Clinical Case for Discussion: A needle-phobic 16-year-old male is scheduled for a shoulder arthroscopy at a freestanding surgery center. He is tearful and refuses any needles while he is awake. He is 5 feet 3 inches tall, weighs 220 pounds, and has a Body Mass Index of 39.
What would you do?
Discussion: You bring the patient into the operating room and apply the standard monitors. You begin an inhalation induction with 70% inspired nitrous oxide and sevoflurane. You increase the concentration of sevoflurane gradually after each breath. After 2 minutes, at 4% inspired sevoflurane, the patient begins to cough, buck, and have stridor, and the oxygen saturation plummets below 60%. You see no site to place an I.V., and the nurse and surgeon are no help. You are not able to improve the airway with jaw thrust, mask ventilation, continuous positive airway pressure, or an oral airway. You place an laryngeal mask airway (LMA), but the patient continues to have stridor and a weak cough. No ventilation is possible. You give intramuscular succinylcholine at 4 mg/kg, but while you are waiting for the drug to take effect, the patient’s ECG changes to ventricular fibrillation. You scream for the defibrillator, and do direct laryngoscopy to attempt placement of an endotracheal tube in the now-flaccid patient. Your heart rate is 180 beats–per-minute, and you are praying for the patient’s heartbeat to return. You can’t believe that this boy walked into the surgery center as healthy as can be, and that within minutes you have brought on the circumstances of cardiac and respiratory arrest.
In a parallel universe, you anticipate all the above issues, and prepare yourself. You are aware that his BMI = 39 places him at increased risk for an inhalational induction. You explain to the patient and his parents that there are risks for an overweight patient being anesthetized without an I.V., and lobby hard for him to permit you to attempt an awake I.V. placement. You offer him oral midazolam as an anti-anxiety premedication, and topical EMLA to numb the I.V. site. Alas, he is crying and still refuses any needle. You place an automated blood pressure cuff on his upper arm, and note that veins are visible on his hand when you inflate the cuff in Stat mode on that extremity. His airway appears normal. You describe to the parents that there is a risk that their son might have dangerous low oxygen levels during the mask induction of anesthesia. They agree to accept this risk, and you document the same in the medical records. You make a plan to proceed with inhalation induction, using the automated cuff to maximize the size of the veins on his hand.
(Note: If you do not have confidence in proceeding, you may delay the patient until another anesthesiologist is present to assist you, or cancel the case. Also note that if the anesthetic is done in a hospital rather than a freestanding surgery center, the identical clinical issues will be present, and the anesthetic plan will be similar except for the presence of additional backup anesthesia personnel.)
You enter the operating room and apply the standard monitors. You place a mask strap behind the patient’s head to help hold the anesthesia mask over his airway, and have him breathe 100% oxygen with high flows of 10 liters/minute for two full minutes prior to beginning induction. Next you add 8% sevoflurane to the gas mixture, and ask the patient to take deep vital capacity breaths your anesthetic circle system. This technique is known as Vital Capacity Rapid Inhalation Induction. (Yurino M, A comparison of vital capacity breath and tidal breathing techniques for induction of anaesthesia with high sevoflurane concentrations in nitrous oxide and oxygen, Anaesthesia.1995 Apr;50(4):308-11). For safety reasons, I prefer sevoflurane induction with 100% oxygen instead of using nitrous oxide, which limits the delivered oxygen concentration.
As soon as the patient is anesthetized deeply enough, (seeing the eyes conjugate in the midline is a useful monitoring sign), you activate the blood pressure cuff on his upper arm in the Stat mode, and you move to his lower arm to start the I.V. You leave the patient breathing on his own with the straps holding the mask over his face, and use both of your hands to place a 20-gauge I.V. catheter. Once the intravenous catheter is placed, you continue the anesthetic using intravenous and inhalation drugs, with either an LMA or endotracheal tube for airway management.
Ambulatory anesthesia in freestanding facilities is a gravy train of healthy patients and straightforward cases, right? Not all the time.
In the hospital, when you anesthetize elderly, sick patients for complex surgeries, you have a multitude of advanced technologies at your disposal. You have invasive monitoring, transesophageal echocardiogram machines, laboratories, blood banks, and intensive care unit backup, as well as dozens of other anesthesia providers available within seconds to assist you if you get into trouble. In addition, it’s understood by the patient and family that there are significant risks if the patient is old, sick, or if the surgery is complex.
In anesthetics for healthy outpatient surgery, the patient and the family expect the rate of adverse outcomes to be … zero. Despite your informed consent that rare problems could occur, there will be anguish and anger if problems indeed do occur.
Treat needle-phobia with respect. It can be a life-threatening problem in the hands of an inexperienced anesthesia provider.
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:
Learn more about Rick Novak’s fiction writing at ricknovak.com by clicking on the picture below: