Always Learning

In a community hospital with a high volume of deliveries, it's easy to get complacent about obstetric anesthesia. For the most part, the procedures are straightforward; we do hundreds of epidurals for labor and spinals for Cesareans a year. There are certainly red flags for those that might be challenging - the patient with severe scoliosis or multiple back surgeries - but the vast majority of women are otherwise healthy, and getting an epidural or spinal is no problem.

I'm always learning though. Several months ago, I was doing the anesthesia for a patient getting a repeat C-section. Her prior C-section happened in a different country and she said she had a spinal which "didn't work." She had so much pain, they had to "put her out." Nevertheless, spinal anesthesia is still the preferred anesthetic for a Cesarean, and after talking to her, we decided to attempt it.

I placed the spinal smoothly in my first attempt; I got back clear CSF, which in nearly all cases, confirms the placement of the medication and the efficacy of the anesthetic. Her response, however, was unusual. She developed a patchy spinal block; there were parts of her leg and abdomen that were completely numb, but other parts that retained normal sensation. This occurred on both sides and at multiple levels; I could not explain this anatomically. We did not have adequate coverage for anesthesia, so I offered to do an epidural. I did not want to do a second spinal because overdosing someone with a spinal can be life threatening. Placing an epidural catheter, however, would allow me to carefully titrate the level of the block.

Again, the epidural went smoothly; the procedure itself suggested it would work well. Nevertheless, as I bolused medications into the epidural, she continued to have a patchy block. After speaking to her and the surgeon, we decided to convert to a general anesthetic. Fortunately, it was in well-controlled conditions; the baby was delivered within two minutes of intubation, there were no problems, and at the end, she awoke to the sounds of a healthy baby's cries.

Even if 99.9% of anesthetics are simple, straightforward, and easy, we will still run into that unusual presentation or odd case that baffles us. Nevertheless, we draw on our education and training, our problem-solving and critical thinking, our knowledge of anatomy, physiology, pharmacology, and medicine, and our skills developing a strong patient-doctor relationship in order to tackle these challenges when they present themselves.