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!).
“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,