PACU Emergency

As the scheduler for the ambulatory surgery center, I also respond to emergencies. I've had calls for help for difficult airways, tough IVs, and challenging inductions, but I learned most from a PACU emergency. A patient after an abdominal surgery has increasing amounts of pain. After giving the maximum allotted fentanyl and hydromorphone, a PACU nurse notices his patient is still moaning in pain and tachycardic. I am paged to evaluate the patient. His heart rate is 130, his blood pressures are dropping, and he is incoherent and moaning. This is not normal post-operative pain. One look at the patient, and I knew he was in extremis. I quickly called for help, increased frequency of vitals, put him on a nonrebreather face mask, and started pouring in fluids. Examining the patient, I noticed that his abdomen was quite rotund, and he looked very pale. Within moments, I recognized this to be a surgical emergency. There was bleeding in the abdomen. The patient would need to go back to the operating room.

Resuscitation in the operating room is one thing. We learn that quickly. Anesthesiologists take control, open IV fluids, call for blood, prepare emergency medications. We obtain additional access, insert an arterial line, alter our anesthetics, control the airway. But here, the beast has changed. I needed to be a leader. I directed nurses to put in additional IVs, get fluids, check labs, call for blood. All the things I would normally do, I instead delegated. As the ASC scheduler, I had to plan ahead.

My next step was to call the surgeon. They needed to evaluate the patient and determine if it was surgical bleeding needing reoperation. Though I was convinced, I needed them to cut. Then I had to identify an operating room. I scanned the board, found a room in between cases, and told them to prepare that room for a stat exploratory laparotomy. I had to work with the nursing staff to get a nursing team. I had to figure out my anesthesiologists. Since I didn't have that many available, I ended up starting the anesthetic myself. A lot of other players were contacted: pharmacy, blood bank, the lab. I didn't know if this would require a massive transfusion or fancier resources like interventional radiology or a trauma surgeon. I had to mobilize everything just in case.

The biggest thing I learned, though, is that I had to do this while wearing the hat of ASC scheduler. I continued to be called for routine inquiries. I had to manage the other rooms. I had other surgeons, other add-ons, and other requests bombarding me. In the end, we rushed the patient back to the OR, induced anesthesia again, found a bleeder, and successfully resuscitated the patient. When an emergency like this happens, leadership is critical to patient safety.