Tag Archives: CRNA

Staring Down Dragons

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Every crisis chooses its heroes. The heroes do not volunteer for the role. Brave souls do not rush to the front line to save us. The heroes, ordinary folk until now, are plucked from their previous lives without warning, whether they are willing or not, whether they are ready or not. In this crisis, there are many heroes (see Heroes in Masks with Mops). Everyone who shows up for their shift—whether they be nurse, houseman, security guard, food service worker, physician, or one of the countless other individuals needed to care for the tsunami of sick COVID-19 patients overwhelming our hospitals–is truly performing an act of courage each and every day. The heroes for the history books, though, the heroes who will be remembered by their colleagues long after this plague passes, are the anesthesiologists, nurse anesthetists, respiratory therapists, and ENT surgeons who find themselves staring down this monster every day–some many, many times on a really bad day. These are the special people whom we will always remember with an admiring nod and a tear of appreciation.nurse-anesthetist-vs-anesthesiologist.jpg.5c6db5df59cf2f07619cd04bbc39f0c1

The AIDS epidemic was the last plague that truly threatened US medical workers. While Ebola and H1N1 challenged us, neither of these crises presented a general threat to the health of our practitioners in this country. AIDS, however, during the terrible years of the late Eighties and early Nineties, killed our practitioners as well as our patients. We forget now, because of brilliant scientists like David Ho and countless others, who have given us effective treatments for HIV. But for several years, AIDS actually was the leading cause of death of people under age 40 in this country, the only time any disease displaced trauma from the top of the list. AIDS killed EVERYBODY it infected. And if the medical professional caring for the critically ill AIDS patient suffered a significant exposure, there was a definite possibility that they would die–horribly, because everyone with AIDS in those days died, horribly. Whole wards were filled with young people dying, horribly. Many AIDS patients developed severe intra-abdominal crises that required urgent surgical intervention. Surgery on these patients was fraught with the possibility of killing the surgeon, because these patients generally had extremely high viral loads at the time of their surgical crisis. This was the first time in memory when we had a national discussion about whether a doctor or nurse was morally obligated to care for an ill patient.

Doctors and nurses were dying. General surgeons, resident surgeons in training, orthopedic surgeons, surgical techs, and scrub nurses were at risk from needle sticks, blood splatters, intra-operative incidents of all kinds; significant or seemingly mundane, but now mortal injuries. Some surgeons refused to operate on HIV positive patients, hiding behind the argument that the patients were all dying anyway. This left the rest of us scrubbing on more and more of these dangerous procedures as others subtly deferred consults. Scrub techs and nurses willing to operate in dangerous conditions were increasingly called upon to fill in for those who declined. NY state entertained a law requiring surgeons who seroconverted to notify all patients of their status in the never-proven concern that a patient might contract the disease from the practitioner. So we stopped getting tested after every needle-stick, we even stopped donating blood, because we were not only risking our health, but also our ability to practice. It was a double-edged sword, with both edges pointed toward the practitioner. We stopped telling our spouses and colleagues about every torn glove or needle stick during an AIDS patient operation, because we stopped thinking about it as soon as we left the OR. But we kept operating on HIV patients, trying blunt-tip needles, extra-thick latex gloves, even chain-mail gloves—none of which helped in the least. Be careful, assume every patient is positive, universal precautions, we were told—all of it went right out the window with the next trauma patient in shock.

This plague has picked a different hero. Now, the riskiest moment for the health care practitioner is the intubation of a deteriorating COVID infected patient. In every hospital, anesthesiologists, anesthetists, and respiratory therapists, as well as many emergency medicine physicians and ENT surgeons, are placing their heads in the maw of the dragon as they insert an endotracheal tube needed to save a patient’s life. There is not a more dangerous maneuver in our current practice. Even worse than the surgeon operating on the AIDS patient, our modern knights staring down this dragon are not protected with chain-mail gloves, cannot even see the enemy, because it attacks—not in a spray of blood or with the pain of an errant needle—but in an invisible miasma. The risk of each individual intervention may be less, but the anxiety so much greater, as no one knows as they pull off their mask if, on this occasion, the dragon’s breath got past their shield. There is no choice but to take a deep breath, say a little prayer, and go on to the next patient.

When our anesthesiologists, anesthetists, ER docs, and respiratory therapists applied for training, none of them took a moment to ask themselves if they were brave enough to do this work. The job interview didn’t include a question about courage. No one signed up for this. They just do the work we need them to do to save our lives. When this is finally over, we will not forget that.

(CRNA)nesthesia isn’t Easy-2

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Sunday at the VA edition

[N.B.:  As our troubled VA system is currently in the news, I should say that this post makes reference to a very bygone era, by which I mean the Eighties.  The conditions described herein in no way reflect the status of our modern VA system.  I’m sure.  I hope.]

Not surprisingly, it took less than 48 hours after posting “Anesthesia isn’t Easy-1” before I heard from my nurse anesthetist friends.  And a few other anesthetists.  Quite a few, actually.  Unfortunately, the awkwardness of our medical lexicon precluded the appropriate repeated reference to our anesthetist colleagues (how many times can I write “anesthesiologist/anesthetist” in a 500 word blog post before even I stop reading the thing?).  It goes without saying (since it seems I didn’t say it) that pretty much everything I wrote in AIE-1 applies to our CRNA brethren.  There, I said it.Tinc of Cocaine

As I mentioned in that last post, a doctor’s early training is formative in many, many ways.  In my own experience, I came to love CRNA’s in general (and one in particular) during the second year of my general surgical residency. No, not the CRNA my future wife kept trying to fix me up with so that I’d quit asking her out. Different CRNA.

I was doing a rotation at the enormous VA Medical Center associated with my residency.  This was an institution that could easily serve as a setting for Game of Thrones or, maybe more appropriately, The Desolation of Smaug.  Built in medieval times, this fortress hospital was over a thousand beds and could be seen from space. It was somewhat past its prime.  By about a half century.  Many dusty corners, so to speak.  Actually, entire haunted wards.  Scary.  Dark.  Huge.  On one occasion I remember, when we sent a medical student to go find the patient who was using the central venous catheter so that we could clean it off and use it on another, really sick patient, the student got so lost we didn’t see him for almost a week.  We had to send a posse to a neighboring VA hospital for the catheter, I think.

Despite the incredible hugeness of the facility, it possessed an Emergency Room about the size of a broom closet.  This was specifically designed, I believe, to discourage our veteran  patients from considering the VA hospital as a potential site for emergency care. Which was an especially good thing, since despite the overwhelming hugeness of the facility, there was only one junior surgical resident on call in house on weekends. For all surgical specialties.  All of them.

Surgery call was especially exhausting due to the ridiculous policy that the surgery resident was required to respond to all Code Blue calls throughout the hospital, specifically because there were no respiratory therapists or anesthesia personnel in house.   So the surgery resident was required to do all intubations (establishing emergency airways in patients).  This was particularly problematic since many (most) junior surgery residents pretty much suck at intubations.  And since nobody else on the code team could do anything until the patient was intubated, some codes were very, very brief.  And even though over half of the wards had been closed down, there was no consolidation of the active wards.  Patients were scattered through two towers of a dozen stories each, with an elevator system dating back to the Civil War.  Any attempt to wait for the one functioning elevator car and you’d invariably arrive in time to pronounce the patient dead.  And since this was the VA hospital, it wasn’t unusual for there to be two or three codes in an hour, at any time of day or night. We were all in great shape as a result.  The original stairmasters.

One time as a second year resident,I found myself on call, alone, on a sunny Sunday afternoon.  I was running around doing all the scut work that we had to do in those days, drawing arterial gases on the ICU patients, admitting the preop patients who would have surgery during the coming week, that sort of thing.  The sort of thing that could easily keep four or five junior residents too busy to eat or sit down.  I was doing pretty well, thanking my lucky stars that there miraculously hadn’t been any codes to interrupt my work, when I simultaneously heard myself stat paged overhead and my beeper went berserk.  I didn’t recognize the number.  Which turned out to be the ER.  “We have an ER?” I asked the frantic nurse on the other end of the phone.  “Get down here STAT!”  was her reply.

I had to ask a janitor where the ER was, but I got there.  When I arrived, I saw an elderly internist/ED doctor and several nurses crammed into the tiny space around the one stretcher.  Sitting up on the stretcher was the largest vet I had ever seen.  Easily over 400 pounds and like six six, he was hunched over and breathing really, really fast.  He was also making a sound that no person should be making–a high-pitched crowing sound called stridor.  This, I remember thinking, is not good.  “Thank god you’re here,” the ancient internist said, turning to me.  Nobody had ever said anything like that to me before.  “Not really,” I remember thinking.  “His dentist sent him over,” the internist continued over the loud crowing sound of the man struggling to breathe.  “Really?” I said, trying to sound calm.  “His dentist?”  “Yes, yes,” the internist continued, pulling me up to the stretcher in an effort to get me to take charge.  “He thinks he might have Ludwig’s angina.”  I nodded sagely.  “Could be.  He might.”  No idea what Ludwig’s angina might be.  Looked bad, though. “What would you like me to do?  He need a line?” I asked.  I was really good at starting IV’s.  “No, no,” the internist said, gobsmacked.  “He’s got an IV.  You need to take care of his airway.  Right now!  Or he’s gonna die!”  Oh.  I remember the patient following this conversation with great concern.  I think he felt pretty much as the internist did.  “Of course,” I said, reassuringly.  “I’ll be right back.”   Then I ran away as the internist asked where I was going.

I ran to the OR.  There was no chance that I was going to be able to intubate this guy, of this I was sure.  Besides the fact that the man was huge, panic-stricken, and had an airway that was swollen almost completely shut–I sucked at intubation.  Just ask my last three code patients.  Except you can’t, because they’re dead.  The only hope was to grab an emergency tracheostomy tray so that when the guy was unconscious from hypoxia and not quite dead, I might be able to do an emergency trach.  About one chance in a million, give or take.  Still better odds than me successfully intubating the guy awake in that ER.

I slid around the corner into the OR and stopped dead in my tracks.  Usually, the OR would be dark and empty on a Sunday afternoon.  But the lights were on.  I ran into the anesthesia office and saw two huge shoes on the desk.  Tiny Ted was asleep in the chair.  Ted was the Chief and only CRNA at the hospital.  Actually, he was the entire anesthesia department, functionally speaking.  A grizzled bear of a man in his late forties, Tiny Ted was pretty much the only person interested in actually administering anesthesia to our patients.  The anesthesiologists in the department specialized in explaining why our patients couldn’t have surgery.  If you really wanted to operate on someone, you got Ted.  He was good natured, always wanted to work, and was supremely capable.   “Ted!” I yelled at him, shaking him awake.  “What are you doing here?”  “Stocking the drawers, getting ready for tomorrow,” Ted said, coming awake.  “And staying away from my wife.  Why?  You look like you’re about to piss in your pants, Geller.  What’s up?”  I explained about the patient with Ludwig’s angina.  “Nasty,” he commented, rubbing his stubbled chins.  “Let me guess, Geller–you came here to grab a tray so you can do a slash trach down in the ER?”  I nodded sheepishly.  “Why don’t you just shoot him in the head?  Be more humane, less messy.  Less likely to kill him, too.  I heard about your last trach, Geller.”  {see “Equinimity“} He let me squirm for a minute before slapping me hard on the back.  “Get your patient up here and set up a room for a trach.  I’ll give you a hand.”  “Thanks, Ted,” I said, relieved.  “Where are you going?” I asked.  “Get some coke,” he said, leaving.  “You’re thirsty?” I asked.  “Not that kind of coke, Geller.”  Oh, I thought.  Maybe I caught Ted at a bad time.

With the help of two orderlies, I got the patient lying semi-reclined on an operating room table.    I had set up my instruments and a scalpel, which the patient was staring at fixedly.  He was also breathing about forty times a minute and his stridor was even higher pitched than before.  He looked about twice the size of Ted, and Tiny Ted was a rather big man.  That’s why we called him Tiny Ted.  Also, I noticed at this point, the patient had the interesting anatomic feature of having no visible neck.  His head apparently sat directly upon his chest.  Great.  “This here,” Ted said, interrupting my rising sense of panic, “is the entire stock of cocaine in this institution.”  He held up an impressively large vial labelled 4% Tincture of Cocaine.  “Can we talk about that later, after this?” I asked him.  I really needed Ted’s help.  “This is what’s going to happen,” Ted continued, ignoring my comment.  “I am going to take one shot at intubating our friend here.  Exactly one shot, period, amigo.  If I can’t tube him, it’s your turn.”  He stared at me.  The patient stared at me.

I nodded solemnly.  “And then he’ll die a horrible, bloody death,” I thought to myself.

“And then he’ll die a horrible, bloody death,” I heard out loud.  I thought somehow my thoughts had become audible.  But no, it was just Tiny Ted saying what we were both thinking at that point.  The patient appeared somewhat more distressed at this.  “Don’t worry,” Ted said brightly to him, “you’re going to do fine.”

“Probably not,” I thought.  “Just kidding,” Ted said.  “But I’ve got cocaine.  You ever do coke?” he asked the patient.  The patient barely managed to shake his head, being pretty much fully occupied with struggling to draw his last breaths through an airway about the width of a swizzle stick.  “You’re going to be fine,” Ted said again.  Tiny Ted, the master of mixed messages.

At this point, I took up my position over the patient with a #10 scapel in (trembling) hand.  Ted lowered the head of the OR table as the patient’s eyes, now big as saucers, never left mine.  Ted began a complex ritual of spraying cocaine into the patient.  This was accompanied by a soothing Hindu prayer chant, intermixed with an off-key rendition of Tupac’s “God Bless the Dead.”  (Actually, I made that last part up as a shameless, subliminal pitch for my first novel.  He actually was tunelessly singing “White Lines (Don’t Do It)” by Grandmaster Melle Mel.)  After something intravenous, Ted began a process of inserting a series of cocaine soaked cotton tipped applicators deeper and deeper into the patient’s nose.  Eventually he had about four sticking out of each nostril.  The patient seemed happier.

“Here goes nothin’,” Tiny Ted announced as he dramatically took endotracheal tube in hand and waved it over the patient’s face.  The patient had his eyes closed.  Seemed like a good idea, so I closed mine and silently promised God all sorts of stuff if He didn’t make me cut open this man’s throat.  A chocolate ice cream sundae, if the occasion arose.  And other stuff, too. Like learning to intubate better.

“Done,” Ted announced.  I opened my eyes.  There was a tube sticking out of the patient’s nose.  The stridor had stopped, replaced by the sound of easy, ventilator-assisted breathing. Ted was busy pushing enough muscle relaxant through the IV to put down an elephant for a month.  “This should keep him from pulling the tube out until I get of here.  After that, he’s your problem, Geller.”  I nodded and put away my scapel.  I could have hugged him, but it would’ve been awkward.

“Thanks, Ted.”

“No problem, Geller.”