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03 April 2012

Anaesthetics= Safe passage through Surgery

This is my one week exploring the wonderful world of anaesthetics.  So far I have done cannulas and laryngeal mask insertions.  Most of the consultants and registrars have the same reasons for liking their fellowship:
1) results are always immediate; they can chemically speed up or slow down a patient's heart rate and blood pressure as needed. They can make them breathe and watch the oxygen saturation rise correspondingly.
2) The lifestyle is good
3) you only manage one patient at a time, and pretty much never have to deal with complication after surgery is completed.
If done properly, anaesthetics is a pretty laid back job.  Enough so that they catch a bit of flack:

I have sat in with the anaesthetist during orthopedic surgery, lithotripsy (breaking up kidney stones), and cardiac surgery.
During the lithotripsy session, the patient developed hiccups after administering the Propofol (a milky looking drug that makes you lose consciousness). Normally we wouldn't have to paralyze the patient, but his diaphragm wouldn't stop jumping around, some rocuronium was added, and that was the end of that. Start the ventilator!

I sat in on a coronary artery bypass, and I had to write it down before the amazingness of seeing someone's heart and lungs while they were still using them slipped away like a dream.  It was an awe inspiring thing. Standing next to the anaesthetist during the procedure is the best seat in the house to watch open heart surgery.  Cauterizing as they go, an incision is made down to the sternum.  Vapourized flesh curls up in small plumes like from your morning coffee; the surgical assistant suctions off the acrid smelling smoke.  Then out comes the electric bone saw.  The rib cage collapses slightly to one side once they finish sawing. The chest is winched open, and there is the heart, convulsing in its space. The lungs gently expand and recede over the heart like slow waves on the shore. It smells of salt and iron, and the scent reminds me a bit of fresh uncooked steak. The main artery and veins are placed on bypass, and a machine takes over the work of both heart and lungs. The lungs are allowed to collapse, they flatten and shrink away into the back of the chest.  The heart takes a dose of potassium salts, and slowly quivers to a halt- cardiac arrest.  Last week in emergency department, the same condition would have sent a small army of doctors and nurses into a flurry of activity. It looks shriveled and deflated and defeated, cowering in the bottom of the thoracic cavity. The surgeon dumps a cup of sterile ice on it, which will cool it and slow the muscle's metabolism. Now the surgeons can get to work, replacing clogged coronary arteries with cleaner ones donated by the adjacent internal mammary artery and more distant saphenous vein sites.

All the while, the head of the person having this done to them sticks out from under the drape with eyes taped shut. The patient is pink and peaceful, even though by some standards he/she is dead. They have no heartbeat and no pulse, only the steady whirsh of blood in the tubes of the bypass machine.  The temperature has dropped into hypothermic ranges. And the insides are outside, which only 300 years ago meant you were dead or heading there. No breathing. No movement or awareness. Hopefully the brain is in a quiet, nothing place while this is going on.  So surreal. The grafts are finished and tested. The heart is started again with what looks like electrified salad spoons on either side of it. The grafts hold as they take on the challenge of feeding oxygen to a hungry heart. The lungs are re inflated, and the chest is put back together with wires and sutures. They will let the anaesthetic wear off later tonight, and the patient will recover over the next weeks.  The sternotomy scar will remain, but I doubt the patient will ever comprehend what actually happened in that OR.

BBC produced a great history of surgery, and Episode 2 demonstrates how the ability to do heart surgery evolved:

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