Stay Humble #1
Every so often - completely out of the blue - along comes one of those days that kicks you up the rear and shouts,
"Hey, you ain't as smart as you think."
Well today was one of those days.
Hey are you anaesthetics?
Standard courtesy to be expected of a 3 am surgical registrar I suppose.
"I am - what do you need?"
"We have a laparotomy."
"It's 3 am, does it need doing right now?"
"Yeah boss says needs doing straight away.
"Cool what's the name? I'll go see."
Now, I realise that a large proportion of you will disagree with me on the following, but please hear me out.
I genuinely, hand on heart and no fingers crossed, love middle of the night laparotomies.
They feel big, important and dramatic and I get to do lots of procedures and look like a real anaesthetist, and there aren't as many people clucking around to get in the way and slow things up as there are during the day.
But then I also love doing ward cannulas so I appreciate I'm the problem child here.
So off I toddle
First things first, I find the patient on the computer and flip straight to their history to see what kind of baseline we're looking at before the endathebedagram skews my judgement.
- Independent
- No surgical history
- No medical diagnoses
- 67 and still working and driving
Fair play sir, off to a good start.
Onto the bloods:
- Hb 130
- WCC 9
- Platelets 217
- LFT normal
- Clotting normal
- EGFR normal
- Lactate 1.2
- CRP 1
Clearly this abdominal catastrophe needs fixing immediately.
Hello sir, I'm your anaesthetist
I pull back the curtains to find a man lying comfortably on the trolley, chatting merrily with his wife who just so happened to look worse than he did.
"How are you feeling?" I asked tentatively.
"Ah much better doc, big fart sorted me out."
He giggled with sufficient heartiness that ruled out peritonitis from the end of the bed.
"Are you still vomiting?"
"Not since yesterday evening doc."
"Fantastic - I've looked through your notes and it seems you've not got any medical diagnoses* or regular medications?"
"Quite right sir - fit as a fiddle."
A quick sidebar
There are plenty of unlabelled hypertensive, hypothyroid diabetics with ischaemic heart disease who have 'no diagnoses'.
(Hower in this case, he was slim with an athletic build and reassuringly bouncy forearm veins and all three thirds of his eyebrows intact, so it seemed fairly legit.)
"Excellent, have the surgeons explained what they'd like to do?"
"Yeah they say I've got blocked bowel and need to go in and sort it out."
The conversation continued with the usual blend of chit chat, non-judgemental alcohol consumption enquiries and staring into the back of his mouth before I toddled back rather bemused to Mr Surgeon.
Right now?
I found him in his office with his SHO updating the list. As he looked up from his phone he piped up with his characteristic loquacity,
"Ready to brief?"
"Yes absolutely I've just seen him and I'm very happy to do it now, but I have to ask - given his CRP is 1, lactate is normal, he's comfortable, not vomiting and he's passing wind - is it not safer to wait until the morning?"
"That's what I thought - his pain has resolved and he's not perforated on the scan - but the boss wants to do it now."
"Alright - let's go then."
Sleepy time
Given my history with 'life or limb' cases overnight, I'd double checked with my own consultant (who also triple checked with the consultant surgeon) to confirm that yes this does indeed require doing overnight, so we cracked on with the case.
- Spinal - (2ml 0.5% heavy bupivacaine and 800 mcg diamorph since you ask)
- RSI - (100 mg prop, 100 mg ket, 100 mcg fent, 80 mg roc)
- Videolaryngoscope - (LoPro S3)
- Arterial line - (flowswitch obvs)
- Big drip
- NG
- Pressure points and position
And relax.
The surgeons traipsed in with the enthusiasm of a sloth filling out a tax return and starting prepping, while I drew off an arterial blood gas and an up-to-date group and save that hadn't quite made it from the printer in ED.
- Lactate 0.8
- Hb 135
- Base excess 0.6
I showed it to the surgical registrar who gave me a sigh of agreement and started painting the abdomen orange, just before the consultant came bustling through the door.
I stand corrected
The surgical registrar's eyes widened wearily as he stared into the abdomen. I couldn't see what he was looking at but he looked at me and said,
"We made the right call".
"I do know what I'm talking about, you know." quipped the consultant calmly, as around a foot and a half of very unhappy small bowel was hoisted out of the abdomen.
It hadn't perforated yet, but it wasn't going to be long, and it definitely wasn't viable.
"How do you have gut like that and a lactate, base excess and CRP all less than 1?" I asked, genuinely mystified.
The consultant gave me a knowing look and uttered "it's not just about the numbers" before returning to the open abdomen in front of her.
"Great call," I replied, without mentioning the fact that literally every surgical referral ever has required an impressive lactate to be granted an ear, and quietly got back to my paperwork.
The rest of the case was uneventful and the patient woke up comfortably and went to the ward.
Stay humble
This case genuinely scared me, because if it weren't for the persistence of that particular surgical consultant, this patient would likely have had a very different outcome.
Granted, there would probably have been a decline in the patient's condition over the next few hours that would have signalled the immediacy of the issue, and they would have still undergone an overnight laparotomy, but certainly in a much worse state.
To be that fine and have such compromised bowel was incredible, and a real testament to the clinical acumen of a very experienced surgeon.
Even the surgical registrar admitted that with many of his other consultants, he would have told them it could wait until the morning and they would likely have agreed with him based on the numbers.
Reflection
I came away from this case with a renewed humility that actually I'm not as swish as might like to think.
I've always struggled with anxiety and imposter syndrome, but I had noticed an increasing sense of confidence building over the last few years - nice to see that's been thoroughly put back in its place.
Here are my take away points:
- Guidelines are guidelines, not definitive rules
- Patients haven't read the rulebook, and will merrily present with whatever damned illnesses they like, however they want
- Sometimes you have to trust in others' expertise, even if it means questioning your own knowledge
This is one of my favourite things about this career - the constant self-improvement that will occur indefinitely, as long as you let it happen.
Got a similar story?
We know you do.
We'd love to hear from you, either in the comments, or email us at anaestheasier@gmail.com.
- What happened
- What your gut was telling you
- What you learned
We can then share it (anonymised of course) so that our other wonderful readers can learn from your experience.
Check out our other mental health and wellbeing posts here
