Never Seen a Doctor

Anesthesiologists like to have all the information available. We can get a little obsessive over when an echo was done or the last time an alcoholic drank or which medications the patient took this morning because it can make all the difference between a smooth well-prepared anesthetic plan and a scramble to keep things under control. The worst, though, is the situation where we know nothing about the patient. A victim of a car accident is brought in by ambulance with an open fracture needing reduction and fixation. I'm on edge because maybe the patient is on methamphetamines or maybe she has a heart condition or maybe she is allergic to an antibiotic I'm about to give or maybe she's on dialysis and nobody thought to check for a fistula. This is one of the reasons why I don't like trauma.

But even outside of trauma, these situations happen. An older woman is brought in for an acute abdomen. She's never seen a physician. Her blood pressure in the emergency department is 200/100. She is audibly wheezing. All I know is that she smokes. She's never been to a hospital, doesn't take any medications, has never had surgery. While sometimes a patient who's never been to a hospital is lauded for keeping good health, I had a hunch this wouldn't be the case. Her dentition suggested she'd never been to a dentist. Her scleral icterus suggested she might have liver problems. Her wheezing could be heard without a stethoscope. She had a hacking cough that brought up thick yellow sputum.

This is why emergency cases are riskier and more challenging that scheduled elective surgeries. After I intubated her, I noticed that her capnogram suggested severe chronic obstructive pulmonary disease. I struggled to keep her blood pressure from bouncing too high or too low. She could have heart disease no one has diagnosed. Her abdominal pathology could be causing her to go into sepsis. The endotracheal tube kept getting flooded with secretions from her 50 years of smoking. In cases like these, I have to have constant vigilance and high standards for care. At the end of the case, I waited a long time to make sure she was able to manage her breathing before extubating her. I stayed in the recovery unit getting her blood pressure into an appropriate range. These are things we should do for all our cases, but for someone whose diseases are uncontrolled, it requires constant attention and intervention.