Anyway, back to business. Anesthesia week has been great, I really enjoy running anesthesia because it's different every time, regardless of the procedure being done. Sometimes it's straightforward, easy peasy and SOMETIMES it's a little crazy and you have to do all kinds of trouble shooting and problem solving and anticipating potential issues and solving those potential issues before they are actual issues. Crazy.
So earlier this week, I was running anesthesia for an oncology case. It was a cat that had a mass in it's mouth so, in order to ensure that all of the tumor was removed, it underwent a hemi-maxillectomy. That basically means that half of the cat's upper jaw was removed. Ok so that's pretty invasive and involves cutting of bone, which is very painful. As an anesthetist, that's something we have to think about and plan for. It's important to keep the patient at a safe depth/plane of anesthesia (so not too deep and not too light), but we also have to ensure that they are not feeling too much pain during even the most invasive of procedures. We were cruising along for a while, frolicking through anesthesia land while lymph nodes were being removed and margins of the mass were being determined. Then began the cutting of the bone and with it, the frolicking in anesthesia land quickly ended. At first, the cat's vitals went all wonky, blood pressure, heart rate, respirations all way out of our happy ranges. Ok, pain response, understandable. We increased the vaporizer setting and when that didn't help, bolused some of the morphine CRI. That brought us back to a workable level for a little bit. The next time that the cat's vitals spiked we had to give dexmedetomidine, an alpha-2 agonist (sedative) to chill her out. Naturally, each time that these things occurred, I was by myself in anesthesia-ville but luckily an anesthesia tech would roll in just in time. Ok so yay for Dex, she was chilled out and we were cruising again and the techs left me again. So then, as I watch the respirations slowly climb and the heart rate increase as well and I've just decided to again bolus some more morphine, the surgeon says "Mara, she's getting light again." Fab. During a hemi-maxillectomy, there's really no way that I'm going to assess depth by looking at jaw tone, eye position or palpebral reflex because the surgery and, thusly, the sterile field is all up in that area. So after the morphine and the increased vaporizer haven't helped, the surgeon asks me to give another dose of Dex. Done. Except this time, not only does it not really make a huge difference but we have the added joy of VPCs. That's ventricular premature contractions by the way. A VPC looks different from a regular heartbeat on the ECG monitor and it means that the heartbeat itself is being generated from a different place in the heart than a normal beat.
Here's a normal ECG trace:
Here is a trace with VPC's:
The VPC's are the ones with the big arrows pointing to them. See how they are distinctly different from the rest of the heartbeats? They are often described as "wide and bizarre".
One or two VPCs here and there is not something we get worked up about because the drugs that we use during anesthesia can cause VPCs and some other arrhythmias. But friends, this was not one or two here and there, it wasn't even one or two every screen. It was all VPCs, all over the place, with one or two normal looking beats mixed in. Great, fab, awesome. Ok so I'm thinking, I need some Lidocaine for this cat (and maybe for myself, because I think I just pumped out some stress related VPCs myself). The anesthesia tech that came in agreed that we had an issue and we got the kid some Lidocaine. Alright so things were ok for a little bit (I know, longest surgery of MY LIFE) and it was at the point that an anesthesia tech was staying with me full time now, thank you! Ok so then, THEN we start seeing some other funky ECG trace. It was kind of VPC-ish but different. Apparently, it was funky enough and rare enough that it merited taking a video of the ECG monitor and subsequently showing that video to a cardiologist who diagnosed it as a right bundle branch block. Whaaaaat??? I don't recall that one from Vet Sci 4 class!!
Here's what it looked like:
Thankfully, the next surgery of the day went beautifully aside from the tube to the circulating water blanket shooting off and spewing water everywhere in the middle of surgery. That, I can handle.
Yesterday was a much less stressful day. There were a few basic surgeries: castrations, spays, etc. I helped moved patients in and out of surgery and recover them. The anesthesia techs apparently have confidence in me that I have some sense of what I'm doing, because they left me to assist some of the vet students as they were monitoring anesthesia. I felt like I was able to successfully correct some minor anesthetic issues and share some of my anesthesia knowledge with the students, so that was pretty spiffy.
Then today I jumped back in with the oncology kids. The head onco tech, who incidentally is fantastically awesome and lets me do all kinds of fun stuff, asked me if I wanted to help out on their surgery case. Um, YEAH. Despite the insanity of the previous surgeries, I was ready for more. They had a little dachshund that was in for a mastectomy. She had two masses in the inguinal (groin) area. I placed an IV catheter in her little dachshund leg (not the easiest of tasks), induced her with Propofol, successfully passed her ET tube and THEN, hold on to your hats people because this is cool. I got to administer epidural pain meds! Cool cool cooooooool! This procedure involves palpating the space in between the last lumbar vertebrae and the first sacral vertebrae, getting a spinal needle through that space and into the epidural space which is between the vertebrae and the layers of tissue that surround the spinal cord. It's done mostly by feel. You insert the needle and then put some fluid in the hub of the needle, once you get in to the correct spot, the fluid should get sucked down into the needle. There is a little pop when you get through the tissue and into the epidural space. So my massage therapist skills were kicked in to high gear, I palpated the wings of the ilium (part of the pelvis) as a landmark and then found the space between the two vertebrae (even through a chubby dachshund bum). I had to "walk" the needle around a little bit to get down between the vertebrae and then get to the proper depth to get into the epidural space. I felt a little pop and my fluids got sucked down. We tested the placement by attaching a syringe with some air and fluid in it and seeing if it got sucked down as well, it did! So then the pain meds were administered. I must mention that I was instructed by the rock star onco tech throughout this procedure and would have been clueless as to what to do if it were not for her. Success! I was pumped! Afterwards, one of the anesthesia techs was palpating the dog and asked how I even felt the various bony landmarks because the dog had a big 'ol fat pad right where we were working. Hello? Massage therapist over here, uber sensitive ninja fingertips! Kachow! Alright, enough tooting my own horn. I was just really excited that I got the chance to do that and that I did it successfully on the first attempt. The anesthesia part of things was smooth and fantastic (no doubt due to a stellar epidural...ok for real that's the last comment on that). With that, anesthesia week drew to a close. Sad day. I really enjoyed that rotation. There is a chance I will get a few more days in anesthesia land the last week of internship, so we shall see.
Next week? Dermatology!
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