A 50 year old long time smoker presents with squamous cell cancer of the lungs and is scheduled for a lobectomy. Thoracic surgery offers unique anesthetic concerns for several reasons. Not only do smokers have diseased lungs, but when the surgeons operate on the lung, they prefer not to have a moving target. We have to oxygenate and ventilate the patient with one diseased, poorly functioning lung. Lung isolation poses a problem as well; how do you intubate the patient such that one lung is doing all the work while the other lung remains still? Post-operatively, the pain of the thoracotomy incision is quite intense, which can cause patients to "splint" - that is, take very small, shallow, and ineffective breaths. Without coughing and deep breathing, patients are predisposed to pneumonia, which can be fatal in someone who just had part of the lung resected. So the anesthetic can be challenging, but sometimes that's what makes it fun.
Before going off to sleep, we put a thoracic epidural into the patient. Similar to an epidural for labor, this catheter delivers local anesthetic that numbs up the chest where the surgeons are cutting. This helps with post-operative pain control because the medications are not sedating, allowing patients to work on deep breathing without discomfort. But thoracic epidurals are technically harder than lumbar epidurals to place because of the spinal anatomy. My preference is to do a paramedian approach, aiming for the space from one side at an angle.
After inducing anesthesia, we place a double-lumen endotracheal tube. The tip of the tube goes into one of the lungs, but there is also a passageway that ends proximal (earlier). When the surgeons need lung isolation, we ventilate the bronchial lumen only. When they are ready to go to two-lung ventilation, we ventilate both lumens. These tubes can be difficult to place because they're larger than regular tubes and getting the lumen placement just right requires adjustments with a fiberoptic bronchoscope. During this case, we had a little trouble getting pure lung isolation, but managed to give the surgeons adequate operative conditions. During one lung ventilation, the oxygen drops and carbon dioxide builds up, and as anesthesiologists, we have to manage these physiologic disturbances.
My favorite part of the surgery, though, was at the very end when we extubated the patient and brought him to the ICU. We had given some local anesthetic through the epidural, and when I asked him if he had any pain, he said, "Nope, I'm ready to zumba."
skip to main |
skip to sidebar
In ancient Greece, the asclepion was a healing temple dedicated to Asclepius, the God of Medicine. Asclepius learned the art of surgery from the centaur Chiron and had the ability to raise the dead. The Rod of Asclepius is a roughhewn branch entwined with a single serpent.
Blog Archive
Hi! I am Craig Chen, a third year resident physician in anesthesiology at Stanford Hospitals and Clinics. I went to medical school at the University of California, San Francisco. Prior to medical school, I studied philosophy and biology at Stanford University, along with a minor in creative writing.
Labels
- Book Review (56)
- Death (73)
- Philosophy and Ethics (81)
- Poems and Stories (136)
Search This Blog
Posts
Disclaimer
The author of the site does not provide any medical advice and information here should not be construed or used as such. Using this site does not create a physician-patient relationship and is not intended to replace the services of a licensed, trained physician or health professional. No health or medical related decision should be based in whole or in part on anything contained here. Any opinions expressed here are not necessarily those of the author nor do they reflect the opinions of any of the author's affiliations. Content on this site may be changed without notice and is not guaranteed to be complete, correct, or up-to-date. Any comments posted to the site can be edited, modified, or removed by the author of this site.
2 comments:
Thanks, Dr. Chen! Hilarious ending! :)
This is the sort of stuff which excites me about anesthesia and which makes me love it even more. It's a perfectly blend of medicine (in your first paragraph) with a touch of enough surgery as well as plenty of thorny but very cool sounding procedures. Ah, man, I can't wait for med school to end; I really hope I make it into anesthesia someday.
By the way, can I ask you please, was it hard to master procedures? They all seem so tricky to me. I love reading about them and seeing them in person. But I'm always worried what if I don't have the hand dexterity.
I think everyone, in any specialty, has that uncertainty about procedures. As a medical student, you can't really get a sense of how it would be to do procedures independently, and even harder, troubleshoot them on your own. It's not even that easy as a resident.
Talking to most people in fields like surgery, anesthesia, and emergency medicine, it seems to be the kind of thing that everyone gets by the end of residency. Residency is set up so that you get graduated independence in doing procedures and that you have to do a certain number to reach proficiency. Residents who aren't particularly dexterous can still acquire the skill set through practice and perseverance - in one of Atul Gawande's books, he writes that motivation is a more important factor than baseline finger skills. We can all train muscle memory, and for some of us, it takes more practice than for others, but we all reach a point where we can take care of patients safely. And - perhaps this is sad to say, but it is a reality - there are avenues from each field if the manual intervention part of things doesn't work out; surgeons who develop arthritis may go into critical care, anesthesiologists who no longer like complex airways may become pain physicians, and neurosurgeons with a tremor may do research. In any case, I wouldn't let this apprehension dissuade you from the field you want to pursue.
Post a Comment