“Hello – I’m going to stick this needle in your spine now”

Today I want to talk to you about some of the really (I mean REALLY) cool things that I have been doing recently in anaesthetics. Now to put this in some context, as a young (well, moderately young) wet behind the ears junior doctor (the ears are still slightly wet but fast drying out) I would break frequently into a sweat at the sight of a challenging cannula (-if you recall, these are the tubes we stick into your veins to give fluids etc.).

Today however, I have charged triumphantly past these earlier ‘sweat-inducing feat’, and was sticking rather large needles into patients’ spinal canals. This was to give them anaesthetic that would numb their lower limbs….in theory at least. Joking – they all were adequately anaesthetised!

So let me set the scene for you: I am standing there ‘scrubbed’ in mask, gown and gloves in front of my patient who are laying in the ‘left lateral position’ – that’s the foetal position to most of us…holding a very long needle (having already applied some local anaesthetic to the skin at the area of the spine that I will be anaesthetising). Yes my hand is slightly shaking. Bad for me and bad for the patient! So I take a breath and approach the spine with my needle. It pierces the skin…a drop of blood appears and the patient tenses up. “Stay nice a relaxed, Sir” I say in my most professional – I’m not at all nervous [cough] voice. I steady the needle now sticking out of his skin and after a sharp intake of breath I press my thumb and index into the end of the needle and advance the needle.

The patient grimaces.

I grimace.

As I keep advancing I am waiting for the ‘pop’ that tells me that I have pierces the thick ligamentum flavum and enters the needle into the subarachnoid space. This is the space that contains the cerebrospinal fluid (this is the fluid that bathes your brain and spinal cord).

I keep waiting.

I advance the needle further.

Still waiting.

After an internal debate in my head of ‘should I’, ‘shouldn’t I’ advance the needle even further (and with a wry smile to myself at the thought of peering over the patient and seeing the needle poking out of his belly button!)…I decide to advance further…

POP.

Success! As I exhale with a blend of relief and triumph at the POP, withdraw a part of the needle that essentially leaves a hollow tube connecting the outside world to our inner bath of our brain and spinal cord. Now in theory a drop of cerebrospinal fluid should appear at the end of the tube to tell me that I am in the right spot.

I wait once again.

Willing the droplet to appear, I stare at it like a child staring at the chimney on Christmas eve with a carrot and milk in their tiny excited hands. Relief! It appears.

I nod at the drop, like it and I have met for the first time. It was a welcome sight indeed – mainly because the patient’s blood pressure was dropping. I insert the anaesthetic and 15 minutes later the patient’s lower body is numb.

Now this was indeed a victorious time for me – I stood over my patient deeply satisfied. I should however be honest and put this victory in context – today I attempted 8 spinal anaesthesia proceedures. I achieved 5 out 8 successfully. The other 3 required the seasoned head of the registrar anaesthetist (who later tells me that he must have done well over a thousand of these in his career!).

A good day indeed….

See you next week.

Dr Nick

Certifying a Death: The happy-sad balance.

Now one thing that I am beginning to realise working in the Intensive Care Unit (ICU) is that the patients there are very very sick. They are indeed there for a reason – they need intensive treatment. Sometimes the lengths to which we go to ‘treat’ a patient will be capped. We call this a ‘ceiling of care’. This is a very complex, decision making process that is about balancing the advantages of pursuing an aggressive treatment course that may indeed cause distress and harm to the patient – versus – a kinder pathway that is about supporting the patient without such extreme methods but with an understanding that this will in all likelihood gently lead them to dying. There is no black and white in such a decision making process – it is done on an individual patient basis and involves discussions with the relatives at length to agree on a plan that is best for the patient. It is ALL about the patient.

With the above in mind, it is no surprise that I have found myself certifying a lot of deaths. As this is quite a delicate, sensitive area of medicine I thought I would share it with you. We will, after all, all have experienced a family death and so this process been completed. Once a person has died, a death certificate needs to be completed as soon as possible. This is a legal document that needs to be completed as soon as possible for without it, the family cannot have the body released for burial or cremation etc. The first thing that will happen is that the team looking after that patient will agree on the cause of death and the processes that led to it. There are very distinct parts to this certificate – referred to as PART 1 and PART 2

Part 1 of a death certificate is in three parts and is essentially the journey of the patient’s illness that led to their passing. It broken into:

1a.

1b.

1c.

So for example, if we had a patient who developed a community acquired pneumonia that led to them developing a respiratory failure and acute kidney injury, the certificate may read:

1a. Respiratory Failure

1b. Acute Kidney Injury

1c. Community Acquired Pneumonia

Part 1 of a death certificate is just 1 part and is simply all the co-morbidities that may have indirectly made it harder for that person to survive an illness. This could be anything from type two diabetes to chronic kidney disease to ischaemic heart disease.

Now, I know that this all sounds very clinical. It is. It is meant to be completed as quickly, professionally and respectfully as possible so the family can continue with their grieving process. Where it gets difficult (and I have experienced this three or four times now) is where a cause of death IS NOT clear. If you remember what I said – this means that no death certificate can be completed. As such, the family have to wait. What’s more distressing to them is that if no cause is determined, then I, as the junior doctor, have to call the local coroner to discuss the case. Sometimes this is just a chat and an agreed cause of death is reached with their help….or the decision cannot be reached and a post mortem is required.

Post mortems are distressing for any family and I feel so much for every one that has to endure it. They cannot move on, they cannot grieve fully and the distress is magnified. Afterall their loved one is dead – no word written on a line of a death certificate will bring them back. Personally, I hate having to tell families a post mortem is required – because it is was my family – I would fight them doing it. Professionally however I realise the importance to understand how a life is lost – especially if it is not clear. The lessons learned from it could prevent a future one being lost.

In medical school we learned something  called the Kubler-Ross Grief Model. It states that where we grieve we can go through a set cycle of emotions. These are:

1. Denial

2. Anger

3. Bargaining

4. Depression

5. Acceptance

My time on ITU has shown all those emotions in the faces and words of the families that I have seen. I wish I didn’t have to because it always reminds me that one day I will be in their shoes. That is the very cycle of life after-all.

Not wanting to end of a somber note I want to show you the upside of ITU. We get to see the relatives of ones who have died come back – and believe you me they do. They come back to say thank you (not to me obviously, as I am after all just a paper pusher!) to the doctors and importantly nurses that have looked after their loved ones. Seeing them always makes me smile as you can see that they have moved to a, well, let’s call it a better place, on their grieving cycle. That makes it worth it.

See you next week,

Dr Nick

“Ok, Nick, now insert the tube down her throat….”

Today, ladies and gentlemen was a fantastic day! I am currently on the anaesthetic component of my intensive care training. Now this means I get to spend the day in operating theatres putting patients to sleep – not with my boring chat – but with amazingly potent drugs with names and mechanisms of action that leave me somewhat baffled.

And what a rush it is.

Let me run through how it all works. The patient, let’s call her Doris (not a real patient’s name of mine), gets rolled into the operating theatre’s anaesthetic room for her hip replacement. Inside the theatre are the surgeons waiting to get their hands on that hip. But before that happens, we have to make the very awake Doris, well, very asleep. This is not a straight forward process as it involves taking control of her airway (i.e. stopping her throat from collapsing shut when we put her to sleep), relaxing ALL of her muscles, and giving her pain relief continuously…and doing this all throughout what could be a 3 or 4 hour surgery…and then waking her up again for her to take over! So in the small anaesthetic room with my consultant anaesthetist, here’s how it goes:

“Nick, draw up all the medications”

I draw up a raft of different cocktails of drugs including an anaesthetic (the one that puts Doris to sleep) called Propofol, a neuro-muscular blocker (that relaxes her muscles) called Rocuronium, an analgesic (the pain relief) called Remifentanil, an anti-sickness drug called Ondansetron; PLUS then all the emergency drugs to reverse all of those drugs (and this list includes atropine, metaraminil and ephedrine)…All in all, it takes a while I can tell you.

So there I am armed with a pharmacy of drugs but ah, yes, no way to get them into Doris.

“Right, put a large bore cannula in the patient” my consultant tells me.

This task, I have talked about before – these are those tubes we insert into the veins of patients. This is, I have to say now, quite easy, but I must confess, doing so in front of a Consultant anaesthetist – the masters of all things insertable into the human body – it was a little more nerve racking. But, after 2 attempts, it goes in no problem.

After this I go the head of the patient. This is where the anaesthetic team comes into its own. They are the kings and queens of the ‘airway’. The airway refers to the passage from your mouth to your lungs. Without this you cannot get oxygen in air to your body. “Losing the airway” will kill you before most any other thing such as blood loss or inability to breathe.

The airway is top priority.

So that’s why the next part is all the more exciting. After “pre-oxygenating” i.e. giving the patient oxygen via an oxygen face mask, we inject the medications I mentioned above. This means that in a short period of time:

1. The patient falls into a deep sedated sleep

2. They stop breathing for themselves

3. Their airway is lost

All planned…but it gets your heart racing.

Because then this happens:

“Ok, Nick take the laryngoscope in your left hand, and insert it, identifying the epiglottis and vocal folds”

I insert a huge metal scope into Doris’s mouth, sliding the tongue out of the way to the left and pulling the jaw up to show me down her throat. I identify them.

“Now take the endotracheal tube and insert it through the vocal folds. Be careful not to damage the vocal cords. And remember this patient is now not breathing so you have about 3 minutes before you make them oxygen starved” (no pressure then!).

I take the endotracheal tube and thread it down the throat in between the vocal cords (my own heart in my mouth at this point!).

“I’m in”.

“Ok, now bag the patient” my consultant anaesthetist tells me with the confidence of somebody who has done this a thousand times.

I attach a bag to the tube I inserted into Doris – a bag which is connected up to a machine that not only supplies oxygen and so on – but artificially ventilates and breathes for Doris (as we have now effectively paralysed all her muscles – including breathing muscles [a necessity for certain surgeries]).

With this done, we stand back, survey and we check:

1. Airway – in place and secure with the endotracheal tube

2. Breathing – being done by the artificial ventilator

3. Circulation – heart beating, blood pressure good and intra-venous fluids flowing from a drip

4. Emergency drugs drawn up just in case

The three aspects of any life – Airway, Breathing, Circulation – all supported and accurately controlled by us, as doctors and the patient’s natural physiology. These are the key to life, for without it Doris would be no more.

With all this done, we wheel her out into the operating theatre….

I got to do this three more times today on different patients, and all I can tell you is – I loved it.

I may be an anaesthetist in the making…!

See you next week,

Nick