Emergency

True surgical emergencies, the kind that have to go immediately, are uncommon. Other than stat C-sections, there are few disease states or injuries that don't even allow five minutes to evaluate the patient, prepare medications, and set up equipment. Even cases like appendectomies, exploratory laparotomies for a perforated viscus, debridement and fixation of an open fracture, etc. allow time for laboratory studies, imaging, and evaluation before going to the operating room.

The other day, however, I had a true emergency. As I was taking my prior patient to the post anesthesia care unit, the anesthesia scheduler told me that a patient was coming up from the emergency room now and that I had to get as much prepared as I could. An elderly gentleman with an unknown history presented with altered mental status. He was found to be tachycardic, hypotensive, and hypoxic with an oxygen saturation of 60%. The emergency department attempted to intubate him, but because of tracheal stenosis, they could not pass a regular size breathing tube, and instead put in a tube that was too small to adequately ventilate him. He needed an emergency tracheostomy, a surgical procedure to put a breathing tube through the neck.

The procedure was really emergent; as the patient rolled in, he had unstable vital signs, and we rushed to get him on the operating table, hook up our monitors, check our IV access, and prep the neck for surgery. Once the new airway was secured, we were able to oxygenate and ventilate the patient. This case taught me the priorities for an emergent case; here, the surgery was the definitive solution and nothing should delay that. From an anesthesia standpoint, my priorities were trying to oxygenate and ventilate the patient, supporting the blood pressure, and checking my IV access and monitors. Once these were satisfied, I had to ensure amnesia and give antibiotics. I didn't have the usual luxury of time and planning, but identifying the most important steps were critical to the anesthetic.