control of bleeding being the key to outcome. 65–75% of patients die before they arrive at hospital and up to 90% die before they reach the operating room. (Brown LC, Powell JT, Annals of Surgery 230 (3): 289–96, September 1999). An abdominal aortic aneurysm will usually rupture into the retroperitoneum, which permits tamponade of the hemorrhage. About 25% of abdominal aortic aneurysms rupture into the peritoneal cavity, and these cases have a greater amount of bleeding, at a greater pace. In select cases, if the patient is stable enough, the surgical team may elect to treat the ruptured aorta by an endovascular approach to the abdominal aorta. Either way, your role as the anesthesiologist is to get the patient into an OR, and put an endotracheal tube in without delay, so the surgeon can clamp the proximal aorta and control bleeding. Common mistakes are: (1) Delays in the ER to put in IV’s or invasive monitoring lines. A 14-gauge IV will not keep up with blood lost from an aorta; and (2) Delays in transport to the OR. You can not rely on traditional hospital transport systems. Physicians need to “scoop and run”, much like a trauma helicopter team in the field, and get their patient into an OR.
The remainder of the anesthetic management is familiar territory, discussed in textbook chapters on abdominal aortic repair. Management will involve transfusion of the appropriate amount of blood products, optimizing cardiac function, acid-base status, respiratory status, temperature, and urine output. The patient is taken to ICU sedated and ventilated for postoperative care.
This patient was an “ASA 5” classification who survived surgery because you were swift and wise.
Take this advice from a former ER doc: Know when and how to get out of the ER fast.
Published in September 2017: The second edition of THE DOCTOR AND MR. DYLAN, Dr. Novak’s debut novel, a medical-legal mystery which blends the science and practice of anesthesiology with unforgettable characters, a page-turning plot, and the legacy of Nobel Prize winner Bob Dylan.
In this debut thriller, tragedies strike an anesthesiologist as he tries to start a new life with his son.
Dr. Nico Antone, an anesthesiologist at Stanford University, is married to Alexandra, a high-powered real estate agent obsessed with money. Their son, Johnny, an 11th-grader with immense potential, struggles to get the grades he’ll need to attend an Ivy League college. After a screaming match with Alexandra, Nico moves himself and Johnny from Palo Alto, California, to his frozen childhood home of Hibbing, Minnesota. The move should help Johnny improve his grades and thus seem more attractive to universities, but Nico loves the freedom from his wife, too. Hibbing also happens to be the hometown of music icon Bob Dylan. Joining the hospital staff, Nico runs afoul of a grouchy nurse anesthetist calling himself Bobby Dylan, who plays Dylan songs twice a week in a bar called Heaven’s Door. As Nico and Johnny settle in, their lives turn around; they even start dating the gorgeous mother/daughter pair of Lena and Echo Johnson. However, when Johnny accidentally impregnates Echo, the lives of the Hibbing transplants start to implode. In true page-turner fashion, first-time novelist Novak gets started by killing soulless Alexandra, which accelerates the downfall of his underdog protagonist now accused of murder. Dialogue is pitch-perfect, and the insults hurled between Nico and his wife are as hilarious as they are hurtful: “Are you my husband, Nico? Or my dependent?” The author’s medical expertise proves central to the plot, and there are a few grisly moments, as when “dark blood percolated” from a patient’s nostrils “like coffee grounds.” Bob Dylan details add quirkiness to what might otherwise be a chilly revenge tale; we’re told, for instance, that Dylan taught “every singer with a less-than-perfect voice…how to sneer and twist off syllables.” Courtroom scenes toward the end crackle with energy, though one scene involving a snowmobile ties up a certain plot thread too neatly. By the end, Nico has rolled with a great many punches.
Nuanced characterization and crafty details help this debut soar.
Click on the image below to reach the Amazon link to The Doctor and Mr. Dylan:
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