Finishing Things Up

My last three cases of residency are quite interesting. One of them was a surgery I'd never seen before: a robotic-assisted distal pancreatectomy. It's interesting to think of surgical techniques as evolving over time because it means that someone has to try something new. The change from laparoscopic to robotic approach is not a dramatic difference and robotic approaches are used in similar surgeries, but it is still interesting to be involved in one of the early operations. Although it took quite long, everything went very smoothly. The anesthetic management isn't too different, but positioning the patient to accommodate the robot is an interesting puzzle of spatial configuration.

The following day, I was called for an emergency craniotomy in a patient who bled into his skull and was herniating his brainstem. This is a life-threatening emergency. I rushed down to the ICU and helped wheel the patient into the operating room. He was already intubated but his access was limited. We didn't have time to put in a central line, and I knew that decompressing his skull was the priority. We turned him prone (onto his stomach) and I managed to get two 18 gauge IVs into his feet. It's was definitely necessary because he needed platelets and blood transfusions. The surgery gave me a realization that I am pretty ready to graduate. Although it was a sick patient who was imminently dying undergoing a large neurosurgery, I knew what my priorities were. There is a lot to do: prepare for pinning of the skull, hyperventilating the patient, starting mannitol, determining an appropriate anesthetic in a patient who was altered to begin with, sending off an ABG, ordering blood, wrangling the ICU drips, decide on the appropriateness of hypothermia. It will be a tough recovery for the patient, but we did what we could for the anesthetic to protect the brain.

Tomorrow, I have a patient with severe ischemic heart disease and an ejection fraction of 15% (normal being around 60%). The heart is a failing pump, and designing a gentle anesthetic is a challenge. We'll see how it goes.