Not All Cookie Cutter

Some people perceive anesthesia as being fairly straightforward, and most of the time it is. Many surgeries have a routine: assess patient, start the IV, bring the patient back, place monitors, induce anesthesia, intubate the patient, give antibiotics, maintain anesthesia throughout the case, wake the patient up, extubate, and bring the patient to recovery. And there are many days when we do not deviate from this steadfast course. But like everything in medicine, it isn't the routine that pushes our skills as physicians, but the exceptions.

When a day goes smoothly, I am thankful and I learn things, but I await those cases that challenge me. Some may seem minor; for example, I anesthetized a patient who had nausea and vomiting after every other surgery in the past. So we took out all the stops, giving steroids at the beginning of the case, multiple antiemetics at the end, avoiding emetogenic agents, and maintaining anesthesia with an intravenous infusion of propofol rather than inhaled gases. The outcome? She was thoroughly impressed and very satisfied with the anesthetic after the surgery.

Other cases that stress us involve life-threatening disease states. While on call, I was asked to prepare a patient for anesthesia who had a solid organ transplant, a bone marrow transplant, and active chemotherapy; all her blood counts were flagged bright red in our electronic medical record. Prior to incision, we gave two units of FFP, platelets, and packed red blood cells. Her infected knee was likely causing a low-grade sepsis, she had altered mental status, and her kidneys were failing. While a knee incision and drainage isn't a serious surgery, this was a patient requiring us to use all our available tools to maintain homeostasis.

Lastly, it's not just the medical and technical aspects of anesthesia that are challenging. One morning, my first case of the day was for a patient with Down syndrome. Although relatively high-functioning for someone with trisomy 21, he acted more like a child than an adult. I had to sit with him and coax him to allow me to take a look at his veins. He was understandably scared and reluctant to have anything done, and it took me ten minutes to place an IV (luckily, I got it on the first try as I knew he wouldn't let me have a second). I had to develop a trusting patient-physician relationship before he'd let me do anything.